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C L I N I C A L I S S U E S

The effect of patient education and home monitoring on medication

compliance, hypertension management, healthy lifestyle behaviours and

BMI in a primary health care setting

Rabia Hacihasanoğlu and Sebahat Gözüm

Aim. The aim of this study was to determine the effect of anti-hypertensive patient-oriented education and in-home monitoring

for medication adherence and management of hypertension in a primary care setting, by providing education on healthy lifestyle

behaviours and medication adherence.

Background. Hypertension is the third most common cause of death worldwide. Prevalence of hypertension in Turkey is

approximately 30% in the general population and 45–50% in population over 50.

Design. Randomised controlled study.

Methods. This study conducted in Turkey used a study group comprised of 120 subjects (40 Group A, 40 Group B, 40 controls),

all previously diagnosed with hypertension and who started medication therapy at least one year prior to start of study. The study

was conducted between February–November 2006 at public primary health care facilities and homes of the study participants.

Participants in Group A and B received a total of six monthly education sessions, four times during clinic visits and two home

visits. Medication adherence education for Groups A and B and education about healthy lifestyle behaviours for Group B were

administered in a structured and individualised format. The control group was routinely monitored in health care facilities.

Results. Healthy lifestyle behaviours and perception of self-efficacy regarding medication adherence showed improvement after

education sessions in Groups A and B. Systolic and diastolic blood pressures of subjects in Group A and B showed a significant

decrease compared with those of the control group; the blood pressure decrease in Group B was greater than in Group A.

Conclusion. Nurses play an important role in uncontrolled hypertension detection and can improve medication adherence and

healthy lifestyle behaviours.

Relevance to clinical practice. Patient education medication adherence alone and in combination with healthy lifestyle behaviour

teaching is an effective tool for blood pressure reduction in the hypertensive population in primary health care settings.

Key words: blood pressure, healthy lifestyle behaviours, hypertension, in-home monitoring, medication adherence

Accepted for publication: 13 August 2010

Introduction

Previous reports state that hypertension is responsible for

6% of adult deaths worldwide (Cooper 2004), making it the

third leading cause of worldwide (Bolli et al. 2005) and one

of the most preventable cardiovascular risk factors (Lip

2004). Hypertension affects approximately 50 million people

in the USA and 1 billion worldwide (JNC 7 Report 2003). In

Turkey, the prevalence of hypertension in the adult popula-

tion is approximately 30% and 45–50% in the population

over 50 (Diagnosis and Treatment Guidelines for Primary

Health Care, Turkish Ministry of Health 2003). It has been

Authors: Rabia Hacihasanoğlu, PhD, RN, Assistant Professor,

Nursing Department, Erzincan University School of Health,

Erzincan; Sebahat Gözüm, PhD, RN, Professor (Adviser of the

study), Department of Public Health Nursing, Akdeniz University

Antalya School of Health, Antalya, Turkey

Correspondence: Rabia Hacihasanoğlu, Assistant Professor, Erzincan

University School of Health, Nursing Department, Erzincan, Turkey.

Telephone: +90 446 226 58 61.

E-mail: [email protected]

692 � 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 692–705 doi: 10.1111/j.1365-2702.2010.03534.x

reported that, unless extensive and efficacious precautions are

undertaken, hypertension prevalence will increase even more

as the global population ages (JNC 7 Report 2003). Hyper-

tension is a major independent risk factor for cardiovascular

and renal disease, increasing the risk of myocardial infarc-

tion, stroke, heart failure and renal disease (JNC 7 Report

2003, Kabakci 2006). The primary goal in the treatment of

hypertension is the avoidance of hypertensive complications

(Feldman et al. 1998) by regulating blood pressure to within

normal limits (Casey 2004).

Despite the known benefits of lowering blood pressure in

hypertensive patients, control of hypertension in all settings,

including primary care, is still far from optimal (Banegas

2006) and continues to be a major public health problem

(Düsing 2006). One of the most important factors affecting

efficacy of blood pressure globally and in Turkey is the lack

of patient adherence with prescribed antihypertensive thera-

pies (Kabakci 2006). Similar to the Feldman and colleagues

report, Kabakcı report that pharmacological non-adherence

is prevalent and is an important factor in both poor blood

pressure control as well as the incidence of hypertensive-

related complications (Feldman et al. 1998, Kabakci 2006).

Adherence is the level of conformity between the patient

behaviour and clinical recommendations, such as using the

medications properly, following prescribed diet and incorpo-

rating relevant lifestyle behaviour changes. Non-adherence

may begin with the lack of adherence to medication therapy,

such as failure to procure the prescribed medication or failure

to self-administer medication according to prescribed sched-

ules (Hill & Miller 2004). According to Coleman, reasons for

non-compliance include: poor follow-up explanation or

inadequate initial explanations (by health care providers) of

medications; disbelief in the benefits of taking medications

regardless of how the patient feels physically; forgetting to

take medication; purposefully skipping medication (Coleman

2005). Other unhealthy habits that reduce the efficacy of

anti-hypertensive therapy include: not attending follow-ups

regularly; smoking; inadequate physical activity; and diets

with excess of calories, fat or sodium (Hill & Miller 2004).

Obesity, excessive alcohol consumption, sedentary life-

style, unhealthy diet and stress factors are contributing

factors in high blood pressure (Campbell et al. 1999).

Changes in lifestyle and adoption of a healthy lifestyle are

crucially important in the prevention or amelioration of high

blood pressure. Changes in lifestyle decrease blood pressure,

increase the efficacy of antihypertensive drugs and decrease

cardiovascular risk (The JNC 7 Report 2003).

Successfully managing hypertension requires that patients

make a commitment to achieving and maintaining control of

their blood pressure. They must keep follow-up appointments

and adhere to non-pharmacologic treatment recommenda-

tions as well as pharmacotherapy regimens (Clark & Afflu

1995). Effective efforts to control blood pressure levels and

improve the quality of life of hypertensive patients include

appropriate combinations of health care services, informa-

tion, counselling, reminders, self-monitoring, support and

family therapy (Kaplan 2003).

Roy’s adaptation theory and Pender’s health promotion

model were used to construct a framework for the hypothesis

of this study. According to Roy, the individual and the

environment are sources of stimuli that require modification

to promote adherence (Chitty 1997). A subject’s behaviour is

affected by their abilities as well as internal and external stimuli

(Velioğlu 1999). Thus, adherence education given by the nurse

to get blood pressure under control contributes to adaptation

of the patients to their disease and to the therapy as an external

stimulus. To sustain integrity and homeostasis, hypertensive

patients would become better informed through education and

counselling provided by the nurse and then would adapt more

easily to the changes brought about by hypertension.

In Pender’s health promotion model, cognitive perception

factors effect the appearance of terminal behaviour change

such as: the importance ascribed to health, health control,

perception of self-efficacy, definition of health by the individ-

ual subject, perceived benefits of health-promoting behaviour,

perceived supports or hindrances to health promotion behav-

iour. All of these factors are sensitive to change and can be

improved by education (Galloway 2003, Toukola 2007).

Perceived medication adherence self-efficacy is one of the

cognitive perception factors in this model that can be

improved by education. Through education, a nurse can

teach the hypertensive patient appropriate behaviours to help

control their hypertension. Education can improve patients’

expectations regarding self-medication adherence, such as on

time administration, regular medication use, procuring more

medication before the previous prescription is completely

consumed and continuing to use the medication even if there

are some slight side effects. Education also enables the patient

to understand hypertension better, its complications, effects

of regular medication adherence on the control of blood

pressure and the role of their own behaviours in blood

pressure control. Such education further affects other cogni-

tive factors in the model further enabling behavioural change.

There are many studies in the literature demonstrating that

educational interventions, as part of anti-hypertensive

therapy, increases medication adherence and improves

healthy lifestyle behaviours and significantly decreases blood

pressure levels (Garcia-Pena et al. 2001, Çakır 2003, Rudd

et al. 2004, Bosworth et al. 2005, Reid et al. 2005, Svetkey

et al. 2005). However, to date, there has been no study of the

Clinical issues Effect of patient education and home monitoring

� 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 692–705 693

effects of a combination of hypertension, medication adher-

ence and healthy lifestyle behaviour education with health

care facility follow-ups, home monitoring and phone inter-

views on hypertension and lifestyle behaviour changes.

Neither has there been a study published to date that

compares the efficacy of the medication adherence education

vs. healthy lifestyle behaviour using two study groups and a

control group subjects.

Aim

The aim of this study was to determine the effect of

anti-hypertensive patient-oriented education and in-home

monitoring for medication adherence and management of

hypertension in a primary care setting, by providing education

on healthy lifestyle behaviours and medication adherence.

Methods

This experimental study involved three groups, a test group

A, a Group B and a control group C. Participants in Groups

A and B received a total of six monthly education sessions,

four times during clinic visits and two home visits. Medication

adherence education for Groups A and B and education about

healthy lifestyle behaviours for Group B were administered

in a semi-structured and individualised format. The control

group was routinely monitored in health care facilities.

Our hypotheses were as follows: (1) Education in medica-

tion adherence and healthy lifestyle behaviours will improve

medication adherence in the study groups (Groups A and B).

(2) Education in medication adherence and healthy lifestyle

behaviours will result in lower average blood pressure values

in study groups (Groups A and B). (3) Medication adherence

levels in study Group B (education in both medication

adherence and healthy lifestyle behaviours) will be higher

than that of the patients in group A (who receive only

medication adherence education). (4) The average blood

pressures of patients in study Group B who have received

education for both medication adherence and healthy lifestyle

behaviours will be better than the patients in study group A

who have received only medication adherence education.

Design

The study was performed as a pretest–post-test study.

Participants

The study group was comprised of 120 hypertensive patients

residing in central Erzincan, Turkey, who were diagnosed at

least one year prior to study entry, aged ‡35, had blood pressure ‡140/90 mmHg, were prescribed antihypertensive medication, literate, able to communicate easily and cooper-

ate with researchers and who did not have any disease or

condition (e.g. diabetes mellitus, heart failure, renal impair-

ment) that would prevent them from participating in the

study. The study was conducted between February–Novem-

ber 2006 at public primary health care facilities No. 1, 2 and

3 and homes of the study participants.

Data collection

Pretest data were collected through the administration of a

descriptive questionnaire, medication adherence self-efficacy

scale (MASES), health-promoting lifestyle profile (HPLP) to

130 hypertensive patients in the 1st, 2nd and 3rd primary

health care facilities of Erzincan province and from personal

data (blood pressure, height, weight available in the

subjects’ medical records). Hypertensive patients (average

blood pressure is 140/90 mmHg or more after a rest period

of 10–15 minutes following arrival at the primary health

care facility and after two measurements within 5–10 minute

intervals) were selected for the study.

Group A and B were composed of 43 randomly selected

hypertensive patients, and the control group was composed

of 44 patients. Randomisation was provided by enrolling the

patients into Group A on Monday, into Group B on Tuesday

and into Control group on Wednesday and so on. To prevent

bias, following week days were changed. Allocation and

outcomes data were not blind but statistician blinded. Three

patients each in both Group A and B and four patients in the

control group were excluded from the study because of

reasons such as having frequent travel precluding regularly

scheduled appointments, follow-up problems or discontinu-

ing the education after study start. Thus, the study was

completed with 120 patients, 40 patients in three groups. The

total sample size was set at 120 with 40 subjects for each

group based on power as 0Æ95, a as 0Æ05 and effect size as

0Æ70.

Final data were collected through re-administration of

the pretest questionnaires and scales, blood pressure mea-

surements and weight measurement. All data were obtained

by face-to-face interview. The entire education intervention

was comprised of six interviews, two during a home visit

and four at the primary care facilities. Each intervention

lasted 30 minutes for medication adherence education

(Group A) and 45 minutes for the combination of healthy

lifestyle behaviour and medication adherence education

(Group B). For both home and clinic visits, a comfortable,

quiet room was used for educational sessions. Furthermore,

R Hacihasanoğlu and S Gözüm

694 � 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 692–705

monthly follow-up phone calls were conducted to provide

Group A and Group B study subjects with general

information about hypertension and to remind them about

visit dates. Monthly visit was also conducted with the

control group for the recording of blood pressures and

weight. Control group was routinely monitored in health

care facilities.

Physiological/physical measurements

After a 10–15 minutes rest period, systolic and diastolic

blood pressures of patients were obtained from the patient’s

right arm with the patient in a seated position. Two

successive measurements were performed at intervals of 5–

10 minutes. Patients were requested not to smoke and to

avoid caffeine (coffee, colas) intake 30 minutes prior to blood

pressure measurement. A sphygmomanometer (ERKA) was

used for the measurement. Systolic (SBP) and diastolic blood

pressures (DBP) were recorded based on Korotkoff sounds.

Height measurement was obtained using a tape measure

with the patient standing on a horizontal surface with the

head, shoulder, hip and heel touching a vertical wall. Values

were recorded in centimetres (cm). Weight measurement was

obtained using a standard scales with patients wearing

lightweight clothes. Values were recorded in kilograms (kg).

Body weight (kg)/height (m)2 was calculated as BMI accord-

ing to the WHO standards. BMI values under 18Æ5 were

considered to be thin, values between 18Æ5–24Æ9 were

considered normal, 25–29Æ9 was considered to be overweight,

between 30–39Æ9 as obese and 40 or more were considered

morbidly obese (Report of the WHO Consultation on

Obesity Geneva 2000). To reduce measurement error, end

of the day sphygmomanometer and platform scale matched

and controlled with another measurement instrument.

Interventions

Group A – education in medication adherence (Study A) (Fig. 1)

This group had six educational sessions in person directed at

medication adherence following the pretest. Areas of discus-

sion included the importance of regular medication adherence,

efficacy of antihypertensive drugs, possible side effects and

what to do in case of side effects, importance of follow-up

visits). These subjects were given general information about

healthy lifestyle behaviours (nutrition, weight reducing,

exercise etc.) and hypertension (definition of hypertension,

risk factors, complications). Educational methods included

standard narration, question–answer and discussion. Also,

follow-up phone call interviews were performed monthly to

provide information about hypertension. A nursing education

programme in hypertension care was planned, which involves

unstructured non-pharmacological treatment and structured

medication adherence treatment.

Group B – education in medication compliance in addition to

education in healthy lifestyle behaviours (Study B) (Fig. 2)

This group received six monthly education sessions in person

following the pretest and had individual education regarding

medication adherence (importance of regular medication

adherence, efficacy of drugs, possible side effects and what to

do in case of side effects, importance of follow-up visits) and

further received education in healthy lifestyle behaviours

(nutrition, relevant diet, importance of reduced salt intake,

how to deal with stress, weight control, exercise, risks of

alcohol and smoking, etc.) as well as general information

about hypertension (definition of hypertension, risk factors,

complications). A nursing education treatment programme,

which included hypertension care, consisted of structured

non-pharmacological and medication adherence treatment.

Similar to Group A, education methods included standard

narration, question–answer and discussion. Also similar to

Group A, phone call interviews were conducted once a month

to give information about hypertension.

Control group

This group had six interviews after the pretest but only blood

pressure and weight measurements were checked at each

interview (i.e., no educational intervention). Phone calls were

made to remind participants of upcoming appointments dates

and times (Figs 1 and 2).

Ethical considerations

Institutional approval was obtained from Ataturk University

Medical Sciences Ethical Committee and Erzincan District

Health Board. Study aims, plans and benefits were explained

to patients who met the study criteria. Patients were asked if

they would voluntarily participate in the study and their

written/oral consents were obtained. Confidentiality was

maintained at all times. Education given to the study groups

was also given to the control group after posttest adminis-

tration. The effect of education given to the control group

could not be evaluated because of the limited time. However,

it is assumed that such education would be effective as it was

with the experimental groups.

Outcome measures

Basic measurement outcomes were blood pressure, height and

weight, medication compliance and lifestyle behaviours.

Clinical issues Effect of patient education and home monitoring

� 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 692–705 695

Interim measurement outcomes were blood pressure

and weight at each study visit. Final measurement outcomes

were blood pressure and weight, medication compliance and

healthy lifestyle behaviours. A descriptive questionnaire, med-

ication adherence/compliance self-efficacy scale (MASES) and

HPLP were administered as pre- and post-test to all study

subjects.

The descriptive questionnaire queried the socio-demo-

graphic characteristics of the patients. It was designed by

the investigator based on similar studies and consisted of 12

questions, nine of which are related to patient’s descriptive

characteristics (age, sex, marital status, educational status,

profession, income level (based on self-reporting; income

higher than expenses, income equivalent to expenses, income

less than expenses), family situation (lives with nuclear family,

lives with extended family), smoking and alcohol consump-

tion)and three related to the specifics of patient regarding

hypertension (duration of therapy, comorbid diseases and

whether prescribed medication is taken on a regular basis).

Medication adherence self-efficacy scale

MASES was developed by Ogedegbe et al. in 2003, to

measure situation-specific efficacy beliefs regarding adherence

to prescribed antihypertensive medications in a population at

high risk for hypertension-related morbidity and mortality

(Ogedegbe et al. 2003). The MASES is a 26-item, patient-

derived, self-administered instrument. The participants were

asked to rate their degree of confidence in taking their blood

pressure medication in a variety of situations. The response to

each item was formatted on a three-point Likert scale with

1 = not at all sure, 2 = somewhat sure and 3 = very sure. The

lowest total score is 26 and the highest is 78. All responses

were added to obtain a summary score with higher scores

indicating greater self-efficacy. The MASES has a Cronbach’s

alpha coefficient of 0Æ92. Results of the Cronbach’s alpha and

test–retest reliability demonstrate that this MASES is inter-

nally consistent and yields stable scores over time. This scale is

a brief instrument, which is easy for patients to use and to

understand, taking on average, about five minutes to com-

plete (Gözüm & Hacıhasanoğlu 2009). For this specific study,

the internal reliability coefficient for the MASES was 0Æ92.

Health-promoting lifestyle profile scale

The Health Promotion Life-Style Profile Scale was developed

in 1987 by Walker, Sechrist & Pender (Walker et al. 1987).

Validity and reliability of the scale was tested in Turkey by

Esin in 1997. Questions in this scale measure a subject’s

behaviours that can improve health. The a value of the scale

was determined to be 0Æ91 (Esin 1997) and was calculated to

be 0Æ90 for this specific study. The scale consists of 48 items,

all positive behaviour categories and contains six subgroups.

Subgroups are self realisation, health responsibility, exercise,

nutrition, inter-personal support and stress management. The

total score obtained from the scale indicates the level of

healthy lifestyle behaviours. Scoring is performed on a four-

point Likert Type Scale. One point is given to the answer

‘never’, 2 points are given to ‘sometimes’, 3 points to

‘frequently’ and 4 points to ‘regularly’. The lowest total

score is 48 and the highest is 192. A higher score indicates

that the subject performs a higher level of the indicated

behaviours (Esin 1997).

Data analysis

Data were analysed using SPSSSPSS statistics software, version

11.0 for Windows. To treat analysis, minimum and max-

imum values were controlled before the evaluation of the

data. Chi-square and variance analysis (ANOVAANOVA) were used

for the assessment of the experimental groups and the

control group; paired t-test was used for intra-group

assessment of significance of the difference between the

average pretest–posttest scores of MASES, HPLP, BMI and

SBP-DBP; variance analysis was used for inter-group

assessment of significance of the difference between the

average pretest–posttest scores of MASES, HPLP, BMI and

SBP-DBP; Tukey test was used for advanced analysis; and

McNemar test was used for assessment of significance of

the difference between the pretest–posttest levels of

regular and irregular using of medications in experimental

groups and the control group. Internal consistencies of the

MASES and HPLP scales were tested using Cronbach’s

alpha reliability coefficients. A significance level of p = 0Æ05

was used for all comparisons.

Results

At pre-test, there were no statistically significant differences

between any of the groups (both intervention and control

groups) in terms of descriptive characteristics, SBP-DBP,

MASES, HPLP scales or BMI pretest results (see Tables 1 and

2). When the effectiveness of interventions in the both control

and intervention groups was compared using the SBP, DBP

MASES, it was found out that the both interventions were

effective, but combined education (Group B) more effective

than medication adherence education alone (Group A) on

blood pressure (Table 3). MASES scores of intervention

groups were significantly increased. Significant differences

were noted when comparing HPLP average scores between

R Hacihasanoğlu and S Gözüm

696 � 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 692–705

the two study groups and between study groups and the

control groups (p < 0Æ001). For BMI, no difference was

found between the study groups A and B, nor between Group

A and the control group (p > 0Æ05); however, significant

differences were observed between Group B and the control

group (p < 0Æ05) (Table 3, Fig. 3).

The most significant reduction in systolic and diastolic

blood pressure was seen in the intervention Group B (Fig. 4).

The differences between systolic and diastolic blood pres-

sures, MASES, HPLP and body mass index pre- to post-test

total score averages study groups were statistically significant

(p < 0Æ001) for both study groups, while there were not

Table 1 The comparison of descriptive features of intervention and controls groups

Descriptive features

Intervention

Group A (n = 40)

Intervention

Group B (n = 40)

Control group

(n = 40)

Test value

significance

Age 58Æ00 SD 8Æ9 56Æ92 SD 8Æ04 55Æ62 SD 8Æ46 F = 0Æ840 p = 0Æ434

Treatment duration in years 5Æ10 SD 4Æ32 7Æ10 SD 6Æ16 5Æ37 SD 5Æ17 F = 1Æ689 p = 0Æ189

n (%)* n (%)* n (%)*

Gender

Female 20 (50Æ0) 20 (50Æ0) 22 (55Æ0) v2 = 0Æ267 SD = 2

p = 0Æ875 Male 20 (50Æ0) 20 (50Æ0) 18 (45Æ0)

Marital status

Married 36 (90Æ0) 33 (82Æ5) 35 (87Æ5) v2 = 1Æ010 SD = 2

p = 0Æ604 Widowed 4 (10Æ0) 7 (17Æ5) 5 (12Æ5)

Education level

Literate 3 (7Æ5) 6 (15Æ0) 2 (5Æ0) v2 = 5Æ399 SD = 8

p = 0Æ714 Primary school 24 (60Æ0) 21 (52Æ5) 26 (65Æ0) Secondary school 3 (7Æ5) 6 (15Æ0) 3 (7Æ5) High school 6 (15Æ0) 3 (7Æ5) 5 (12Æ5) University 4 (10Æ0) 4 (10Æ0) 4 (10Æ0)

Profession

Officer-worker 1 (2Æ5) 3 (7Æ5) 2 (5Æ0) v2 = 2Æ359 SD = 6

p = 0Æ884 Housewife 17 (42Æ5) 20 (50Æ0) 19 (47Æ5) Retired 20 (50Æ0) 15 (37Æ5) 16 (40Æ0) Farmer 2 (5Æ0) 2 (5Æ0) 3 (7Æ5)

Economic status

Income > expenditure 1 (2Æ5) 1 (2Æ5) 4 (10Æ0) v2 = 3Æ292 SD = 4

p = 0Æ510 Income = expenditure 35 (87Æ5) 34 (85Æ0) 32 (80Æ0) Income < expenditure 4 (10Æ0) 5 (12Æ5) 4 (10Æ0)

The type of family

Nuclear family 35 (87Æ5) 37 (92Æ5) 35 (87Æ5) v2 = 0Æ690 SD = 2

p = 0Æ780 Extended family 5 (12Æ5) 3 (7Æ5) 5 (12Æ5)

Tobacco use

Smoking 3 (7Æ5) 8 (20Æ0) 5 (12Æ5) v2 = 2Æ740 SD = 2

p = 0Æ254 Non-smoking 37 (92Æ5) 32 (80Æ0) 35 (87Æ5)

Alcohol use

Drink 1 (2Æ5) 2 (5Æ0) 3 (7Æ5) v2 = 1Æ053 SD = 2

p = 0Æ591 Does not drink 39 (97Æ5) 38 (95Æ0) 37 (92Æ5)

Comorbid illnesses

Yes 18 (45Æ0) 20 (50Æ0) 16 (40Æ0) v2 = 0Æ808 SD = 2

p = 0Æ668 No 22 (55Æ0) 20 (50Æ0) 24 (60Æ0)

*Per cent of column.

Clinical issues Effect of patient education and home monitoring

� 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 692–705 697

significant pre- to post-test differences in the control group

(p > 0Æ05) (Table 4). In Groups A and B, the number of

patients who regularly use medication was significantly

increased after education (p < 0Æ001); there was no signif-

icant increase in medication compliance in the control group

(p > 0Æ05) (Table 5).

Discussion

To the authors’ knowledge, this study is the first nursing

intervention study to improve both medication adherence and

healthy lifestyle behaviours for hypertensive patients in

Turkey. In this study, we shed light on professional educator

roles of the nurse. Our results indicate the importance of

receiving nursing intervention for controlled blood pressure,

healthy lifestyle behaviours and medication adherence self-

efficacy (Tables 3–5). The finding of study supported our

hypothesis. Our results can be applicable to primary care

facilities worldwide because uncontrolled blood pressure,

non-adherence medications and unhealthy lifestyle behav-

iours are global problems.

Groups in the study were similar in terms of descriptive

characteristics (Table 1). It has been shown in many descrip-

tive studies that certain personal characteristics such as age,

sex, being overweight, educational level, marital status,

income level, smoking, alcohol consumption, comorbid

diseases are associated with the prevalence of hypertension

(Schutte et al. 2003, Esposti et al. 2004, Altun et al. 2005,

Taşçı et al. 2005, Erem et al. 2008). Control of changeable

characteristics is important for accurate testing of the efficacy

of educational interventions.

Results of the pre-test, which was carried out before

education and home monitoring started, showed that the

averages of the two study groups and the control group were

Table 2 Comparison of pretest results

regarding hypertensive control, blood

pressure, MASES, HPLP scores and BMI

values

Variable

Group A

mean ± SD

Group B

mean ± SD

Control group

mean ± SD Test and

p-valueBefore education Pretest Pretest Pretest

Systolic BP 159Æ25 ± 12Æ48 158Æ62 ± 12Æ85 158Æ50 ± 14Æ24 F = 0Æ037 p = 0Æ964

Diastolic BP 95Æ75 ± 5Æ00 95Æ50 ± 5Æ03 94Æ75 ± 5Æ05 F = 0Æ427 p = 0Æ653

MASES 55Æ30 ± 7Æ57 55Æ55 ± 7Æ67 55Æ12 ± 8Æ53 F = 0Æ029 p = 0Æ971

HPLP 87Æ20 ± 9Æ25 86Æ62 ± 10Æ43 86Æ52 ± 11Æ32 F = 0Æ049 p = 0Æ952

BMI 25Æ27 ± 2Æ87 25Æ62 ± 2Æ87 26Æ07 ± 4Æ09 F = 0Æ581 p = 0Æ561

MASES, medication adherence self-efficacy scale; HPLP, health-promoting lifestyle profile.

Table 3 Comparison of posttest results

regarding hypertensive control blood

pressure, MASES, HPLP and BMI Variable

Group A

mean ± SD

Group B

mean ± SD

Control group

mean ± SD Test and

p-valueAfter education Posttest Posttest Posttest

Systolic BP 139Æ75 ± 11Æ31a 133Æ50 ± 12Æ25b 156Æ00 ± 11Æ55c F = 39Æ291 p = 0Æ000

Diastolic BP 86Æ00 ± 4Æ69a 83Æ50 ± 4Æ83b 93Æ00 ± 4Æ35c F = 45Æ215 p = 0Æ000

MASES 71Æ10 ± 6Æ42a 72Æ27 ± 5Æ27a 56Æ85 ± 6Æ10b F = 83Æ131 p = 0Æ000

HPLP 97Æ80 ± 8Æ35a 118Æ80 ± 13Æ88b 87Æ65 ± 6Æ71c F = 98Æ417 p = 0Æ000

BMI 24Æ42 ± 2Æ81ab 24Æ26 ± 2Æ76a 26Æ04 ± 4Æ21b F = 3Æ478 p = 0Æ034

MASES, medication adherence self-efficacy scale; HPLP, health-promoting lifestyle profile.

Averages shown with different letters in the same line are different (from each other).

R Hacihasanoğlu and S Gözüm

698 � 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 692–705

similar in terms of systolic, diastolic blood pressures, MASES,

perceived self-efficacy, HPLP and BMI (Table 2). The average

blood pressure levels were classified as Grade 1 and 2

hypertension; antihypertensive medication adherence/compli-

ance and self-efficacy perception were above average; healthy

lifestyle behaviours were at a medium level; and average BMI

was slightly high. Although there are several studies evalu-

ating the medication adherence of hypertensive patients in

Turkey (Çetinkaya et al. 1996, Eryonucu et al. 1999, Kara-

kurt 2004), reliability and comparability of their results are

limited because of the lack of standardised instruments used

in the surveys. In a study by Ogedegbe et al. (2003), the

developer of the MASES, carried out on an Afro-American

study group, it was found that medication adherence self-

efficacy levels were higher compared to the results of the

study carried out by Gözüm and Hacıhasanoğlu (2009).

Study protocol procedures

Trial group A Trial group B Control group

In te

rv ie

w 1

In te

rv ie

w 2

In te

rv ie

w 3

In te

rv ie

w 4

In te

rv ie

w 5

In te

rv ie

w 6

Education about importance of regular use of medications Respond to questions about general health Give information about hypertension Check blood pressure, weight

Education about effects and side-effects of medications Respond to questions about general health Give information about hypertension Check blood pressure, weight

Education about importance of attending follow-up visits to treat hypertension Respond to questions about general health Give information about hypertension Check blood pressure, weight

Education about the importance of regular use of medications Respond to questions about general health Give information about hypertension Check blood pressure, weight

Education about the importance of regular use of medications Discussion with family members about hypertension Respond to questions about general health

Repetition of the entire education protocol Respond to questions about general health Check blood pressure, weight

Education about importance of regular use of medications Education about importance of diet compliance and reduced salt intake Give information about hypertension Check blood pressure, weight

Education about effects and side-effects of medications Education about importance of regular exercise and weight control Give information about hypertension Check blood pressure, weight

Education about importance of attending follow-up visits to treat hypertension Respond to questions about general health Give information about hypertension Check blood pressure, weight

Education about the importance of regular use of medications Respond to questions about general health Give information about hypertension Check blood pressure, weight

Education about the importance of regular use of medications Discussion with family members about hypertension Education about the importance of regular exercise and weight control

Repetition of the entire education protocol Check blood pressure, weight

Posttest

Medication adherence self-efficacy scale Health promoting lifestyle behaviors scale Application of the form that contains questions of information Blood pressure and weight measurement

Check blood pressure, weight

After administration of pretest to Study Groups A and B, general information was provided about hypertension.

Pretest Collection of descriptive data Administration of medication adherence self-efficacy scale Administration of health promoting lifestyle behaviors scale Blood pressure, height, weight measurement

Figure 1 Education plan for each of the six study visit.

Clinical issues Effect of patient education and home monitoring

� 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 692–705 699

Gozum & Hacihasanoglu translated the MASES into Turkish

and conducted the study in a similar group in Erzincan

province. Differences between the Gözüm and Hacıhasanoğlu

(2009) study and Ogedegbe et al. (2003) study may result

from the inclusion of patients whose blood pressures levels

are already taken under control in Ogedegbe et al. (2003)

study. Compared with a previous study (Çakır 2003)

performed in Turkey on hypertensive patients, healthy

lifestyle behaviour level of the patients in the present study

before education was lower, a result that may be because of

the lower average blood pressure level of the patients in the

study of Çakır (2003).

Taken together, Tables 3 and 4 and Figs 3 and 4, it is of

interest that the two different educational protocols were

effective in both study groups; however, the change in Group

B is more prominent, probably attributable to the combina-

tion of the medication adherence education and healthy

lifestyle behaviours education for that group. Systolic and

Study plan

Posttest

MASES

PLPH tnemerusaemerusserpdoolB

Descriptive questionnaire

Weight measurement

130 subjects who were diagnosed with hypertension who had a history of at least one year of medical therapy, whose blood pressure was not under control (140 mmHg or over) who were literate and who voluntarily ag reed to participate were included in the study.

Variables Age, sex, education, family type, economical status, smoking, alcohol consumption status, weight and blood pressure levels

Study group n = 43 (A)

Study group n = 43 (B)

Control group n = 44 (C)

Pretest MASES HPLP BMI Blood pressure Descriptive questionnaire

Monthly education program for a 6-month period

Health care facility monitoring (monthly, 4 times) In-home monitoring (monthly, 2 times) Medication adherence education Healthy lifestyle behaviors education (According to patients demands) Blood pressure measurement Weight measurement Phone call (monthly)

Health care facility monitoring (monthly, 4 times) In-home monitoring (monthly, 2 times) Medication adherence education Healthy lifestyle behaviors education Blood pressure measurement Weight measurement Phone call (monthly)

Health care facility monitoring (monthly, 4 times) In-home monitoring (monthly, 2 times) Blood pressure measurement Weight measurement

Study group n = 120

Group A = 40 Group B = 40 Control group = 40 (10 subjects dropped out during the course of the study)

Figure 2 Study plan.

R Hacihasanoğlu and S Gözüm

700 � 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 692–705

diastolic blood pressures decreased to normal levels in both

study groups. Systolic (57Æ5%) and diastolic (65%) blood

pressures of more than half of the patients in Group A

decreased to below hypertension limits (140/90 mmHg). The

decrease in Group B was higher (67Æ5% in systolic, 75% in

diastolic) (Table 3, Figs 3 and 4), thus confirming our fourth

hypothesis. A higher decrease in blood pressure levels in

Group B may be explained by the administration of both

education programmes as opposed to just the medication

adherence protocol. Further, there was more improvement in

healthy lifestyle behaviours in the Group B than in Group A

or the control group, which supports our consideration. The

current results are in agreement with many studies showing

that educational initiatives in hypertensive patients increase

Table 4 Comparison of pre- and posttests according BP, MASES, HPLP and BMI

Before and after education Systolic X ± SD Diastolic X ± SD MASES X ± SD HPLP X ± SD BMI X ± SD

Group A

Before education 159Æ25 ± 12Æ48 95Æ75 ± 5Æ00 55Æ30 ± 7Æ57 87Æ20 ± 9Æ25 25Æ27 ± 2Æ87 After education 139Æ75 ± 11Æ31 86Æ00 ± 4Æ69 71Æ10 ± 6Æ42 97Æ80 ± 8Æ35 24Æ42 ± 2Æ81 Significance t = 19Æ953

p = 0Æ000 t = 12Æ854 p = 0Æ000

t = �15Æ688 p = 0Æ000

t = �17Æ450 p = 0Æ000

t = 12Æ302 p = 0Æ000

Group B

Before education 158Æ62 ± 12Æ85 95Æ50 ± 5Æ03 55Æ55 ± 7Æ67 86Æ62 ± 10Æ43 25Æ62 ± 2Æ87 After education 133Æ50 ± 12Æ25 83Æ50 ± 4Æ83 72Æ27 ± 5Æ27 118Æ80 ± 13Æ88 24Æ26 ± 2Æ76 Significance t = 20Æ154

p = 0Æ000 t = 17Æ423 p = 0Æ000

t = �14Æ320 p = 0Æ000

t = �14Æ099 p = 0Æ000

t = 20Æ222 p = 0Æ000

Control group

Before education 158Æ50 ± 14Æ24 94Æ75 ± 5Æ05 55Æ12 ± 8Æ53 86Æ52 ± 11Æ32 26Æ07 ± 4Æ09 After education 156Æ00 ± 11Æ55 93Æ00 ± 4Æ35 56Æ85 ± 6Æ10 87Æ65 ± 6Æ71 26Æ04 ± 4Æ21 Significance t = 1Æ803

p = 0Æ079 t = 1Æ934 p = 0Æ060

t = �1Æ487 p = 0Æ145

t = �1Æ027 p = 0Æ311

t = 0Æ274 p = 0Æ786

MASES, medication adherence self-efficacy scale; HPLP, health-promoting lifestyle profile.

Table 5 Comparison of medication usage status before and after training

Drug use status

Group A Group B Control group

Before

education S (%)*

After

education S (%)*

Before

education S (%)*

After

education S (%)*

Before

education S (%)*

After

education S (%)*

Regularly use 10 (25Æ0) 32 (80Æ0) 9 (22Æ5) 34 (85Æ0) 11 (27Æ5) 17 (42Æ5) No regularly use 30 (75Æ0) 8 (20Æ0) 31 (77Æ5) 6 (15Æ0) 29 (72Æ5) 23 (57Æ5) Significance** p = 0Æ000 p = 0Æ000 p = 0Æ238

*Per cent of column.

**Test of McNemar.

100

150

200

Systolic Diastolic MASES HPLP BMI

Group A Group B Control

Figure 3 Posttest comparison between groups’ for BP, MASES,

HPLP and BMI index.

100

120

140

160

180

0 1 2 3 4 5 6 Months

B lo

o d p

re ss

u re

le ve

Systol Group A

SystolGroup B

Systol Group C

Diastol Group A

Diastol Group B

Diastol Group C

Figure 4 Blood pressure distribution of groups analysed by month.

Clinical issues Effect of patient education and home monitoring

� 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 692–705 701

medication adherence and healthy lifestyle behaviours and

decrease blood pressure levels (Bosworth et al. 2005, Clark

et al. 2000, Rudd et al. 2004, Çakır 2003, Garcia-Pena et al.

2001, Svetkey et al. 2005). Similarly, Canzanello et al.

(2005) reported significant decreases in blood pressures of

hypertensive individuals following an education programme

taught by physicians and nurses promoting medication

adherence and health lifestyle behaviours. In a study by

Stergio et al. (2003), control was achieved in SBP of 51% and

diastolic blood pressure of 84% of hypertensive patients

through implementation of individual treatment strategies by

general practitioners for improving medication adherence

during a six-month monitoring period. The present study

showed that a six-month education programme taught by the

investigator, who is a nurse, along with in-home monitoring

had a significant impact on blood pressure control. This

finding supports the literature and verifies our second

hypothesis.

The greatest improvement in healthy lifestyle behaviours

occurred in study Group B (Tables 3 and 4, Fig. 3). Of note,

however, during educational interviews, hypertensive pa-

tients in Group A who had only medication adherence

education asked questions about the role of nutrition and

exercise on hypertension. These questions were usually

about salt intake limitations, questions about nutrition and

weight control. Information given to hypertensive patients

in Group A about healthy lifestyle behaviours was limited to

the extent of their questions. However, the average HPLP

post-test score of this group (Group A) was higher than pre-

test for this same group and higher than as those of the

control group.

Although medication adherence average score increased

most in Group B, no significant difference was found between

Group A and B and further, the medication adherence

average scores of Groups A and B were significantly higher

than that of the control group (Tables 3 and 4, Fig. 3). These

results confirm our first and third hypothesis and emphasise

the importance of patient education in the treatment and care

of hypertensive patients. Even if long-term education is not

possible, the act of answering relevant questions alone in

hypertensive patients could potentially help in blood pressure

control (Table 3 and 4).

Following education, we found a statistically significant

decrease in the BMI averages of patients in both study groups

and no BMI decrease in the control group (Tables 3 and 4).

Many studies in the literature (Çakır 2003, Grandi et al.

2006, Drevenhorn et al. 2007) have shown that hypertensive

patients lose weight after education, monitoring and coun-

selling. A meta-analyses by Neter et al. (2003) have clearly

demonstrated decreases in weight, which also resulted in

decreased blood pressure in hypertensive patients after

educational interventions including suggestions for decreased

caloric intake, increased physical activity and a combination

of both.

In the present study, the gradual decrease in blood

pressure in the two study groups was associated with the

education provided on medication adherence and the

resultant higher compliance rates for regular medication

use (Table 3, Fig. 4). In the medication adherence educa-

tion, we emphasised the importance of regular use including

the importance of trying not to miss even one dose and

continuation of medication even after a slight and antici-

pated side effects; patients were referred to a specialist

whenever a serious or potentially side effect was noted. At

study completion, the regular medication adherence was

significantly improved in Groups A and B (regular medica-

tion use ratios were 25% and 22Æ5% before education,

respectively, and increased to 80% and 85% after educa-

tion) (Table 5). The self-efficacy perception of patients in

this study was responsive to the education; in fact, MASES

scored improved such that scores were near maximal at

post-test in Groups A and B (Table 4). Similar to the current

results, Çakır (2003) found that regular medication use

increased from 73Æ3–100% after education. Lee et al. (2006)

reported in their experimental study with controls that

six months after the educational intervention, the medica-

tion adherence ratio that included knowledge of medication

name, side effects, usage types and indications increased

from 62Æ1–96Æ9%.

Overall, the present study, as well as those previously

published, have shown that education positively impacts

hypertension, knowledge of side effects, regular medication

use and medication adherence. Education administered by

nurses about hypertension and life-long antihypertensive

medication therapy will inevitably provide increased

success in blood pressure control. Health professionals,

even if they do not have the opportunity to give a long-term

education, must be aware of the fact that responding to

questions of hypertensive patients is influential in incre-

menting compliance to medication and enabling them to

choose a healthy life style. Individual patient education has

positive effects on hypertension; however, we advise for

future studies that group education may be more appropri-

ate in some settings because it saves time and is more cost-

effective.

In this study, standardisation of physical measurement

tools was not compared by an accredited institution. Use of

other robust tools for end might be considered as an

important limitation for this study. Therefore, further

research is required to establish this.

R Hacihasanoğlu and S Gözüm

702 � 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 692–705

Conclusion

Educational interventions in hypertensive patients are effi-

cacious in hypertension management and can make a major

contribution to improvement in the patients’ healthy

lifestyle behaviours, medication adherence, blood pressure

and BMI. Considering the results of the present study,

nurses working in primary health care facilities may

confidently use both educational and counselling services

to improve patient adherence and to lower blood pressure.

Nurses play a significant role in patient compliance and

blood pressure control in Turkey where hypertension is

important problem. It is important that primary health care

nurses be educated in proper methodologies for teaching

patients about hypertension, medication adherence and

healthy lifestyle behaviours.

Finally, it must be acknowledged that some patients with

hypertension will always be inclined to non-adherence

medication and unhealthy lifestyle behaviours. Therefore,

future efforts should be made to encourage nurses to educate

their hypertensive patients. This study results may have

implications for both Turk and other nurses who have given

care to hypertensive patients because non-adherence medica-

tion is important problem in other countries. So, the results of

this study may have implications for nurses working in other

countries too.

Relevance to clinical practice

Patient education medication adherence alone and in combi-

nation and healthy lifestyle behaviour teaching is an effective

tool for blood pressure reduction in the hypertensive popu-

lation in primary health care settings.

Acknowledgements

This study was performed as part of a doctoral thesis under

the supervision of the second author. We thank all study

subjects for their willing participation. This study was

presented as an oral presentation in the XIIth National

Public Health Congress, Turkey (21st–25th October, 2008)

and received the award for third best presentation.

Contributions

Study design: SG, RH; data collection and analysis: RH, SG

and manuscript preparation: RH, SG.

Conflict of interest

The authors declare that they have no conflict of interest.

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