Nursing

Author, year; Credentials Article #1

Aghakhani, N. (PhD), Parizad, N. (PhD), Soltani, B. (MSN), Khademvatan, K. (MD), & Rahimi, Z. (MSN) (2019)

Article Focus/Title

The effect of the blended education program on treatment concordance of patients with hypertension: A single-blinded randomized, control trial

Research Design/Intervention

Randomized control trial, single-blind. The intervention was education that was blended in style between face-to-face education and online education.

Level of Evidence

Level I (Dearholt et al., 2012)

Sample/# of subjects

Patients age 20-65, hypertension diagnosis, blood pressure greater than 140/90 but less than 180/110, agree to participate in the study, able to read and write, able to receive emails and texts, no severe underlying disease (ex. Kidney disease or heart problems) that could impact the study. Total number of participants - 60

Evaluation Tool

CASP for randomized control trial Score 11/11

Data Collection procedure

Questionnaires/tests were administered and scored; control and intervention group received respective education; two weeks after education programs were finished, the same questionnaire/test was administered and scored

Type of Instrument

Questionnaire/test that included demographic information and questions addressing treatment in three dimensions; dietary adherence, compliance to medication regimen, and physical activity plan, the questionnaire had thirty four, twelve, and fourteen items per category respectively.

Reliability and Validity

The questionnaires were used in another study that confirmed validity and reliability. The face and content validity was inspected and in this other study Cronbach’s alpha was used along with intraclass correlation coefficient to confirm reliability. Standard data collection was performed. Approved by IRB and informed consent was obtained prior to the beginning of the study. Adequate statistical data is presented and appropriate statistical methods were used.

Data Analysis

Data was analyzed by a researcher who was blind to the data. Descriptive statistics including mean and standard deviation were utilized and inferential statistics including t-tests (independent and paired), Chi-squared test, and Fischer exact tests were utilized. P-values were two tailed, and the significance level was less than 0.05.

Results/Themes

There was a statistical difference in the results of the post-test between the control and the intervention groups for dietary adherence ( P=<.001), medication adherence ( P=<.001), and physical activity ( P=.04). Medication adherence scores increased the most in the intervention group from pre-test to post-test.

Themes: blended educational program; improving medication adherence

Discussion/

Significance/

Limitations

Is an additional study that strengthens the evidence on the use of blended education programs. The use of blended education programs could promote better treatment/recommendation adherence in patients by increasing the effectiveness and desirability of the educational experience.

Limitations: The sample was a convenience sample from one geographical area. The intervention period was relatively short.

Helpful/Reliable/Compared to other art

Helpful, reliable, results were statistically significant. Clear statement of findings.

Compared to other articles: Consistent findings in regard to education programs and increased medication adherence. Similar to Ozoemena et al. where multiple types of education were present (2019).

Author, year; Credentials, Article #2

Delavar, F., Pashaeypoor, S., & Negarandeh, R. (2020). Published in the Journal of Patient Education and Counseling. All authors were associated with Tehran University of Medical Sciences.

Article Focus/Title

The effects of self-management education tailored to health literacy on medication adherence and blood pressure control among elderly people with primary hypertension: A randomized controlled trial

Research Design/Intervention

Randomized control trial. The intervention was education based on the participants health literacy for two weeks in the form of two, thirty to forty-five minute face-to-face sessions. After the two weeks of face-to-face education, there were two weeks of fifteen minute educational sessions held via telephone call, two each week. Educational topics included hypertension, risk factors, complications, medications, side effects, management of side effects, importance of medication adherence, and doctors appointments.

Level of Evidence

Level I (Dearholt et al., 2012)

Sample/# of subjects

Elderly patients who had uncontrolled hypertension and inadequate health literacy who had been referred to the cardiovascular clinic at Fayyazbakhsh hospital in Iran. Inclusion criteria: over the age of sixty, diagnosed uncontrolled hypertension (BP over 140/90 or more), prescription for antihypertensives, can speak Persian, does not have cognitive or psychiatric disorders, not addicted to drugs, and inadequate health literacy defined by the Health Literacy for Iranian Adults (HELIA) scale (score of less than sixty six percent). Exclusion criteria: unwilling to stay in the study, development of serious health conditions that led to hospitalization or death, failure to attend one of the face to face sessions of the intervention, or failure to answer two or more of the telephone calls. Intervention group n=54, control group n=58, total sample size N=112

Evaluation Tool

CASP for randomized control trial Score 10/11

Data Collection procedure

Data was collected/measured by demographic questionnaire, eight-item Morisky Medication Adherence Scale (MMAS), and blood pressure measurement at the beginning of the study; the control and intervention groups received their respective education; then the same tools were used to collect/measure data six weeks after the intervention was completed.

Type of Instrument

Questionnaire: ten questions related to the demographic information of the participants

Eight-item MMAS: has seven yes/no style questions and one Likert scale question that is scored the same as a yes/no question. The scores can vary between zero and eight (eight indicating good medication adherence)

Blood pressure measurements: instrument used was a mercury sphygmomanometer

Reliability and Validity

The eight-item MMAS was translated to Persian and was reported to be validated by two other studies. The reliability of the eight-item MMAS was shown by an intraclass correlation coefficient (ICC) of 0.71.

The blood pressures were collected using standardized procedures. The measurement device’s validity was confirmed based on measurement precision and authenticity of manufacturer. Reliability was confirmed through repeated measurements on twenty patients, the ICC of the systolic and diastolic blood pressures were 0.81 and 0.60 respectively.

Standardized data collection procedures were used. Ethical considerations were made. Approved by the Ethics Committee of Tehran University of Medical Sciences. Written, informed consent was obtained from participants.

Data Analysis

SPSS was used to analyze data. Fischer’s exact tests and Chi-squared tests were used to assess between group comparisons for categorical variable. Independent t-tests and Mann-Whitney U tests were used to assess between group comparisons for numerical variables. Paired t-tests were used to assess within group differences. An analysis of covariance (ANCOVA) was performed. The significance level was less than 0.05.

Results/Themes

The systolic and diastolic blood pressures of the intervention group were significantly lower in the post-test ( p=<0.001 for both pressures). The medication adherence scores of the intervention group was significantly better than the scores of the control group in the post-test ( p=0.002). The rates of controlled/uncontrolled blood pressures after the intervention in the between group analysis was nonsignificant ( p=>0.05).

Themes: Patient education based on health literacy; improving medication adherence; uncontrolled hypertension; elderly population

Discussion/

Significance/

Limitations

Shows improvement in medication adherence after an educational program about hypertension/medications compared to basic education given when prescription is given. Identifies the benefit of using education tailored to the health literacy level of the patient.

Limitations: Limited validity because author credentials are not expressed in the article, only the Universities they are affiliated with. Risk of type II error because fifty nine participants were needed per group and that was not achieved. Researchers discuss limitations related to short intervention time and possibility of unrealistic responses from participants about adherence.

Helpful/Reliable/Compared to other art

Helpful but cautious, small sample size and no credentials of the authors contributes to lack of validity, clear statement of findings.

Compared to other articles: Consistent with Aghakhani et al. (2019); both establish that education beyond what is traditionally provided with the start of a prescription improved medication adherence.

Author, year; Credentials, Article #3

Farazian, F. (MSN), Moghadam, Z. E. (Assistant Professor), Nabavi, F. H. (Assoictate Professor), & Vashani, H. B. (Instructor) (2019). Published in the Journal of Evidence-Based Care. All are faculty at Mashhad University of Medical Sciences

Article Focus/Title

Effect of self-care education designed based on bandura’s self-efficacy model on patients with hypertension: A randomized clinical trial.

Research Design/Intervention

Randomized control trial. The intervention was one forty-five minute educational session each week for four weeks. The sessions were designed based on Bandura’s social learning theory and the content was based on Bandura’s self-efficacy theory

Level of Evidence

Level I (Dearholt et al., 2012)

Sample/# of subjects

Sample was collected using a two-stage random sampling technique. Population was the residents of Mashhad, Iran who had hypertension. Inclusion criteria: age of 40-70, living with family, resident of Mashhad, had been diagnosed with hypertension for more than one year, diagnosis confirmed by a cardiologist, active medical file at the health center, no cognitive impairment, no participation in self-care programs within the last six months. Exclusion criteria: participation in another educational program, missing more than one session, failure to participate in the post-test. Sample size n=60.

Evaluation Tool

CASP for randomized control trial Score 10/11

Data Collection procedure

All participants completed the demographic form and the questionnaire before the intervention started. Then the intervention group received their education and the control group received routine education. The questionnaire was administered again immediately after the intervention was complete and then again one month later.

Type of Instrument

Questionnaire with twenty nine questions addressing self-care for patients with high blood pressure. Topics that were a part of the questionnaire include; medication adherence, adherence to a low-salt diet, physical activity, smoking, alcohol and weight management.

Reliability and Validity

Research approved by the research ethics committee at the Mashhad University of Medical Sciences, Consent obtained, Standard data collection methods. Potential bias is evident – the researcher was the educator and also exchanged phone numbers with participants to provide additional encouragement or counseling if needed. Validity was tested by assessment of the questionnaire by ten experts according to word choice, grammar, and readability, potential for bias because all ten experts were also faculty of the same University that the researchers were affiliated with. Reliability was confirmed by measuring internal consistency, the Cronbach’s alpha was measured ( a=0.84).

Data Analysis

Data was analyzed using SSPS (version 16). CI of 95%, significance level was less than 0.05. A repeated measures ANOVA was used to test the hypotheses, Kolmogorov-Smirnov test was used to confirm the normal distribution of the quantitative data, and Shapiro-Wilk test was used to confirm the normal distribution of the qualitative data.

Results/Themes

Significant positive effect overall on self-care and self-management of hypertension. Statistically significant results in categories for medication adherence, physical activity, and weight management. Statistically non-significant results in categories for low salt diet and non-smoking. Repeated measures ANOVA was used and in regard to medication adherence showed that the effect of the group ( p=0.006) and time ( p=0.04) were both significant and their mutual effect was significant ( p=0.01). Th

Themes: self-care in patients with hypertension, educational interventions

Discussion/

Significance/

Limitations

Highlighted the use of an educational program to improve self-care in patients with hypertension. Shows that educational programs are superior to routine education that is provided at practices. Shows medication adherence and some of the other aspects of self-care are still improved one month after the intervention is finished.

Limitations: Lack of knowledge about patient’s baseline knowledge about hypertension management and the degree to which they could be influenced by other sources of information. Short time frame for follow up. Potential for bias is evident in the intervention itself and in the assessment of the validity of the questionnaire.

Helpful/Reliable/Compared to other art

Helpful but cautious, the potential bias negatively impacts the validity and the reliability of the study. Clear statement of findings. Importance of the topic was established. Rigorous data analysis.

Compared to other articles: Consistent findings in regard to education programs and increased medication adherence.

Author, year; Credentials, Article #4

Ozoemena, E. L., Iweama, C. N., Agbaje, O. S., Umoke, P. C. I., Ene, O. C., Ofili, P. C., Agu, B. N., Orisa, C. U., Agu, M., & Anthony, E. (2019), Published in the Archives of Public Health

All authors are associated with the Department of Human Kinetics and Health Education and are faculty at the University of Nigeria except B. Agu and C. Orisa. Agu is associated with the Department of Public Health and is faculty in health sciences at Madonna University Elele. Orisa is associated with the Department of Human Kinetics, Health, and Safety Education and Ignatius Ajuru University of Education.

Article Focus/Title

Effects of a health education intervention on hypertension-related knowledge, prevention and self-care practices in Nigerian retirees: A quasi-experimental study.

Research Design/Intervention

Quasi-experimental study. Intervention was a twelve-week health education course about hypertension and was based on the information-motivation-behavioral skills model. There were twelve sessions each one lasting around sixty minutes.

Level of Evidence

Level II (Dearholt et al., 2012)

Sample/# of subjects

Two-stage sampling procedure. Purposeful selection of three specific zones to enhance representativeness, then convenience sampling to acquire the 400 participants. Participants were randomly assigned to the control or intervention groups. Inclusion criteria: over or equal to the age of sixty, classified as a retiree, gave informed consent, located in the geographical zone selected. Exclusion criteria: those who were ill prior to the study, those who declined participation. Total participants = 400, each group containing 200 participants.

Evaluation Tool

JBI checklist for quasi-experimental studies score 8/9

Data Collection procedure

Pre-test post-test was used. Demographic information was collected at baseline as well. The intervention lasted twelve weeks and there was a post-test at the sixteen week mark and a follow-up one month after that. The tests were administered/facilitated by health education experts and nurses but were supervised by the principal researchers. Height and weight were taken to calculate BMI and blood pressure was taken from each participant. It is not stated exactly when these measures were taken,

Type of Instrument

Questionnaire. Included questions about demographics, hypertension knowledge, practices on prevention and self-care related to hypertension, physical activity (IPAQ-SF), the quality and pattern of sleep (PSQI), substance (smoking and alcohol) use, maintaining a healthy diet, medication adherence (MMAS-4), and home blood pressure monitoring. Face validity, content validity, and construct validity were all confirmed. Kuder-Richardson-20 coefficient was used to confirm reliability (0.72).

Reliability and Validity

Written script was used to ensure standardization of material provided to participants. Standardized data collection procedures were used. No apparent bias. Approved by the Ethical Committee on Research Projects at Enugu State Ministry of Health. Informed consent obtained. Repeated measures were performed. Appropriate statistical methods were used.

Data Analysis

Data analysis was done using SPSS (version 20). Demographic data was analyzed using independent sample t-tests and Chi-squared test for continuous and categorical variables respectively. One-way repeated measures ANOVA was used to analyze the effect of the intervention on hypertension knowledge, self-care, and prevention. Statistical significance is p<0.05. Data is presented in the text as well as in tables in the article. Some P values are presented at 0.000 in the text but are clarified in the tables as 0.0001.

Results/Themes

All participants showed improved hypertension knowledge from the pre-test to post-test. The intervention group had significant ( p<0.0001) improvement from the control group. There was significant improvement between pre- and post-tests in the intervention group in the factors of self-care and prevention compared to the control group. For medication adherence p=<0.0001.

Themes: Education program to improve hypertension knowledge, Self-care, Follow-up testing, Educating older adults

Discussion/

Significance/

Limitations

Highlighted that adequate knowledge about hypertension can help improve medication adherence and lifestyle changes. Provides an example of an effective education program that utilizes educational booklets, videos, charts, and discussion.

Limitations: Credentials of authors are not stated, only their associations/Universities. There was baseline differences in the gender and BMI categories that were statistically significant. Self-report measures were used with participants which introduce risk for bias. Potential for poor generalizability because the population was only retirees from Enugu state.

Helpful/Reliable/Compared to other art

Helpful, reliable, valid. Clear statement of findings. Importance to topic established in thorough literature review.

Compared to other articles: Consistent findings in regard to education programs and increased medication adherence.

Author, year; Credentials, Article #5

Yazdanpanah, Y. (MSC of Geriatric Nursing), Saleh Moghadam, A. R.(Assistant Professor), Mazlom, S. R. (Instructor), Ali Beigloo, R. H.( MSC of Medical Surgical Nursing), & Mohajer, S. (PhD) (2019), Published in Journal of Evidence-Based Care

Article Focus/Title

Effect of an educational program based on health belief model on medication adherence in elderly patients with hypertension.

Research Design/Intervention

Randomized control trial. The intervention was eight educational sessions about hypertension based on the Health Belief Model (HBM). Sessions were held twice a week for four weeks and lasted about an hour in length.

Level of Evidence

Level I (Dearholt et al., 2012)

Sample/# of subjects

Population was elderly patients with hypertension at health centers in the western region of Mashhad, Iran. Inclusion criteria: aged sixty years or older, able to read and write, history of office visit in the past six months, history of hypertension (self-report and health record), history of use of hypertension medication daily for at least six months, and no psychological or cognitive disorders. Exclusion criteria: declined participation, failure to attend in two or more sessions, and suffering from acute illness or hospitalization. It is not stated what method is used for collecting the sample. The separating into intervention and control groups was randomized but it is not clear as to if there was any blinding involved. Total number of participants was sixty, with thirty in each group (intervention and control).

Evaluation Tool

CASP for randomized control trial Score 10/11

Data Collection procedure

Pre-test post-test method was used. The pre-test was administered prior to the intervention, then the intervention group received their education sessions on hypertension and the control group received sessions typical to the centers the sessions were provided at. The post-test was administered after the last session.

Type of Instrument

Questionnaire including demographic information and the MMAS-8. Content validity was confirmed. Reliability was confirmed with internal consistency using Cronbach’s coefficient alpha (0.69). Reliability was also confirmed by test-retest method. The Pearson correlation coefficient was r=0.86.

Reliability and Validity

Sessions were administered by one of the researchers while the rest of the researchers supervised. Data collection was standardized. Approved by the Ethics Committee of Mashhad University of Medical Sciences. Informed consent was obtained. Ethical considerations were assessed, and the control group was provided with all of the information the intervention group received after the study was complete.

Data Analysis

Data was analyzed using SPSS (version 20). Mann-Whitney U test was used to check for significant difference between the control and intervention group ( p=0.12). Chi-squared test and Fischer’s exact test showed no significant differences between the demographics of the two groups T-tests were utilized to assess the between-group and within-group differences. A two way ANOVA was also used but additional testing to find the specific difference was not mentioned.

Results/Themes

Overall, the education program is associated with improved the medication adherence of the intervention group. The results of the independent t-test showed that the difference between the post-test scores of the intervention and control groups were statistically significant ( p=<0.001). The results of the paired t-test showed that the change in mean medication adherence score of the intervention group from pre-test to post-test had significance ( p=<0.001). There was not a significant difference in the same measurement for the control group ( p=0.56). A two-way ANOVA was done and showed that there was significantly improved medication adherence according to demographic information for both groups. There was no additional explanation of follow-up testing in the article.

Themes: Education program for elderly patients with hypertension, improving medication adherence, Health-belief model

Discussion/

Significance/

Limitations

It was estimated that implementing this educational program could increase medication adherence by about fifty nine percent. This research provides additional strength to the evidence that education designed based on the HBM can help improve medication adherence.

Limitation: The method of sample collection is not clear and blinding about group assignment is not expressed. Self-report method can present the possibility for bias from participants. The sample was elderly so mental or psychological conditions that older adults experience may have had an effect on their answers.

Helpful/Reliable/Compared to other art

Helpful but cautious, the Cronbach’s coefficient alpha is 0.69 which is moderately low this indicates a lower reliability of the questionnaire and the ANOVA did not have a post hoc analysis. There was a clear statement of findings. The importance of the topic was established by a thorough literature review.

Compared to other articles: Consistent findings in regard to education programs and increased medication adherence. Similar to Farazian et al. in the way the education program is created based on a model (Bandura’s self-efficacy model and the HBM) (2019).