Health-Promoting Lifestyle: A Considerable Contributing Factor to Quality of Life in Patients With Hypertension

Abstract

Aim: Investigating the relationship between health promoting behaviors and quality of life in patients with hypertension. Methods: In this cross-sectional study, health-promoting behaviors and quality of life in patients with hypertension were assessed in a cardiology clinic of a university hospital in an urban area of Iran. The sample consisted of 93 patients with hypertension who were recruited using a convenience sampling method. Demographic data, Health Promoting Lifestyle Behaviors Profile (HPLP II) and World Health Organization Quality of Life–BREF (WHOQOL-BREF) questionnaires were used to gather data. Data were analyzed using SPSS software version 21. Results: The mean score of health promoting behaviors was moderate (2.51 ± 0.47) with highest and lowest scores in nutritional (2.80 ± 0.52) and physical activity (1.78 ± 0.62) dimension, respectively. There was a statistically significant relationship between health-promoting behaviors and quality of life. The relationship between health-promoting behaviors and quality of life had the highest power in psychological health dimension (β = 5.353, P < .001) and lowest power in the environmental dimension (β = 0.365, P < .001). Conclusion: Improving quality of life of patients requires paying attention to educational interventions for creating changes in the lifestyle to improve all aspects of quality of life.

‘Many risk factors for hypertension are lifestyle-associated behaviors.’

Hypertension is one of the most common chronic diseases across the globe. It accounts for 12.8% of total deaths and is known as a “silent killer.” The World Health Organization (WHO) has declared it as a public health crisis.^1,2 The WHO has reported that the prevalence of hypertension in the world is 40% in individuals older than 25 years. In the WHO’s regions, the highest prevalence of hypertension was reported in Africa (46%) and the lowest was reported in the United States (35%).² The prevalence of hypertension is increasing in general, especially in developing countries.³ In Iran, the prevalence of hypertension is 24.3% among men and women and both genders separately having a prevalence of more than 20%. However, the prevalence of hypertension in men is 26.1%, which is higher than that of women (22.4%).⁴

Hypertension is one of the most important causes of coronary artery diseases, cerebrovascular diseases, chronic kidney diseases, early death and disability,^5-7 and the high costs of health care on the family and society.⁸ Hypertension is influenced by 2 types of risk factors. Nonmoderated risk factors are higher age, family history, and race. Moderated risk factors are weight gain, obesity, lack of physical activity, smoking and alcohol consumption, high sodium intake, diet, stress, and diabetes.⁵ Many risk factors for hypertension are lifestyle-associated behaviors. According to Kuemsun, the focus of treatment in chronic illnesses should be changed from medical treatments to the improvement of individuals’ lifestyle in the course of treatment. To achieve this goal, health-promoting activities are recommended in patients with chronic diseases as a strategy to control the cost of care and improve quality of life.^9,10 Health-promoting behaviors, as one of the key determinants of health,¹¹ are behaviors or actions that people make as they tend to improve their own health status.¹⁰ Health-promoting behaviors are behaviors by which a person receives adequate nutrition, does regular exercise, avoids malicious behaviors and drugs, protects against accidents, follows timely diagnosis of symptoms in the physical aspect, makes emotional and thoughts control, adapts with situations, removes stress, and rectifies interpersonal and social relationships.¹¹ Nowadays, special emphasis has been placed on promoting health behaviors, because according to the WHO, 70% to 80% of deaths in developed countries, and 40% to 50% of deaths in developing countries are influenced by lifestyle-related diseases.⁹ Kemppainen et al¹² in their study described a moderate status of health-promoting behaviors in patients with hypertension. Health-promoting behaviors in patients with hypertension have a potential impact on health and quality of life.¹⁰ Quality of life is of paramount importance due to the consideration of several dimensions such as physiological aspects and performance as health-related indicators.¹³ Evaluation of quality of life in patients with hypertension is very important.¹⁴ The results of some studies indicated that most patients with hypertension had a poor level of quality of life.^15,16 Ebadi et al¹⁷ in their study showed that the quality of life of patients with hypertension was lower than healthy individuals. To improve quality of life in individuals with hypertension, attention should be paid to factors affecting quality of life, including health-promoting behaviors, as a way for identifying problems for lifestyle modification and improving quality of life.¹⁴ Because of the importance of this issue and lack of studies in Iran regarding the relationship between health-promoting behaviors and quality of life in patients with hypertension, this study aimed to investigate the relationship between health promoting behaviors and quality of life in patients with hypertension. The findings of this study can help health care providers identify factors affecting quality of life in patients with hypertension. Also, they can help design and implement educational programs based on priorities for effective improvement of patients’ quality of life.

Methods

This was a cross-sectional (descriptive-analytic) study to investigate the relationship between health-promoting behaviors and quality of life in patients with hypertension. The study was carried out in a cardiovascular clinic located in a teaching hospital in an urban area of Iran. The sample consisted of 93 patients with controlled chronic hypertension referred to this clinic to check their cardiovascular status. They were selected using a convenience sampling method. Inclusion criteria were (a) suffering from chronic hypertension, (b) no presence in the acute phase of the disease, and (c) willingness to participate in this study. To recruit participants, the researcher referred to the cardiology clinic after obtaining the required permissions. A cardiology specialist introduced the researcher to probable samples. After ensuring about the inclusion criteria and acquiring informed consent, the questionnaires were filled out through interviewing the patients. Through the study phase, all the eligible patients referred to clinic were interviewed until the calculated sample size was reached.

The questionnaires used for data collection included demographic information questionnaire, Health Promoting Lifestyle Behaviors Profile (HPLP II) and WHO Quality of Life–BREF (WHOQOL-BREF) questionnaires. The demographic characteristics questionnaire consisted of questions about age, occupation, education level, satisfaction with the economic situation and duration of the disease. To assess the quality of life, the WHOQOL-BREF short-term quality of life questionnaire was used, which examined quality of life in four dimensions and 26 questions. The first 2 questions evaluate self-perceived quality of life and satisfaction with health. The remaining 24 questions represent each of the 24 facets of which the original instrument is composed (WHOQOL-100), divided into 4 domains: physical, psychological, social relationships, and environment.¹⁸ The primary scores acquired from this questionnaire range from 4 to 20, according to guidelines. These scores can be transformed to a 0 to 100 scale to produce scores comparable to WHOQOL-100.¹⁸ Silva et al,¹⁹ in their study to determine cutoff point for WHOQOL-BREF as a measure of quality of life of older adults, reported that considering cutoff <60 for overall quality of life obtained excellent sensitivity and negative predictive value for tracking older adults with probable worse quality of life and dissatisfied with health. So according to this cutoff point, acquiring scores <60 in this study was interpreted as having worse quality of life. The translation and psychometric evaluation of the Iranian version of this questionnaire were performed by Nedjat et al²⁰ in a study on 1164 individuals in Tehran, Iran. Intraclass correlation and Cronbach’s alpha coefficients of this questionnaire were greater than 0.7 for all domains. The results of this study showed that validity, reliability, and acceptability of the structural factors of this questionnaire for healthy and patient groups were appropriate. Reliability of this questionnaire was also studied in this study. The questionnaire was completed by 20 patients within a 2-week interval. Intraclass correlation coefficients varied in 4 domains with a range of 0.80 to 0.85 indicating an appropriate reliability.

Another questionnaire used in this study was the second version of Health Promoting Lifestyle Behaviors Profile (HPLP II). This questionnaire was designed by Walker et al.²¹ It has 52 questions and assesses health-promoting behaviors. The frequency of applying health promoting behaviors was measured in 6 domains, including health accountability, physical activity, nutrition, spiritual growth, stress management, and interpersonal relationships. It has a 4-point Likert-type scale (never, sometimes, often and always). The mean score of responses by individuals was calculated in each domain and in total.²¹ Scores 2.5 to 4 represented a frequent or continuous engagement in health promoting behaviors.²² Psychometric properties of the Iranian version of this questionnaire were assessed by Zeidi et al²³ in an age-group <60 years and by Tanjani et al²⁴ in an age-group >60 years. Both studies validated the psychometric properties of this questionnaire in terms of validity and reliability.^23,24 This questionnaire was also studied in this study. The questionnaire was filled out by 20 patients within a 2-week interval. Intraclass correlation coefficients for this questionnaire ranged from 0.75 to 0.88 indicating a good reliability.

According to studies on the quality of life and health-promoting behaviors in patients with chronic illnesses, the maximum sample size required for each group of chronic diseases was determined. Given α = 0.05, β = 0.8, and ρ = 0.3 and 10% dropout, sample size was calculated using the following sampling formula:

$$n=\frac{{\left(z_{\left(1-\frac{\mathrm{\alpha }}{2}\right)}+z_{\left(1-\mathrm{\beta }\right)}\right)}^2}{{\left(\frac{1}{2}\ln \frac{1+\mathrm{\rho }}{1-\mathrm{\rho }}\right)}^2}=85$$

Data were analyzed using the SPSS software version 21. Descriptive and inferential statistics were used for data analysis. The Kolmogorov-Smirnov test examined the normality of quantitative variables. The independent t test, analysis of variance, Pearson correlation coefficient, and multiple linear regression tests were also used. For the regression analysis, qualitative variables were defined as dummy. A significance level of .05 was considered statistically significant.

Ethical Consideration

The research proposal was approved by the Research Council of Faculty of Nursing and Midwifery, Qazvin University of Medical Sciences. The proposal was also approved by institutional ethics committee board coded as IR.QUMS.REC.1394.225. After obtaining the required permissions, the researcher referred to the cardiology clinic. A cardiology specialist introduced the researcher to probable samples. The researcher explained the research goals and obtained their satisfaction for participating in this study. They were assured that their answers would remain confidential and they could withdraw from the study at any time without being penalized. The questionnaires were filled out through interviewing the patients.

Findings

In this study, 93 patients with controlled hypertension in the age range of 23 to 86 years, with (mean ± SD) age of 58.4 ± 13.21 years participated. The majority of them were women (57%). They were mainly housewives (51%), and most men (48%) had nongovernmental jobs. Most of the participants were married (76%), illiterate (35%), and dissatisfied with their economic situation (39%). The mean duration of hypertension was 5.45 ± 5.05 years and almost half of them (51%) used 2 medication to control their blood pressure. Comparison of the dimensions of quality of life and the dimensions of health promoting behaviors in terms of demographic variables was performed between the groups of women and men. The independent t test did not show statistically significant differences between the dimensions of quality of life and the dimensions of health promoting behaviors in men and women (P < .05). Table 1 shows the distribution of the demographic variables of the participants and their relationships with health-promoting behaviors and quality of life.

Table 1.

Distribution of Demographic Variables Among Participants and Its Association to QOL and HPLP Domains.

		Distribution		QOL				HPLP							Statistical Test (P Value Reported)
Variable		n	%	Physical	Psychosocial	Social Relationships	Environment	Nutrition	Physical Activity	Health Responsibility	Interpersonal Relation	Stress Management	Spiritual Growth	Total
Gender	Male	36	38.7	.27	.51	.79	.37	.69	.56	.14	.26	.71	.53	.75	t test
	Female	57	61.3
Marital status	Married	76	81.7	.37	.26	.47	.46	.95	.28	.06	.84	.29	.23	.27
	Unmarried	17	18.3
Educational status	Illiterate	35	37.6	.08	.03 a	.36	.004 a	.15	.02 a	.1	.23	.07	.03 a	.02 a	ANOVA
	Up to diploma	48	51.6
	Academic	10	10.8
Economical satisfaction	Satisfied	27	29.0	.02 b	.000 b	.000 b	.000 b	.1	.001 b	.22	.09	.29	.011 b	.01 b	ANOVA
	Partly satisfied	32	34.4
	Dissatisfied	34	36.6
Age, years	Mean ± SD	58.42 ± 13.22		−.263	NS	NS	NS	NS	NS	NS	NS	NS	NS	NS	Pearsonc
Disease duration, years	Mean ± SD	5.45 ± 4.32		NS	NS	NS	NS	NS	NS	NS	NS	NS	NS	NS

Abbreviations: QOL, quality of life; HPLP, Health Promoting Lifestyle Behaviors Profile; NS, nonsignificant.

^aDifference due to illiterate group.

^bDifference between satisfied and dissatisfied group.

^cSignificant r reported.

Note: Boldfaced entries are significant p-values.

The mean score of health-promoting behaviors was moderate (2.51 ± 0.47); the highest score was in the dimension of nutrition (2.8 ± 0.52) and the lowest score was for the dimension of physical activity (1.78 ± 0.62). Also, the quality of life in the dimensions of physical health (49.54 ± 15.06), psychological health (51.96 ± 21.21), social relationships (61.06 ± 22.52), and environmental health (55.31 ± 20.57) were reported. The lowest score was related to the physical dimension and the highest score was related to the dimension of social relationships. In general, by considering cutoff point <60 meaning worse quality of life, patients with hypertension had a worse quality of life in all dimensions (Table 2).

Table 2.

Distribution of WHOQOL-BREF Scores and HPLP Subscales Scores Among Participants.

	Mean	SD
General QOL perception (range: 1-5)
QOL satisfaction	3.47	1.05
Health satisfaction	2.95	1.20
WHOQOL-BREF domain (range 0-100)
Physical health	49.54	15.06
Psychological	51.96	21.21
Social relationships	61.06	22.52
Environment	55.31	20.57
HPLP subscales (range: 1-4)
Health-promoting lifestyle	2.51	.47
Physical activity	1.78	.62
Spiritual growth	2.75	.60
Stress management	2.37	.59
Interpersonal relationship	2.71	.58
Health responsibility	2.53	.56
Nutrition	2.80	.52

Abbreviations: WHOQOL-BREF, World Health Organization Quality of Life–BREF; HPLP, Health Promoting Lifestyle Behaviors Profile.

The relationship between different dimensions of quality of life and health promoting behaviors showed a statistically significant positive relationship with different dimensions of quality of life (r = 0.28-0.630, P < .001). The quality of life in the health dimension had the highest correlation with the dimension of nutrition. Spiritual growth had the highest correlation with the psychological dimension of quality of life. Quality of life in the dimension of social relationships had the highest correlation with stress management dimension. In the environmental dimension, the dimension of nutrition and spiritual growth had the highest correlations. The dimensions of psychological health and quality of life in terms of social relationships and physical health showed a higher correlation with health promoting behaviors. Overall, health-promoting behaviors significantly accounted for 21% to 40% of the observed variance associated with quality of life (Table 3).

Table 3.

Correlation Between QOL Domains With HPLP Subscales.^a

		Nutrition	Health Responsibility	Physical Activity	Spiritual Growth	Interpersonal Relations	Stress Management	Health-Promoting Lifestyle
Physical health	r	.481	.288	.321	.366	.416	.338	.456
	P	.000	.005	.002	.000	.000	.001	.000
Psychological	r	.486	.397	.526	.617	.553	.459	.630
	P	.000	.000	.000	.000	.000	.000	.000
Social relationships	r	.413	.353	.402	.442	.331	.468	.496
	P	.000	.001	.000	.000	.001	.000	.000
Environment	r	.496	.363	.379	.457	.385	.383	.509
	P	.000	.000	.000	.000	.000	.000	.000

Abbreviations: QOL, quality of life; HPLP, Health Promoting Lifestyle Behaviors Profile.

^aCorrelation between variables were examined with Pearson correlation.Note: Correlation is significant at the 0.01 level (2-tailed).

To investigate the relationship between health-promoting lifestyle and different dimensions of quality of life, one-variable and multivariate linear regression analyses (to control possible confounding factors) were used. The results of this study showed that improving health promoting behaviors can significantly improve quality of life of patients with hypertension. Improving health-promoting behaviors for 1 score significantly improved quality of life by 2.33 score, in the area of psychological health by 4.58, in the field of social relationships by 3.79, and in the area of the environment by 3.59.

In the single-variable analysis, improvement in health-promoting behaviors had the greatest effect on improving the dimension of psychological health (4.58) and had the least effect on physical health dimension (2.33). After controlling confounding factors through multivariate analysis, the greatest effect of improving health-promoting behaviors was observed in psychological health (3.87), while the lowest effect was observed with a coefficient of 2.02 in terms of physical health. Also, the examination of standardized coefficients in multivariate analysis after controlling possible confounding factors showed a statistically significant relationship between health-promoting behaviors and quality of life. The relationship between health-promoting behaviors and quality of life had the highest power in psychological health dimension (β = 5.353, P < .001) and lowest power in the environmental dimension (β = 0.365, P < .001). Table 4 summarizes the results of univariate and multivariate regression analyses.

Table 4.

Results of Univariate and Adjusted Multivariate Linear Regression Between HPLP and QOL Domains.

	QOL Domain		Physical Health	Psychological	Social Relationships	Environment
HPLP	Univariate	B	2.333	4.582	3.791	3.59
		β	.456	.630	.496	.509
		P	.000	.000	.000	.000
	Multivariatea	B	2.026	3.875	2.959	2.577
		β	.396	.533	.387	0.365
		P	.000	.000	.000	.000

Abbreviations: QOL, quality of life; HPLP, Health Promoting Lifestyle Behaviors Profile.

^aAdjusted for age, gender, duration of disease, marital status, educational qualification, and economic status.

Discussion

The lifestyle of each individual influences his or her health, and health promotion and lifestyle improvements are main strategies for facilitating and protecting health.²³ Health-promoting behaviors as main factors affecting quality of life of individuals were investigated in this study. The results of this study showed that health-promoting behaviors among patients with chronic hypertension had the highest score in the nutrition and the lowest score in the physical activity dimension. The results of the study by Kemppainen et al¹² on health-promoting behaviors in patients with hypertension in Japan and the United States showed that the lowest score was for the physical activity dimension. Both studies showed that the dimension of physical activity had the lowest score in health-promoting behaviors. While physical activity is a very effective factor in reducing blood pressure, more than half of adults in the United States do not have enough physical activity.²⁵ The study of Fethorechi et al²⁶ on comparing the lifestyle of patients with hypertension and healthy people showed that individuals with hypertension did not have an appropriate lifestyle, and also the overall lifestyle score in patients with hypertension and healthy individuals had significant differences. Hussein et al²⁷ also found that poor behavioral habits in stress management, physical activity, and salt intake were common in patients with hypertension. Despite the effect of lifestyle modification programs, including appropriate physical activity on reducing blood pressure, lack of easy access to sports facilities, transportation problems, child care, lower income levels, and education levels can reduce physical activity.¹² The results of this study showed that the highest score of health promoting behaviors was related to the domain of nutrition. Kemppainen et al¹² indicated that in patients with hypertension in Japan, domains of interpersonal relationships and nutrition had the highest scores, while in the United States, the domains of spiritual growth and interpersonal communication had the highest scores. Given differences in the results of previous studies and the present study, the role of cultural variables influencing health-promoting behaviors in patients with hypertension can be considered.

Health-promoting behaviors in patients with hypertension have a potential impact on their quality of life.¹⁰ Assessing quality of life of patients with hypertension and paying attention to health-promoting behaviors are required for improving quality of life.^6,14 Attention to the quality of life of patients with hypertension provides an overview of the patient’s health status.⁸ The data obtained from the study of quality of life of patients with hypertension in the present study showed that the lowest score was related to the physical dimension and the highest score was related to the dimension of social relationships. In general, patients with hypertension in this study had a worse quality of life. Hayes et al¹⁵ also found that most patients with hypertension (73.2%) had moderate and poor quality of life and had lower quality of life than healthy individuals. The study by Farha et al⁶ indicated that hypertension and drug therapy had negative effects on patients’ quality of life, especially in physical and psychological dimensions. Zhang et al²⁸ assessed the quality of life of patients with hypertension using the EQ-5D tool, which included 5 dimensions of mobility, self-care, normal activity, pain/discomfort, and anxiety/depression. They showed that the highest percentages of problems were in the domain of normal activity and the least percentage of problems was related to domain of anxiety/depression.²⁸ The results of this study showed that patients had a worse quality of life, but a study by Ebadi et al¹⁷ showed that patients with hypertension had a good quality of life, but in general, quality of life was lower compared with healthy individuals.

The impact of lifestyle on reducing the burden of disease and severity of the disease is important. The American Heart Association has given special emphasis on the healthy lifestyle including nutrition and physical activity, along with drug therapies for clinical management.¹⁵ The results of some studies in Iran have shown that poor behavioral habits especially in the area of stress control, physical activity, and salt intake in patients with hypertension have led to a reduction of quality of life in hypertensive patients in comparison with healthy individuals.²⁶ The present study showed significant positive correlations between health-promoting behaviors and quality of life in hypertensive patients, especially in the psychological health dimension. Hypertension reduces physiological and physical capacity, and by restricting the diet and changing daily activities and recreational activities, psychological pressure influences patients’ quality of life.²⁶

In univariate and multivariate analyses, the results of this study showed that the improvement of health-promoting behaviors had the greatest impact on improving the psychological dimension of quality of life and had the least impact on improving the physical and environmental dimensions. Improving the score of individuals in health promoting behaviors can improve the quality of life of patients with hypertension. The more people control their domination over the living environment, especially the stressful conditions of life, the greater the feeling of internal satisfaction, self-efficacy, and self-esteem and a better quality of life. Patients with hypertension often suffer from stressful life situations because they lack cognitive and behavioral skills for controlling environmental stressful events, often have doubts about their abilities, and are always concerned about negative assessments of others about themselves and their behaviors.²⁹ Samiea et al³⁰ showed that healthy lifestyle–based behaviors had a decisive role in reducing anxiety, stress, and depression in patients with hypertension. Also, the results of the study by Babaei-Sis et al³¹ showed that lifestyle educational interventions were effective in promoting physical activity, improving weight control, and improving mental health in patients with hypertension. Therefore, blood pressure can be improved through improving the lifestyle.³¹

In addition to health promoting behaviors, demographic variables such as age, gender, marital status, education level, employment status, and race affected the quality of life of patients with hypertension.^3,23 In the present study, no significant differences in the dimensions of quality of life and health-promoting behaviors between male and female patients were found. Among the demographic variables, higher education and favorable economic status increased the scores related to dimensions of health-promoting behaviors and quality of life. Variables such as gender and marriage did not influence health-promoting and quality of life behaviors. Also, age had a significant relationship with physical health dimension of the quality of life. The results of the study by Zhang et al²⁸ in China showed that men had a significantly higher quality of life than women. It also showed that age increased the quality of life of patients and high education, marriage and employment led to higher quality of life in patients with hypertension. Ahangari et al³² showed a significant difference in the quality of life with age, marital status, and gender. With age, quality of life reduced, and married people had better quality of life than others. A significant relationship was found between psychology and education. In the environment dimension, a significant relationship was found between education and marital status as with the increase of education and marriage, quality of life increased.³²

In terms of generalizability, as the study participants were in a controlled status of hypertension, findings can be generalized to hypertensive patients with controlled blood pressure. Besides, the aim of study was not including patients in acute phase of disease. Being diagnosed as a patient with chronic disease may exacerbate problems in different aspects of life, including psychosocial, emotional, and physical. In this regard, it is recommended to investigate the effect of newly diagnosed hypertension disease on quality of life and health-promoting lifestyle.

Conclusion

Findings of this study indicated that quality of life among hypertensive patients was considerably dependent on appropriate health-promoting lifestyle behaviors. In overall, these patients had lowest scores of health-promoting behaviors in physical activity and stress management. Also, the patients participating in this study had worse quality of life with lowest score in the physical dimension. So according to these finding, designing and implementing educational interventions to improve physical activity and stress management among patients with chronic hypertension is suggested.