Abstract
Aims
Hypertension is one of the most serious public health problems, with prevalence increasing with age. Patient education can play a major role in the treatment and management of blood pressure. Therefore, the present study aimed to compare the effect of group training and telenursing on medication and dietary adherence and blood pressure control among elderly with hypertension.
Methods and results
The present clinical trial study was conducted on 90 older adults with hypertension in Abdanan, Ilam province, in 2023.Participants were selected based on the inclusion and exclusion criteria and randomly assigned to three groups: group training, telenursing, and control. The data collection tools included a demographic form and the Hill-Bone Adherence to High Blood Pressure Therapy Scale. The data were analyzed in SPSS software (version 25) using relevant statistical tests. A p-value less than 0.05 was considered statistically significant. The mean age of research participants was 65.18 ± 3.97 years. Systolic and diastolic blood pressure in group training and telenursing groups displayed a significant decrease in the second and third stages of the research (P < 0.05). Moreover, medication and dietary adherence in the intervention groups was statistically significant in the second and third stages (P < 0.05).
Conclusion
As evidenced by the results of this study, group training and telenursing led to a marked improvement in medication and dietary adherence, as well as blood pressure control, in patients. Therefore, it is recommended to distance yourself from routine training techniques and follow newer and more flexible methods, such as telenursing and group training.
Trial registration
The article has been approved in Iranian Registry of Clinical Trials at 20,220,716. IRCT20220130053886N1.
Keywords: Geriatric nursing, Group training, Telenursing, Medication adherence, Older adults, Hypertension
Introduction
Hypertension is one of the most common cardiovascular diseases across the globe [1]. If left untreated, this disease puts patients at risk of severe complications, such as heart failure, heart infarction, aortic aneurysm, peripheral vascular diseases, strokes, and kidney failure [2]. As evidenced by numerous studies, the prevalence of hypertension increases with age [3]. Currently, 76.4 million adults in the United States suffer from hypertension. This, combined with the association between this disease and aging physiology, has turned hypertension into one of the major current public health concerns [4]. A study has demonstrated that hypertension, despite its chronic nature, is preventable and can be controlled by modifying lifestyle, following a diet, and improving self-care behaviors. Researchers have proven the positive effect of drug therapy along with the use of such methods as weight loss, following a low sodium diet, refraining from smoking, and regular physical activity on hypertension control [5].
Medication non-adherence is recognized as the most important behavioral risk factor in hypertension management among older adults [6]. It is usually caused by the absence of any warning signs or symptoms, reduced cognitive abilities, lack of belief in drug therapy, psycho-social status, or high costs of health care [7]. According to the World Health Organization, medication and dietary adherence, as well as lifestyle modification, are the recommendations agreed upon by health service providers [8].
Non-adherence to treatment negatively affects medication effectiveness and treatment outcomes. Moreover, it increases hospital readmission and mortality rates, reduces patients’ quality of life, and imposes high economic costs on families and societies [5, 9]. Sodium plays an undeniable role in controlling cardiovascular diseases, and diet is one of the most effective non-pharmacological strategies with proven beneficial effects on cardiovascular function. Awareness-raising alone is far from enough to reduce sodium consumption; therefore, effective interaction between nurses and older adults will make a substantial contribution to improving their eating habits [10].
Nurses can play a key role in the facilitation of treatment adherence in hypertensive seniors through their involvement in patient education [11]. One of the training methods in nursing is group training, which can profoundly affect older adults [12, 13]. Apart from its cost-effectiveness, the mentioned method causes active learning, providing an excellent opportunity to share ideas and receive support and encouragement among people with common problems and experiences [14, 15]. Given that patients with chronic diseases, in addition to education, need regular and constant follow-up, telenursing (remote nursing or distance education) is also proposed as a suitable program in this regard [16, 17].
Telenursing is particularly effective for hypertensive seniors who encounter numerous problems visiting clinics, offices, and hospitals [1]. Considering that patient education in our country does not exceed short and concise programs during hospitalization and at the time of discharge, telenursing can be proposed as a new approach to providing healthcare and treatment [18]. Studies have referred to various effects of these two healthcare methods. For instance, Rezaei et al. [19], in a clinical trial that aimed to assess the impact of telenursing and face-to-face training techniques on the quality of life in burn patients, concluded that there was no significant difference between these two methods. In their study entitled “Effect of telenursing on the aging perception of Iranian older adults,” Sadegh Moghadam et al. [20] compared the two methods of in-person and telephone follow-up (i.e., telenursing) and reported that the telenursing method was more effective [21].
The rising trend in the elderly population, the marked increase in the prevalence of hypertension in this group, and the low level of treatment adherence highlight the necessity of taking practical measures for hypertension control in this population. As previously noted, different approaches are available in this regard; nonetheless, according to the abovementioned issues, group training and telenursing are effective methods associated with contradictory results in conducted studies. In light of the aforementioned issues, the present study aimed to assess and compare the effect of group training and telenursing on medication and dietary adherence, as well as blood pressure control, among elderly with hypertension clients in Ilam province.
Materials and methods
Study design and participants
This clinical trial study on 90 elderly people aged 60 to 74 with high blood pressure in Abdanan city, Ilam province, started on 2022/08/25 and ended after 3 months with data collection and follow-up. In this study, after the ethical approval by Ilam University of Medical Sciences and obtaining the introduction letter, written informed consent was obtained from participants. They were assured of the confidentiality of their information and their right to withdraw from the research at any time without penalty. Research subjects were selected based on the inclusion and exclusion criteria. Thereafter, they were assigned to three groups of group education, telenursing, and control (30 older adults with hypertension in each group) using permuted block randomization with a block size of 6 (using the table of random permutations, Stata software, and the alloc package).
Inclusion criteria
Age between 60 and 74 years, Willingness to participate in the study, a minimum of six months since the diagnosis of hypertension, no significant speech, hearing, or vision impairments, Ability to read and write, Ability to understand conversations in either Farsi or Kurdish, Access to a personal telephone for direct communication, Completion of the informed consent form, Absence of debilitating physical or psychological conditions such as stroke, Parkinson’s disease, paralysis, epilepsy, or major depression.
Exclusion criteria
Missing more than one face-to-face or telephone training session, Hospitalization or death during the study period, Voluntary withdrawal from the study.
Missing more than one scheduled intervention session, hospitalization or death during the study period, withdrawal of consent at any time, or voluntary withdrawal from the study for any reason.
Intervention
Before the commencement of training, in stage one, basic information was collected from all groups. In this study, participants’ blood pressure was checked according to measurement principles. Demographic characteristic form and Hill-Bone Adherence to High Blood Pressure Therapy Scale were administered to participants, who were instructed on how to complete them. It is noteworthy that the researcher was present to avoid any difficulty and motivate participants through answering the questions. If they had trouble answering, the researcher asked their opinions and completed the questionnaire. Upon the completion of questionnaires, in order to inform the participants about the road map and the classification of educational content that was supposed to be presented within six weeks, it was briefly provided to two groups of telenursing and group training.
Following that, subjects in both groups received the six-week educational intervention, in which they were provided with adequate explanations about hypertension and its management, healthy diet, weight control, smoking cessation methods, the importance of adherence to a drug regimen, stress and anxiety management, physical activity, monthly follow-up care, and regular visit to a specialist. In addition, every week, participants in all three groups were invited to get their blood pressure measured and recorded. In this study, participants in group training attended 45-60-minute weekly training sessions for six weeks in one of the centers of Abdanan, which was more accessible to all areas of the city. The subjects in this group were allocated to five groups (n = 6) and then received training. The time of the sessions each week was set by participants. At the beginning of each session, questions were asked regarding the evaluation of older adults’ adherence to the training provided in the previous session. The topic was presented in each group training session, and necessary training was provided through oral presentation or a PowerPoint file. Following that, participants were asked about their personal experiences with the training topic in that session and encouraged to participate actively in the discussion. After discussion and exchange of opinions, a summary of the training session was presented. It is worth noting that these sessions were held in a quiet and convenient place with circular seating arrangements to increase interactions.
Two 10-20-minute calls were considered every week for the telenursing group for six weeks. It should be noted that the first session of the telenursing group was held in person in groups of 6–8 cases, and the schedule was then coordinated with each person. At the beginning of each call, some questions were asked to assess older adults’ adherence to the training provided in previous sessions. Thereafter, the goals of making that call were briefly explained, and at the end of the training, participants’ questions were answered. The subject headings were the same as those of the training group. Although the control group did not receive any training, they visited the center every week to monitor their blood pressure. Moreover, upon the completion of the research, educational content was provided to them.
In order to enhance internal validity and ensure the fidelity of the interventions, structured adherence control mechanisms were employed throughout the study. For both intervention groups—group training and telenursing—adherence was systematically monitored using standardized tracking protocols. In the group training arm, attendance was recorded for each session using a designated checklist. At the beginning of every session, participants were asked targeted questions to assess their implementation of the previous session’s recommendations. Active participation was encouraged through discussions and peer sharing, and engagement was documented by the facilitator. In the telenursing arm, a structured telephone follow-up protocol was applied. Two scheduled calls per week were conducted for each participant, and the duration, content coverage, and level of responsiveness were logged. At the start of each call, questions were asked to evaluate the participant’s adherence to the previous week’s guidance. Any reported challenges were noted, and tailored support was provided accordingly.
In the control group, although no educational intervention was administered, participants were invited to the health center weekly for blood pressure monitoring. Their attendance and BP readings were recorded to ensure continued engagement with the study. Notably, no sample attrition occurred during the study. All 90 participants completed the three assessment points. The consistent follow-up procedures and continuous researcher engagement played a crucial role in preventing dropout.
During the six weeks of training, the blood pressure of all participants in the study was measured once a week. One week after the six-week educational intervention, participants in all three groups were invited for questionnaire completion and blood pressure reading (stage 2). One month after the completion of training (stage 3), blood pressure was checked for the last time, and the questionnaires were re-administered to participants in order to collect the final information.
Sample size
A study by Kazem et al. [22] was used to calculate the sample size. In this research, after telenursing training, the mean scores of diastolic blood pressure after three months were 75.4 ± 8.9 and 87.5 ± 7.4 in the intervention and control groups, respectively. Considering α = 0.2 and β = 0.2 and based on the following formula, the sample size in each group was estimated at 28 cases. Nonetheless, the final sample size was regarded as 30 subjects in each group, considering sample attrition or missing data.
 |
Data collection tools
The tools used in this research included a mercury sphygmomanometer, as well as two questionnaires of demographic information (including age, gender, height, weight, education level, marital status, history of smoking, history of underlying diseases and drug use, source of information, status employment, type of insurance, history of hospitalization, sleep and rest status) and Hill-Bone Compliance to High Blood Pressure Therapy Scale [23]. This questionnaire assesses adherence to hypertension therapy in three behavioral domains: appointment keeping (two items), diet (three items), and medication adherence (eight items).
The items are rated on a 4-point Likert scale from always [1] to never [4]. The possible range for the total score of the instrument is 12–48, with lower scores indicating greater adherence [24]. The validity and reliability of this questionnaire were obtained in a study by Taher et al. [23]. The validity of the questionnaire was verified by the content validity method, and the reliability of the questionnaire was also confirmed, rendering a Cronbach’s alpha coefficient of 0.8. Prior to utilization, the mercury sphygmomanometer was checked several times for accuracy and correctness of operation. It was calibrated by a medical engineering expert once a week throughout the intervention, according to the manufacturer’s instructions.
Data analysis
The collected data were analyzed using SPSS software (version 25) with descriptive statistics (including mean, standard deviation, frequency, and percentage) and analytical statistics at a significance level of 0.05. Normality of data was assessed with the Kolmogorov-Smirnov test. This manuscript follows CONSORT guidelines. To compare the findings across stage one (baseline or before training), stage two (one week after the educational intervention), and stage three (one month after the educational intervention), where the data were quantitative, repeated measures ANOVA was used. For qualitative data, the chi-square test and Fisher’s exact test were employed. Additionally, the Least Significant Difference (LSD) test was used for pairwise comparisons.
Ethics approval and consent to participate
All participants completed and signed the informed consent form to participate in the research. They were assured that their information would remain strictly confidential. Also, this study has received the code of ethics (IR.MEDILAM.REC.1400.245) from the Ethics Committee of Ilam University of Medical Sciences. To monitor the participants’ health and prevent hypertensive crises, blood pressure was measured weekly for all participants. If there was a hypertensive crisis, necessary therapeutic interventions were performed. Although the control group did not receive educational interventions, they were monitored by visiting the health center every week for blood pressure assessment. This ensured early identification of any hypertensive crises or complications. In addition, after the study was completed, the control group participants were also provided with the same educational materials as a benefit for their participation. These measures were taken to maintain ethical standards and protect the well-being of all participants.
Results
In the current study, as illustrated in Tables 1 and 46.7%, 50%, and 53.3% of participants in the control, telenursing, and group training groups were female, respectively. The three investigated groups did not statistically differ in age, body mass index (BMI), gender, marital status, income level, smoking, employment, insurance, and the type of meals prepared by family members (P > 0.05).
Table 1.
Frequency of demographic variables in control, group training, and telenursing groups
| Variables | Group | p-value | ||||
|---|---|---|---|---|---|---|
| Control | Telenursing | Group training | ||||
| Qualitative variables | Gender | Male | 16 (53.3) | 15 (50) | 14 (47.7) | 0.875 |
| Female | 14 (46.7) | 15 (50) | 16 (53.3) | |||
| Marital status | Single | 3 (10.0) | 4 (13.3) | 1 (3.3) | 0.893 | |
| Married | 17 (56.7) | 17 (56.7) | 18 (60.0) | |||
| Divorced | 2 (6.7) | 1 (3.3) | 2 (6.7) | |||
| Widowed | 8 (26.7) | 8 (26.7) | 9 (30.0) | |||
| Number of children | 0–2 | 4 (13.3) | 1 (3.3) | 3 (10.0) | 0.383 | |
| ≥ 3 | 26 (86.7) | 29 (96.7) | 27 (90.0) | |||
| Level of Education | Primary | 16 (53.3) | 13 (43.3) | 14 (46.7) | 0.619 | |
| Junior high school | 5 (16.7) | 10 (33.3) | 6 (20.0) | |||
| Senior high school | 7 (23.3) | 6 (20.0) | 6 (20.0) | |||
| Academic | 2 (6.7) | 1 (3.3) | 4 (13.3) | |||
| Who do you live with? | Alone | 7 (23.3 ) | 2 (6.7) | 0 (0.0) | 0.816 | |
| Spouse | 12 (40.0) | 13 (43.3) | 12 (40.0) | |||
| Children | 6 (20.0) | 3 (10.0) | 10 (33.3) | |||
| Spouse and children | 5 (16.7) | 12 (40.0) | 8 (26.7) | |||
| Who prepares the meals? | The person him/herself | 15 (50) | 15 (50) | 15 (50) | 0.815 | |
| Spouse | 9 (30.0) | 12 (40.0) | 10 (33.3) | |||
| Children | 5 (16.7) | 2 (6.7) | 5 (16.7) | |||
| Others | 1 (3.3) | 1 (3.3) | 0 (0.0) | |||
| Insurance | Health services insurance | 13 (43.3) | 16 (53.3) | 15(50) | 0.099 | |
| Social security insurance | 12 (40.0) | 14 (46.7) | 15(50) | |||
| Armed forces insurance | 3 (10.0) | 0 (0) | 0 (0.0) | |||
| Bank Insurance | 2 (6.7) | 0 (0) | 0 (0.0) | |||
| Current Employment | Yes | 25 (83.3) | 20 (67.7) | 24 (80) | 0.271 | |
| No | 5 (16.7) | 10 (33.3) | 6 (20.0) | |||
| Smoking | Yes | 10 (33.3) | 5 (16.7) | 8 (26.7) | 0.330 | |
| No | 20 (67.7) | 25 (83.3) | 22 (73.3) | |||
| Amount of sleep (24 h) | Less than 8 h | 28 (93.3) | 23 (86.7) | 17 (67.7) | 0.454 | |
| More than 8 h | 2 (6.7) | 7 (23.3) | 13(43.3) | |||
| Income (million Tomans) | Less than 6 | 8 (26.7) | 4 (13.3) | 3 (10.0) | 0.294 | |
| 6–10 | 7 (23.3 ) | 4 (13.3) | 4 (13.3) | |||
| More than 6 | 3 (10.0) | 2 (6.7) | 7 (23.3 ) | |||
| Quantitative variables | Age (year) | 64.87 ± 3.68 | 66.00 ± 4.32 | 64.67 ± 3.9 | 0.114 | |
| Body mass index (kg/m²) | 24.85 ± 9.96 | 23.66 ± 4.32 | 22.57 ± 2.58 | 0.379 | ||
Qualitative and quantitative variable was presented by n (%) and Mean ± Standard deviation; respectively
To compare the distribution of qualitative variables between groups, the chi-squared test/fisher exact test was used. To compare the distribution of quantitative variables between groups, Analysis of variance (ANOVA) was used
Significant at 0.05
In addition, the three groups were not statistically different regarding a history of hypertension treatment, underlying diseases, drug use, history of hypertension in first-degree relatives, and the time since diagnosis (P > 0.05) (Table 2).
Table 2.
Frequency of variables related to hypertension in the three groups of control, group training, and telenursing
| Variables | Group N (%) | p-value | |||
|---|---|---|---|---|---|
| Control | Telenursing | Group training | |||
| Hypertension treatment | Yes | 13 (43.3) | 16 (53.3) | 21 (70.0) | 0.110 |
| No | 17 (56.7) | 14 (46.7) | 9 (30.0) | ||
| Underlying disease | Yes | 18 (60.0) | 15 (50) | 15 (50) | 0.669 |
| No | 12 (40.0) | 15 (50) | 15 (50) | ||
| Taking hypertension medication | Yes | 26 (86.7) | 18 (60.0) | 15 (50) | 0.058 |
| No | 4 (13.3) | 12 (40.0) | 15 (50) | ||
| History of hypertension in first-degree relatives | Yes | 18 (60.0) | 14 (46.7) | 14 (46.7) | 0.491 |
| No | 12 (40.0) | 16 (53.3) | 16 (53.3) | ||
| Time since diagnosis | 6–11 months | 0 (0.0) | 5 (16.7) | 11 (33.3) | 0.063 |
| 12–24 months | 9 (30.0) | 6 (20.0) | 8 (26.7) | ||
| 2–5 years | 12 (40.0) | 15 (50) | 10 (33.3) | ||
| > 6 years | 9 (30.0) | 4 (13.3) | 1 (3.3) | ||
data was presented by n (%). To compare the distribution of variables between groups, the chi-squared test/fisher exact test was used
Significant at 0.05
As presented in Table 3, at the beginning of the study, the three groups had no significant difference in systolic and diastolic blood pressure; however, after the intervention, systolic and diastolic blood pressure in the group training and telenursing groups displayed a significant decrease (P < 0.05). The assessment of the effect of group training and telenursing on the level of blood pressure control between the groups demonstrated that although the intervention groups improved in terms of the investigated variables in the second and third stages compared to the first stage, no significant difference was observed between the groups (P > 0.05). It is noteworthy that in the telenursing group, the systolic pressure experienced a slight increase in the third stage compared to the second stage although this difference was not statistically significant.
Table 3.
Mean blood pressure before, one week, and one month after the intervention in the three groups of control, group training, and telenursing
| Variables | Group | Effect of time | effect of group | Time-group | |||
|---|---|---|---|---|---|---|---|
| Control | Telenursing | Group training | |||||
| Systolic blood pressure (mmHg) | Stage 1 | 138.03 ± 12.56 | 137.2 ± 07 | 139.93 ± 12.03 |
F = 48.98 P < 0.001* |
F = 2.265 P = 0.110 |
F = 10.186 P < 0.001* |
| Stage 2 | 137.2 ± 11.78 | 129.3 ± 8.68 | 131.6 ± 11.36 | ||||
| Stage 3 | 138.17 ± 10.41 | 129.6 ± 8.64 | 128.6 ± 9.71 | ||||
| Diastolic blood pressure (mmHg) | Stage 1 | 88.53 ± 12.51 | 88.8 ± 9.0 | 92.63 ± 8.58 |
F = 38.010 P < 0.001* |
F = 1.221 P = 0.300 |
F = 6.215 P < 0.001* |
| Stage 2 | 87.17 ± 7.12 | 82.37 ± 7.12 | 83.57 ± 8.17 | ||||
| Stage 3 | 87.03 ± 8.87 | 82.33 ± 6.36 | 82.9 ± 5.73 | ||||
Data was presented by Mean ± Standard deviation. The findings at Stage 1 (baseline), Stage 2 (one week after completion of the educational intervention), and Stage 3 (one month after the intervention) were analyzed using repeated measures ANOVA test
*: Significant at 0.05
Table 4 displays the delta value obtained by subtracting stage 3 from stage 1. As shown, the mean (SD) reductions in the control, telenursing, and group training groups were − 0.87 (7.9), -7.8 (10.05), and − 11.07 (7.74), respectively. The ANOVA test results indicated that the Delta values for systolic (p < 0.001) and diastolic (p = 0.001) blood pressure were significantly different among the three groups. According to the Least Significant Difference (LSD) test shown in Table 5, the reductions in systolic blood pressure were greater in the Telenursing (p = 0.003) and Group Training (p < 0.001) groups compared to the control group. Similarly, the reductions in diastolic blood pressure were greater in the Telenursing (p = 0.019) and Group Training (p < 0.001) groups compared to the control group.
Table 4.
Delta value (mean in stage 3 minus stage 1) in the three groups of control, group training, and telenursing
| Variables | Mean ± Standard deviation | F-statistic | p-value | ||
|---|---|---|---|---|---|
| Control | Telenursing | Group training | |||
| Systolic blood pressure (mmHg) | -0.87 ± 7.9 | -7.8 ± 10.05 | -11.07 ± 7.74 | 10.93 (2, 87) | < 0.001* |
| Diastolic blood pressure (mmHg) | -1.5 ± 7.29 | -6.47 ± 9.71 | -9.73 ± 6.79 | 7.99 (2, 87) | 0.001* |
Data was presented by Mean ± Standard deviation. Delta values were calculated by value in stage 3 minus stage 1. Comparison of delta value in three groups were done by ANOVA test
*: Significant at 0.05
Table 5.
Pairwise comparison of delta value between three study groups using least significant difference (LSD) test
| Variables | p-value | ||
|---|---|---|---|
| Systolic pressure (mmHg) | Control | < Telenursing | 0.003* |
| < Group training | < 0.001* | ||
| Telenursing | < Group training | 0.146 | |
| Diastolic pressure (mmHg) | Control | < Telenursing | 0.019* |
| < Group training | < 0.001* | ||
| Telenursing | < Group training | 0.119 | |
*: Significant at 0.05
According to Table 6, there was no significant difference between the three groups in terms of medication and dietary adherence, as well as appointment keeping before the study. Nevertheless, one week and one month after the educational intervention, group training, and telenursing groups showed a good improvement, which was statistically significant (P < 0.05) (Table 6; Fig. 1). However, in terms of appointment keeping, no significant difference was observed in any of the groups during the study (P > 0.05) (Fig. 2).
Table 6.
Comparison of the effect of group training and telenursing on treatment adherence before, one week, and one month after the intervention
| Variables | Group | Effect of time | Effect of group | Time-group | |||
|---|---|---|---|---|---|---|---|
| Control | Telenursing | Group training | |||||
| Medication adherence | Stage 1 | 24.47 ± 8.87 | 27.87 ± 4.07 | 28.03 ± 3.71 |
F = 83.291 P < 0.001* |
F = 0.121 P = 0.811 |
F = 27.775 P < 0.001* |
| Stage 2 | 24.53 ± 3.08 | 23.4 ± 3.45 | 22.83 ± 3.42 | ||||
| Stage 3 | 25.57 ± 2.64 | 24.73 ± 2.6 | 23.97 ± 3.29 | ||||
| Dietary adherence | Stage 1 | 6.7 ± 1.93 | 7.07 ± 1.48 | 6.9 ± 1.19 |
F = 35.139 P < 0.001* |
F = 2.706 P = 0.072 |
F = 9.005 P < 0.001* |
| Stage 2 | 6.7 ± 1.58 | 6.27 ± 1.8 | 6.07 ± 1.16 | ||||
| Stage 3 | 6.77 ± 1.85 | 6.30 ± 1.56 | 6.10 ± 1.47 | ||||
| Appointment keeping | Stage 1 | 4.47 ± 1.17 | 4.27 ± 1.26 | 4.2 ± 0.92 |
F = 0.204 P = 0.805 |
F = 0.446 P = 0.642 |
F = 1.249 P = 0.292 |
| Stage 2 | 4.3 ± 0.95 | 4.17 ± 1.05 | 4.47 ± 1.17 | ||||
| Stage 3 | 4.2 ± 0.89 | 4.03 ± 1.63 | 4.5 ± 1.43 | ||||
Data was presented by Mean ± Standard deviation. The findings at Stage 1 (baseline), Stage 2 (one week after completion of the educational intervention), and Stage 3 (one month after the intervention) were analyzed using repeated measures ANOVA test
*: Significant at 0.05
Fig. 1.
Comparison of the mean medication adherence in the three investigated groups before, one week, and one month after the educational intervention
Fig. 2.
Comparison of the mean dietary adherence in the three investigated groups before, one week after, and one month after the educational intervention
Furthermore, the investigation of the effect of group training and tele-nursing on medication and dietary adherence between groups pointed out that although the studied groups had improved in terms of variables in the second and third stages compared to the first stage, no significant difference was observed between the groups. (P > 0.05). Moreover, regarding medication adherence, the two groups of group training and telenursing obtained more satisfactory results in the second stage than in the third stage (Fig. 3).
Fig. 3.
Comparison of mean adherence to doctor visits in the three investigated groups before, one week after, and one month after the educational
Table 7.
Frequency of variables affecting blood pressure control in the three investigated groups
| Variables | Group N (%) | P-value | |||
|---|---|---|---|---|---|
| Control | Telenursing | Group training | |||
| Regular medical examination | Stage 1 | 9 (30) | 14 (46.7) | 13 (43.3) | < 0.001* |
| Stage 2 | 10 (33.3) | 18 (60) | 18 (60) | ||
| Stage 3 | 10 (33.3) | 18 (60) | 18 (60) | ||
| Measuring blood pressure at home | Stage 1 | 7 (33.3) | 5 (16.7) | 7 (23.3) | < 0.001* |
| Stage 2 | 9 (30) | 15 (50) | 23 (76.7) | ||
| Stage 3 | 9 (30) | 15 (50) | 23 (76.7) | ||
| Awareness of the signs and symptoms of hypertension | Stage 1 | 26 (86.7) | 13 (43.3) | 11 (36.7) | < 0.001* |
| Stage 2 | 26 (86.7) | 23 (76.7) | 23 (76.7) | ||
| Stage 3 | 26 (86.7) | 23 (76.7) | 23 (76.7) | ||
| Relationship of high-fat diet and fast food with hypertension | Stage 1 | 19 (63.3) | 15 (50) | 21 (70) | < 0.001* |
| Stage 2 | 20 (66.7) | 21 (70) | 27 (90) | ||
| Stage 3 | 20 (66.7) | 21 (70) | 27 (90) | ||
| Relationship of low consumption of fruits and vegetables with hypertension | Stage 1 | 7 (23.3) | 27 (90) | 10 (33.3) | < 0.001* |
| Stage 2 | 7 (23.3) | 10 (31) | 21 (70) | ||
| Stage 3 | 7 (23.3) | 20 (66.7) | 21 (70) | ||
| Having different meals from other family members | Stage 1 | 10 (33.3) | 20 (66.7) | 5 (16.7) | < 0.001* |
| Stage 2 | 10 (33.3) | 5 (16.7) | 19 (63.3) | ||
| Stage 3 | 10 (33.3) | 14 (46.7) | 19 (63.3) | ||
| Regular use of medication | Stage 1 | 21 (70) | 14 (46.7) | 22 (73.3) | < 0.001* |
| Stage 2 | 21 (70) | 22 (73.3) | 29 (96.7) | ||
| Stage 3 | 21 (70) | 25 (83.3) | 29 (96.7) | ||
| Checking the nutrition label before buying a food product | Stage 1 | 1 (3.3) | 25 (83.3) | 7 (23.3) | < 0.001* |
| Stage 2 | 1 (3.3) | 4 (13.3) | 21 (70) | ||
| Stage 3 | 1 (3.3) | 13 (43.3) | 21 (70) | ||
| Walking | Stage 1 | 10 (33.3) | 8 (26.7) | 10 (33.3) | < 0.001* |
| Stage 2 | 10 (33.3) | 17 (56.7) | 22 (73.3) | ||
| Stage 3 | 10 (33.3) | 18 (60) | 22 (73.3) | ||
Data was presented by N (%). The findings at Stage 1 (baseline), Stage 2 (one week after completion of the educational intervention), and Stage 3 (one month after the intervention) were analyzed using chi-squared test
*: Significant at 0.05
Discussion
The findings of the present study pointed out that dietary adherence in the two intervention groups improved during the study, while no significant change was observed in the control group. Both intervention groups exhibited more positive results in the second stage than in the third stage. This finding can be ascribed to the fact that not much time has passed since the end of the research, and older adults can better observe the taught materials. Difficulty in preparing meals different from other family members can also be another reason. It should be noted that the group training group obtained better results than telenursing, although it was not statistically significant. Probably, given that group training encouraged older adults to participate more actively in training and benefit from the experiences of their peers, they obtained a more thorough understanding of the educational material and, as a result, displayed improved dietary adherence.
Shahabi et al. conducted a study entitled “The effect of telenursing training based on family-centered empowerment pattern on adherence with diet regimen in patients with diabetes mellitus type.” They reported that the scores of making an effort for treatment, intention to take the treatment, treatment adherence, and total score of adherence were significantly increased after intervention in the training group. The results of the stated study indicated the positive effects of performing family-centered empowerment patterns using telephone call follow-up on increasing dietary adherence in patients [25]. In their research in Tehran, Mohammadi et al. compared computer-assisted vs. face-to-face education on dietary adherence among patients with myocardial infarction and reported that the face-to-face education group had significantly better adherence with the consumed amount of healthy food compared to the control group. Nevertheless, both computer-assisted and face-to-face educational strategies had positive effects on improving adherence following myocardial infarction [26].
In their research aimed at determining the effect of peer education on diet adherence among elderly hypertensive clients, Sadeghi et al. demonstrated that peer education increases dietary adherence among older adults with hypertension [27]. Given the growing evidence on the effectiveness of community-based interventions, using peer educational programs can greatly help better manage and increase dietary adherence. According to the aforementioned studies and the results of the current research, it can be concluded that since older adults are one of the most sensitive and vulnerable groups in society and more dependent on their peers, group education can have a more dramatic impact on this age group, encouraging them to follow a diet.
Regarding the comparison of the effect of group training and telenursing on medication adherence in hypertensive seniors, the findings pinpointed that medication adherence improved in the two intervention groups during the study, while no significant change was observed in the control group. The results of both intervention groups in the second stage were better than those in the third stage. This finding can be attributed to the attrition of the educational materials after the completion of follow-up. In addition, the group training group obtained better results than telenursing, although it was not statistically significant. This finding can be attributed to the fact that older adults in the group training group had more active participation in provoked discussions which contributed significantly to learning the presented materials and their utilization.
In the same context, Najafi et al. (2016) investigated the effect of telenursing on medication and dietary adherence among patients after myocardial infarction. They pointed to a statistically significant difference between the control and intervention groups (telenursing) in terms of medication and dietary adherence. The two groups significantly differed in the mean medication adherence scores in the pre-and post-test. The results of the mentioned study confirmed the positive effect of telenursing as a remote nursing method on improving medication adherence in patients with myocardial infarction [28].
In their research, Hacihasanoğlu et al. assessed the effect of patient education and home monitoring on medication adherence, hypertension management, healthy lifestyle behaviors, and BMI in a primary healthcare setting. The results of the referred study indicated that healthy lifestyle behaviors and perception of self-efficacy regarding medication adherence showed improvement after education sessions in the intervention groups. Moreover, the blood pressure decrease was more significant in Group B than in Group A [29]. As a result, educational interventions in hypertensive patients are effective in blood pressure management and can make a major contribution to the improvement of healthy lifestyle behaviors, medication adherence, blood pressure, and BMI.
Along the same lines, in their research in South Africa, Magadza et al. (2009) investigated the effect of an educational intervention on hypertensive participants’ levels of knowledge about hypertension, their beliefs about medicines, and adherence to antihypertensive therapy. They concluded that the educational intervention led to an increase in the participants’ levels of knowledge about hypertension and a positive influence on their beliefs about medicines and medication adherence [30]. In a similar vein, Zabolypour et al. (2020) compared the effects of teach-back and motivational interviewing on adherence to medical regimens in patients with hypertension. They pointed out that both teach-back and motivational interviewing increased adherence to the hypertension treatment regimen; however, motivational interviewing was more effective than teach-back in boosting adherence to the hypertension treatment regimen [31].
According to the aforementioned studies and the present research, it can be stated that simultaneous use of group training and telenursing can yield more positive results. Although group training alone yielded better results compared to telenursing, with advancements in remote communication tools, group training can complement telenursing for older adults. A comparison of the effect of group training and telenursing on blood pressure control in hypertensive older patients demonstrated that systolic and diastolic pressure decreased significantly over time in group training and telenursing groups in the second and third stages of the research; however, the difference between the groups was not significant. It is worth mentioning that in the telenursing group, the systolic pressure in the third stage slightly increased compared to the second stage. In their study, Soliman and Mohamed (2016) assessed educational intervention and tele-nursing effects on glycemic control, metabolic parameters, and adherence in adults with type II diabetes. They concluded that blood glucose indicators improved significantly in the study group after intervention. Nonetheless, there was no significant difference between the two groups in terms of triglyceride level and systolic and diastolic blood pressure. During the study, the improvement in adherence percentage was also investigated, and treatment adherence in the intervention group changed from 10% to 70% after the intervention [32].
It can be concluded that if training is accompanied by telenursing, it can be effective in improving dietary adherence. The results of a study by Nasirian et al., which investigated the effect of group discussion training on the self-care behavior of hypertensive patients, illustrated that patients in the intervention group had significantly lower systolic and diastolic blood pressure than the control group [33]. It seems that group discussion training can effectively improve self-care behaviors in hypertensive patients, leading to a significant reduction in blood pressure. Furthermore, they reported that group discussion was more effective in reducing systolic and diastolic blood pressure and increasing self-care than the lecture method.
In a study by Sadeghi et al., which assessed the effect of telenursing on blood pressure and body mass index of hypertensive patients, it was found that the telenursing group had significantly lower mean systolic and diastolic blood pressure after the intervention [34]. Therefore, it can be concluded that telenursing can have potential benefits for maintaining blood pressure in the normal range and reducing BMI in hypertensive patients. In their meta-analysis study, Tom et al. identified the effect of educational interventions on blood pressure control and adherence to lifestyle modification among hypertensive patients. In the mentioned research, individual and group training methods were used in the intervention group. Phone calls, message reminders, and reading materials after education were identified in the studies as supportive methods, demonstrating the great effect on blood pressure control [35].
Unlike the abovementioned studies, the strength of the present research was the employment of two teaching methods. Among the notable limitations of the current research, we can refer to the negative attitude of some health sector managers towards such research projects, some seniors’ concern about completing the questionnaire out of fear of reporting their opinions to their children and relatives, and some participants’ lack of cooperation. Nonetheless, the necessary cooperation was obtained by the researcher’s great efforts to explain the nature of the research. Furthermore, since participants were collected from one single city, great caution should be exercised when generalizing the results.
Conclusion
The results of this study pointed out that group training and telenursing led to a marked improvement in medication and dietary adherence, as well as blood pressure control, among subjects in the intervention group compared to the control group. Therefore, the findings of this study can be used as a basis for evidence-based care in healthcare centers. Given the high prevalence of hypertension among older adults and the importance of medication and dietary adherence in preventing its complications, it is suggested to distance yourself from routine training techniques and follow newer and more flexible methods, such as telenursing and group training.
Limitations
The concerns of some elderly people in answering the questions of the questionnaire due to the fear of reporting their opinions to their children and relatives and the non-cooperation of some elderly people were among the limitations. By trying and spending time to justify them and explain the nature of the research, the necessary cooperation was obtained. Due to the collection of samples at the level of one city, caution should be taken in generalizing the findings.
Acknowledgements
The article was extracted from a master’s thesis in nursing submitted to Ilam University of.
Medical Sciences (IR.MEDILAM.REC.1400.245) registered Iranian Registry of Clinical Trials at 2022-07-16. IRCT20220130053886N1.
Authors’ contributions
A: wrote the main manuscript text and data collecting B: design of the workC: data analysisD: Scientific editorE: have drafted the work F: Translation of the article in English.
Funding
Not applicable.
Data availability
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Declarations
Consent for publication
All authors agree to publish the article.
Competing interests
The authors declare no competing interests.
Footnotes
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References
- 1.Lauffenburger JC, Shrank WH, Bitton A, Franklin JM, Glynn RJ, Krumme AA, et al. Association between patient-centered medical homes and adherence to chronic disease medications: a cohort study. Ann Intern Med. 2017;166(2):81–8. [DOI] [PubMed] [Google Scholar]
- 2.Poorhoseini HR, Shafiee AK. A general Report of the National Plan for High Blood Pressure Control at Tehran Heart Center in 2019. Commonity Health. 2020; 1;7(3):340–4.
- 3.Oliveros E, Patel H, Kyung S, Fugar S, Goldberg A, Madan N, et al. Hypertension in older adults: Assessment, management, and challenges. Clin Cardiol. 2020;43(2):99–107. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Setters B, Holmes HM. Hypertension in the older adult. Prim Care. 2017;44(3):529. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Arabshahi A, Gharlipour Z, Hosseinalipour SA, Mohebi S. Assessment of adherence to self-care behaviors in hypertensive patients in Qom. Qom Univ Med Sci J. 2020;14(2):55–66. [Google Scholar]
- 6.Alessa T, Abdi S, Hawley MS, de Witte L. Mobile apps to support the self-management of hypertension: systematic review of effectiveness, usability, and user satisfaction. JMIR mHealth uHealth. 2018;6(7):e10723. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Sigaroudi AE, Nayeri ND, Peyrovi H. Antecedents of elderly home residency in cognitive healthy elders: A qualitative study. Global J Health Sci. 2013;5(2):200. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.WHO. Geneva: knowledge updated 2003 January 1; cited 2021 September 6 Available from: https://www.who.int/chp/knowledge/publications/adherence_Section1.pdf
- 9.Ravari A, Irani M, Mirzaei T, Raeisi M, Majdabadi HA. Effects of drug use reminder SMS on controlling hypertension in elderlies: A clinical trial study. Koomesh. 2020;22(3):437–45.
- 10.Salehzadeh Nobary M, Shams S, Ghavami H, Khademvatan K, EFFECTS OF APPLYING CONTINUES CARE, MODEL ON DIETARY SODIUM INTAKE AND BLOOD PRESSURE AMONG HYPERTENSIVE PATIENTS. Nurs Midwifery J. 2020;18(2):107–17. [Google Scholar]
- 11.Park HY, Seo SA, Yoo H, Lee K. Medication adherence and beliefs about medication in elderly patients living alone with chronic diseases. Patient Prefer Adherence. 2018;12:175. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Chenarani H, Khammari M, Shirkavand N, Ashoori J. Survey on the effects of group training of life skills on Nursesâ general health and quality of life. Community Health J. 2016;10(3):19–27. [Google Scholar]
- 13.Fatehi Pouladi H, Akbari Kamrani M, Javad Noori M, Farid M. Effectiveness of a group educational program on the Knowledge, Attitude, and participation approach of mothers in the sex education of preschool children. Iran J Nurs. 2019;32(119):14–27. [Google Scholar]
- 14.Rahnavard S, Elahi N, Rokhafroz D, Hagighi MH, Zakerkish M. Comparison of the effect of group based and mobile based education on self-care behaviors in type Ii diabetic patients. Iran J Diabetes Metabolism. 2019;18(2):55–63. [Google Scholar]
- 15.Mohyadini H, Bakhtiarpoor S, Pasha R, Ehteshamzadeh P. Comparison the effectiveness of cognitive behavioral group therapy and drug therapy (Fluoxetine) on symptoms of Obsessive-Compulsive disorder. J Health Promotion Manage. 2021;10(1):23–33. [Google Scholar]
- 16.Fallahpour S, Nasiri M, Fotokian Z, Alipour ZJ, Haji M. The effect of telephone follow up (tele-nursing) on fatigue in the elderly undergoing Hemodialysis. J Crit Care Nurs. 2018;11(4):17–26. [Google Scholar]
- 17.Ghoulami-Shilsari F, Esmaeilpour Bandboni M. Tele-Nursing in Chronic Disease Care: A Systematic Review. Jundishapur Journal of Chronic Disease Care. Press (In Press). 2019;8(2). 10.5812/jjcdc.84379.
- 18.Lashkari T, Borhani F, Sabzevari S, Abbaszadeh A. Effect of telenursing (telephone follow-up) on glycemic control and body mass index (BMI) of type 2 diabetes patients. Iran J Nurs Midwifery Res. 2013;18(6):451–6. [PMC free article] [PubMed] [Google Scholar]
- 19.Rezaei M, Jalali R, Heydarikhayat N, Salari N. Effect of telenursing and face-to-face training techniques on quality of life in burn patients: a clinical trial. Arch Phys Med Rehabil. 2020;101(4):667–73. [DOI] [PubMed] [Google Scholar]
- 20.Sadeghmoghadam L, Ahmadi Babadi S, Delshad Noghabi A, Nazari S, Farhadi A. Effect of telenursing on aging perception of Iranian older adults. Educ Gerontol. 2019;45(7):476–82. [Google Scholar]
- 21.Elham M, Samadi N, Mehrnush N, Mohamad R, Zali M-R. Tele nursing: optimal option for patient educational improvement. J Health Care. 2011;13(3):0. [Google Scholar]
- 22.Kazem S, Shahriari M, Eghbali M. Comparing the effects of two methods of self-monitoring and telenursing on the blood pressure of patients with hypertension. J Res Health Sci. 2016;5:213–22. [Google Scholar]
- 23.Taher M, Abredari H, Karimy M, Abedi A, Shamsizadeh M. The relation between social support and adherence to the treatment of hypertension. J Educ Community Health. 2014;1(3):63–9. [Google Scholar]
- 24.Ebrahimabadi M, Rafiei F, Nejat N. Can tele-nursing affect the supportive care needs of patients with cancer undergoing chemotherapy? A randomized controlled trial follow-up study. Support Care Cancer. 2021;29:5865–72. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Shahabi N, Kolivand M, Salari N, Abbasi P. The effect of telenursing training based on family-centered empowerment pattern on adherence with diet regimen in patients with diabetes mellitus type 2: a randomized clinical trial. BMC Endocr Disorders. 2022;22(1):1–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Mohammady M, Memari A, Shaban M, Mehran A, Yavari P, Salari Far M. Comparing Computer-assisted vs. face to face education on dietary adherence among patients with myocardial infarction. J Hayat. 2011;16(3):77–85. [Google Scholar]
- 27.Sadeghi K, Bakhshi M, Ranjbar H. The effect of peer education on diet adherence among elderly hypertensive clients. J Torbat Heydariyeh Univ Med Sci. 2019;7(2):23–33. [Google Scholar]
- 28.Najafi SS, Shaabani M, Momennassab M, Aghasadeghi K. The nurse-led telephone follow-up on medication and dietary adherence among patients after myocardial infarction: a randomized controlled clinical trial. Int J Community Based Nurs Midwifery. 2016;4(3):199. [PMC free article] [PubMed] [Google Scholar]
- 29.Hacihasanoğlu R, Gözüm S. The effect of patient education and home monitoring on medication adherence, hypertension management, healthy lifestyle behaviours and BMI in a primary health care setting. J Clin Nurs. 2011;20(5–6):692–705. [DOI] [PubMed] [Google Scholar]
- 30.Magadza C, Radloff S, Srinivas S. The effect of an educational intervention on patients’ knowledge about hypertension, beliefs about medicines, and adherence. Res Social Administrative Pharm. 2009;5(4):363–75. [DOI] [PubMed] [Google Scholar]
- 31.Zabolypour S, Alishapour M, Behnammoghadam M, Abbasi Larki R, Zoladl MA. A Comparison of the Effects of Teach-Back and Motivational Interviewing on the Adherence to Medical Regimen in Patients with Hypertension. Patient Prefer Adherence. 2020;14:401–10 [online]. [DOI] [PMC free article] [PubMed]
- 32.Soliman HMM, Mohamed WG. Educational intervention and tele-nursing effects on glycemic control, metabolic parameters and adherence in adults with type II diabetes mellitus. Int J Nurs Didactics. 2016;6(2):1–11. [Google Scholar]
- 33.Nasirian M, Rozbahani N, Jamshidi A. The effect of group discussion on self-care behaviors among hypertensive patients referring to health care centers in Arak City. Sci J Kurdistan Univ Med Sci. 2019;24(5):56–68. [Google Scholar]
- 34.Sadeghi-Gandomani H, Habibi Z, Eghbali-Babadi M, Khosravi A. Impact of telenursing on blood pressure and body mass index of people with prehypertension: A randomized controlled clinical trial. Iran J Nurs Midwifery Res. 2021;26(6):544. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.Tam HL, Wong EML, Cheung K. Effectiveness of educational interventions on adherence to lifestyle modifications among hypertensive patients: an integrative review. Int J Environ Res Public Health. 2020;17(7):251. [DOI] [PMC free article] [PubMed] [Google Scholar]
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