Abstract
Aim
To investigate the status and predictors of self‐care among older adults with hypertension in China by the Chinese version of Self‐Care of Hypertension Inventory.
Design
A cross‐sectional questionnaire survey.
Methods
A convenience sampling of 544 older adults with hypertension was surveyed using the Chinese version of Self‐Care of Hypertension Inventory. SPSS25.0 software was used for statistical analysis of the data. Generalized liner model univariate analysis and the optimal scaling regression analysis were performed to investigate the predictors of self‐care.
Results
The status of self‐care was poor with the median and inter‐quartile range of total scores of self‐care (140.00 ± 67), the scores of self‐care maintenance (50 ± 24.76), the scores of self‐care management (56.25 ± 29.41) and the scores of self‐care confidence (54.79 ± 29.17). Age, family model, primary caregiver, maximum systolic blood pressure, coverage of medical insurance, disease duration, receiving self‐care education, education level, economic burden and family history of hypertension were the most powerful predictors of self‐care among older adults with hypertension.
Keywords: hypertension self‐care, older adults, predictors, Self‐care of Hypertension Inventory (SC‐HI)
What does this article contribute to the wider global clinical community?
It was the first time to perform a cross‐sectional survey using the Chinese version of SC‐HI among a large sample of older adults with hypertension in China.
The status of self‐care among older adults with hypertension in China is poor.
The predictors of self‐care among older adults with hypertension in China are age, education level, economic burden, coverage of medical insurance, family model, primary caregiver, disease duration, maximum systolic blood pressure, family history of hypertension and receiving self‐care education.
1. INTRODUCTION
Hypertension is the highest prevalence of cardiovascular diseases in China (Chen et al., 2018). According to the latest report, there are approximately 250 million people with hypertension, with the prevalence rate of 17.9% (Fan et al., 2020). The incidence of hypertension rises as the population grows older (Hansell et al., 2017; Hypertension Branch of Chinese Association for Promotion of International Communication in Medical Care et al., 2019). China has the world's largest elderly population. According to the latest demographic data from the National Bureau of Statistics in 2019, by the end of 2018, China's ageing population aged 60 and above had reached 249 million, accounting for 17.9% of the population (National Bureau of Statistics of China, 2020). Lu et al. (2017) found that over 50% of the older people in China, who have target organ damage, experience hypertension. Therefore, it is very important for medical staff to help elderly patients with hypertension to improve self‐care ability and effectively control their blood pressure.
2. BACKGROUND
Hypertension is a chronic lifelong disease. If blood pressure is not well controlled, it can cause multiple organ damage, even disability and death. WHO reported that the cost of chronic diseases, mainly hypertension and its complications, and the loss of labour force have seriously hindered the development of the global economy (Organization, 2002). Every year, China pays over 40 billion yuan in expenses related to hypertension, causing a heavy burden on families and society (Hypertension Branch of Chinese Association for Promotion of International Communication in Medical Care et al., 2019). Nevertheless, the situation of hypertension control in China is not ideal. The insights from the China PEACE Million Persons Project revealed that 86.1% hypertensive patients were untreated and only 10.3% of the untreated were aware of having hypertension among 2,310,184 participants (Mahajan et al., 2019). A study conducted in Jiangsu province showed that the rates of awareness, treatment and control of hypertension were 56.6%, 45.3% and 12.0% (standardized rates: 52.2%, 41.0% and11.2%), respectively, and all the rates were positively associated with age (Su et al., 2019). Despite the methods of preventing and treating hypertension had attracted great attention and support from the government and medical institutions, targeted interventions should be considered taking into account differences in gender, urban and rural areas, age, etc. (Cao et al., 2019; Yan et al., 2020).
The American nursing theorist Dorothy Orem put the self‐care theory forward in 1959. Orem believed that the ultimate goal of nursing is to maximize the maintenance and promotion of self‐care for clients (Orem, 2001). In the self‐care theory, self‐care is a human regulatory function, deliberately engaged in by a person in order to attain structural integrity and human functioning for the purpose of maintaining life, health and well‐being (Orem, 2001). Self‐care refers to the voluntary adjustment activities carried out by individuals to maintain, recover or improve their own health (Tabrizi et al., 2018). It helped patients make remarkable achievements in correcting bad lifestyle, improving treatment compliance, preventing complications, improving quality of life and reducing medical service costs (Chobanian et al., 2003; Dickson et al., 2017; Riegel et al., 2012; Tabrizi et al., 2018; Vaughan et al., 2017). In terms of hypertension, self‐care has been proved to be one of the main determinants of hypertension control (Eckel et al., 2014; Li et al., 2015), which requires patients not only to be treated with standardized medication, but also pay attention to daily blood pressure monitoring, weight control, low‐salt diet and regular exercise, etc. In fact, intervention studies to improve self‐care ability in patients with hypertension have been conducted and reported good results. For example, the use of a tablet computer‐based self‐monitoring system helped to improve blood pressure control (Or & Tao, 2016). Self‐management education tailored to health literacy had been proved to significantly promote patients with hypertension medication adherence (Delavar et al., 2019). Study protocol of clinical trial had published that the effectiveness of a multi‐factorial intervention consists of self‐management of antihypertensive medication, self‐measurement of blood pressure, hypo‐caloric and low‐sodium diet and physical exercise in patients with uncontrolled hypertension taking two or more antihypertensive drugs (Villafuerte et al., 2020). However, lack of hypertension self‐care will often seriously affect patients’ health, especially older adults (Zhao et al., 2019). Haveman‐Nies et al. (2003) reported that the self‐care ability decreases with ageing. Furthermore, Orem (2001) noted that socio‐cultural norms and values affect people, families, communities and self‐care responsibilities. Therefore, it is very important to improve self‐care among older adults with hypertension in China. For formulating effective self‐care interventions, it is necessary to investigate the status and predictors of self‐care among older adults with hypertension in China.
The status of self‐care among patients with hypertension is mainly evaluated by scales (Chen et al., 2014). A literature review showed that several of the following instruments of measuring self‐care among older adults with hypertension are in use (Han, Lee, et al., 2014; Han, Song, et al., 2014). However, they all have room to be improved. The Exercise of Self‐Care Agency scale (ESCA) (Wang & Laffrey, 2000) and the Self‐Care Ability Scale for the Elderly (SASE) (Süderhamn et al., 1996) are generic scales and needs to be more specified in terms of diseases. Hypertension Self‐Care Profile (HBP SCP) (Han, Song, et al., 2014) has too many items, which is not suitable for elderly population. Hypertension Self‐Care Activity Level Effects (H‐SCALE) (Warren‐Findlow et al., 2013; Warren‐Findlow & Seymour, 2011) is also a general and more suitable method for large‐scale epidemiological investigation. Hill‐Bone Compliance to High Blood Pressure Therapy Scale (HBTS) (Kim et al., 2000) only involves the evaluation of taking medicine. Therapeutic Adherence Scale for Hypertensive Patients (TASHP) (Tang et al., 2011) lacks evaluation of symptom management and self‐efficacy.
In 2017, Dickson et al. (2017) developed a 23‐item Self‐Care of Hypertension Inventory (SC‐HI) based on the middle‐range theory of self‐care, which could evaluate the effectiveness of self‐care interventions. In previous study (Zhao et al., 2019), we cross‐culturally adapted SC‐HI into Chinese and it was proved to be a valid and reliable instrument for measuring self‐care among older adults with hypertension in China. In this study, we further used the Chinese version of SC‐HI to investigate the status and the predictors of self‐care among older adults with hypertension. The results of this study will give the theoretical basis and practical reference for further research.
3. METHOD
3.1. Study design and participants
According to the STROBE statement checklist (for details, see “File S1”), a cross‐sectional observational study was performed. Following the convenient sampling method, we rolled participants of the departments of cardiology and geriatrics of four tertiary hospitals in Nantong City of Jiangsu Province, China from September 2018–February 2019. Based on the sample size of the survey, it is better to estimate 10–20 times of the total items of the main scale (Andreasen et al., 1996). There are 23 items in the Chinese version of SC‐HI and a sample size of 253–552 people is required, considering 10%–20% of the lost follow‐up rate. The inclusion criteria were that patients aged 60 years or older (Xin et al., 2020), being on antihypertensive medications, being able to provide informed consent and communicating without barriers were rolled. Patients were excluded if they had acute or advanced diseases, for example, acute myocardial infarction or advanced cancer, mental illness or other conditions that precluded participation in the study (Zhao et al., 2019). After identification of participants, 544 older adults with hypertension were invited to participate in the study. Before recruiting patients, the institutional review board approved this study.
3.2. Data collection
Data were collected in the departments of cardiology and geriatrics in four hospitals (N = 544). The researchers explained the purpose and procedure of the study to each participant and participants gave the informed consent. Using paper questionnaires, trained researchers collected data in the one‐on‐one and face‐to‐face interviews. For those who had difficulties in filling out the questionnaires, such as with low education level, degradation of vision and hand shake, the researchers explained the items patiently and helped them with the questionnaires. All the questionnaires were completed on the spot for about an hour a person, with a recovery rate of 100% and no missing entries. Each questionnaire was coded for verification and statistical analysis. All data were typed‐in and checked by two researchers to ensure the accuracy and completeness.
3.3. Main research tools
Participants finished the general situation questionnaire and the Chinese version of SC‐HI.
3.3.1. General information questionnaire
After literature review, the general situation questionnaire was compiled containing patients’ demographic data and clinical characteristics, such as gender, age (years), education level, body mass index (BMI, kg/m2), marital status, pre‐retirement occupations, the economic burden, family model, primary caregiver, coverage of medical insurance, maximum systolic blood pressure, maximum diastolic blood pressure, stable systolic blood pressure after medication, stable diastolic blood pressure after medication, classification of hypertension, family history of hypertension, disease duration, co‐morbidity (i.e. cardiovascular disease, kidney disease, stroke) and self‐assessment of health. All answers were self‐reported by participants.
3.3.2. Chinese version of SC‐HI
Chinese version of SC‐HI is a self‐rating scale and includes 23 items divided into three subscales: self‐care maintenance, self‐care management and self‐care confidence. Each of the three scales scored separately and standardized from 0–100 with higher scores indicating better self‐care. Self‐care is considered adequate if the separate score is 70 or greater (Silveira et al., 2018). The Chinese version of SC‐HI has the Cronbach's α coefficients of 0.858 (0.690–0.891 for each dimension) and 0.701 (0.662–0.884 for each dimension) for Guttman, and 0.701 (0.676–0.885 for each dimension) for sibue formula (Zhao et al., 2019). The retest reliabilities of self‐care maintenance scale and self‐care confidence scale are 0.975 and 0.996 respectively (p < .01) (Zhao et al., 2019). The content validity of the total scale is 0.985, and the item level content validity index is 0.8333–1 (Zhao et al., 2019).
3.4. Statistical analysis
Data were analysed using SPSS Version 25.0. Continuous and normally distributed variables were presented as means and standard deviation (mean ± SD) and categorical variables as frequencies (%). Variables were used independent sample t test of the group difference. Not normally distributed data were described by median and inter‐quartile range (IQR, 25%–75%), and Mann–Whitney U test and Kruskal–Wallis H were used to assess group differences. We used the univariate generalized liner model correlation regression analysis (GLM) and the optimal scaling regression analysis to investigate the predictors of self‐care of older adults with hypertension. Compared with other analysis methods, the optimal scaling regression analysis has a wider scope of application and the results are more stable and accurate. Statistical significance is considered when p < .05 (two tail).
4. RESULTS
4.1. Patient characteristics
This study included 544 older adults with hypertension aged 60–93 years, with an average age of (70.56 ± 8.75) years old. Among the 544 participants, 286 were males, 258 were females, 466 had a spouse, 502 had medical insurance, 481 lived with their spouse or children, 454 had spouses or children as the primary caregivers, 303 had a BMI above normal, 468 had a disease course of more than 10 years, 66 had hypertension grade 1, 208 had hypertension grade 2 and 270 had hypertension grade 3, 305 had a family history, 333 had complications, 114 had never received health education and 89 had poor self‐reported health (see Table 1 for details).
TABLE 1.
The demographic and clinical variables of participants
| Variables | Frequencies | Percentage (%) |
|---|---|---|
| Gender | ||
| Males | 286 | 52.27 |
| Females | 258 | 47.43 |
| Age (years) | ||
| 60–74 | 372 | 63.38 |
| 75–89 | 158 | 29.04 |
| ≥90 | 14 | 2.57 |
| Marital status | ||
| Married | 466 | 85.66 |
| Single/divorced/widowed | 78 | 14.34 |
| Education level (years) | ||
| Primary school and below | 234 | 43.01 |
| Middle school | 146 | 26.84 |
| High school/secondary school | 109 | 20.04 |
| College and above | 55 | 10.11 |
| Pre‐retirement occupations | ||
| Farmers | 199 | 36.58 |
| Workers | 150 | 27.57 |
| Institution staff members | 145 | 26.65 |
| Others | 50 | 9.19 |
| Economic burden | ||
| Light | 144 | 26.47 |
| Average | 276 | 50.74 |
| Heavy | 124 | 22.79 |
| Coverage of medical insurance | ||
| Partial | 473 | 86.95 |
| Full | 29 | 5.33 |
| None | 42 | 7.72 |
| Family model | ||
| Living alone | 37 | 6.80 |
| Living with the spouse | 186 | 34.19 |
| Living with children | 68 | 12.50 |
| Living with the spouse and children | 227 | 4.78 |
| Others | 26 | |
| Primary caregiver | ||
| Spouse | 283 | 52.02 |
| Children | 171 | 31.43 |
| Nanny | 15 | 2.76 |
| Others | 75 | 13.79 |
| BMI (kg/m2) | ||
| <18.50 | 26 | 4.78 |
| 18.50–24.99 | 268 | 49.26 |
| 25.00–29.99 | 206 | 37.87 |
| ≥30.00 | 44 | 8.09 |
| Disease duration (years) | ||
| <1 | 13 | 2.39 |
| 1–5 | 153 | 28.13 |
| >5–10 | 137 | 25.18 |
| >10–20 | 165 | 30.33 |
| >20–30 | 47 | 8.64 |
| >30 | 29 | 5.33 |
| Classification of hypertension | ||
| Stage I hypertension | 66 | 12.13 |
| Stage II hypertension | 2088 | 38.24 |
| Stage III hypertension | 270 | 49.63 |
| Maximum systolic blood pressure (mmHg) | ||
| ≤159 | 113 | 20.77 |
| 160–179 | 204 | 37.50 |
| 180–199 | 147 | 27.02 |
| ≥200 | 80 | 14.71 |
| Maximum diastolic blood pressure (mmHg) | ||
| <90 | 79 | 14.52 |
| 90–99 | 148 | 27.21 |
| 100–109 | 192 | 35.29 |
| 110–119 | 68 | 12.50 |
| ≥120 | 57 | 10.48 |
| Stable systolic blood pressure after medication (mmHg) | ||
| <100 | 1 | 0.18 |
| 100–119 | 25 | 4.60 |
| 120–139 | 318 | 58.46 |
| 140–159 | 186 | 34.19 |
| ≥160 | 14 | 2.57 |
| Stable diastolic blood pressure after medication (mmHg) | ||
| <60 | 8 | 1.47 |
| 60–79 | 202 | 37.13 |
| 80–99 | 322 | 59.19 |
| 100–120 | 10 | 1.84 |
| >120 | 2 | 0.37 |
| Family history of hypertension | ||
| Yes | 305 | 56.07 |
| No | 239 | 43.93 |
| Co‐morbidity | ||
| 0 | 211 | 38.79 |
| 1 | 243 | 44.67 |
| 2 | 58 | 10.66 |
| ≥3 | 32 | 5.88 |
| Receiving self‐care education | ||
| Often | 189 | 34.74 |
| Seldom | 241 | 44.30 |
| Never | 114 | 20.96 |
| Self‐assessment of health | ||
| Good | 217 | 39.89 |
| Average | 238 | 43.75 |
| Poor | 89 | 16.36 |
4.2. Self‐care status
The Chinese SC‐HI and three subscales carried out the normality tests of the scores. The results of Kolmogorov–Smirnov tests showed all non‐normally distributed total scores of SC‐HI and the scores of three subscales (shown in Table 2). Table 2 shows the median and inter‐quartile range of the total score of SC‐HI and three subscales’ scores.
TABLE 2.
Scores of the Chinese version of self‐care of hypertension inventory
| Scale | Number of items | Minimum | Maximum | Median | Inter‐quartile range | Z | p |
|---|---|---|---|---|---|---|---|
| Self‐care maintenance | 11 | 0 | 100 | 50 | 24.76 | 0.057 | .000** |
| Self‐care management | 6 | 0 | 100 | 56.25 | 29.41 | 0.061 | .002** |
| Self‐care confidence | 6 | 0 | 100 | 54.79 | 29.17 | 0.056 | .000** |
| SC‐HI | 23 | 28.13 | 300 | 140.92 | 67 | 0.044 | .013* |
**p < .01; *p < .05.
Based on descriptive statistical analysis, we found that among 544 participants, 477 participants got the total scores <210, suggesting a poor status of self‐care for hypertension. On the subscale of self‐care maintenance, 458 (84.19%) participants got the scores <70, indicating poor self‐care maintenance. In this study, a total of 378 participants who had symptom of elevated blood pressure in the past 1 month filled the subscale of self‐care management. Among them, 278 participants (73.54%) got the scores <70, indicating poor self‐care management. On the subscale of self‐care confidence, 418 (76.84%) participants got the scores <70, indicating poor self‐care confidence.
In the self‐care maintenance domain, the lowest‐score item was item 8 “Ask for low‐salt items when eating out or visiting others?” The highest‐score item was item 7 “Take medicines as prescribed?” In the self‐care management domain, the lowest‐score item was item 12 “How quickly did you recognize that your blood pressure was up?” The highest‐score item was item 15 “Be careful to take your prescription medicines more regularly?” In the self‐care confidence domain, the lowest‐score item was item 21 “Evaluate changes in your blood pressure?” The highest‐score item was item 19 “Follow your treatment regimen?” (see Table 3 for details).
TABLE 3.
Scores of each item in the Chinese version of Self‐Care of Hypertension Inventory
| Item | Median | Inter‐quartile range | Average | Standard deviation | Ranking | |
|---|---|---|---|---|---|---|
| Self‐care maintenance | 1 | 3 | 1 | 2.65 | 0.89 | 6 |
| 2 | 3 | 2 | 3.03 | 0.77 | 2 | |
| 3 | 3 | 2 | 2.93 | 0.97 | 3 | |
| 4 | 3 | 1 | 2.46 | 1.03 | 9 | |
| 5 | 3 | 2 | 2.80 | 0.91 | 4 | |
| 6 | 3 | 2 | 2.61 | 1.13 | 7 | |
| 7 | 4 | 1 | 3.47 | 0.75 | 1 | |
| 8 | 2 | 1 | 1.78 | 0.92 | 11 | |
| 9 | 2 | 2 | 2.58 | 1.07 | 8 | |
| 10 | 3 | 1 | 2.77 | 0.85 | 5 | |
| 11 | 2 | 2 | 1.91 | 1.00 | 10 | |
| Self‐care management | 12 | 2 | 1 | 1.69 | 1.17 | 6 |
| 13 | 3 | 2 | 2.91 | 0.92 | 3 | |
| 14 | 3 | 2 | 2.91 | 0.84 | 3 | |
| 15 | 4 | 1 | 3.51 | 0.69 | 1 | |
| 16 | 3 | 1 | 3.06 | 0.81 | 2 | |
| 17 | 3 | 1 | 2.51 | 1.02 | 5 | |
| Self‐care confidence | 18 | 3 | 1 | 2.82 | 0.72 | 4 |
| 19 | 3 | 1 | 3.12 | 0.70 | 1 | |
| 20 | 3 | 1 | 2.70 | 0.76 | 5 | |
| 21 | 3 | 1 | 2.67 | 0.79 | 6 | |
| 22 | 3 | 1 | 2.88 | 0.73 | 2 | |
| 23 | 3 | 1 | 2.84 | 0.78 | 3 |
4.3. GLM univariate analysis of predictors of self‐care
We performed GLM univariate analysis to preliminarily analyse the predictors of self‐care. The demographic and clinical data of participants were the independent variables and the scores of self‐care maintenance scale, self‐care management scale, self‐care confidence scale and SC‐HI were the dependent variables. According to the requirements of the variables in the analysis, the specific assignments of variables are shown in Table 4.
TABLE 4.
Assignment of variables
| Variables name | Variables | Assigning method |
|---|---|---|
| Gender | X1 | X1 = Males, X2 = Females |
| Age (years) | X2 | X1 = 60–74, X2 = 75–89, X3 ≥ 90 |
| Marital status | X3 | X1 = Married, X2 = Single/divorced/widowed |
| Education level (years) | X4 | X1 = Primary school or below, X2 = Middle school, X3 = High school/secondary school, X4 = College degree or above |
| Pre‐retirement occupations | X5 | X1 = Framers, X2 = Workers, X3 = Institution staff members, X4 = Others |
| Economic burden | X6 | X1 = Light, X2 = Average, X3 = Heavy |
| Coverage of medical insurance | X7 | X1 = Partial, X2 = Full, X3 = None |
| Family model | X8 | X1 = Living alone, X2 = Living with the spouse, X3 = Living with children, X4 = Living with the spouse and children, X5 = Others |
| Primary caregiver | X9 | X1 = Spouse, X2 = Children, X3 = Nanny, X4 = Others |
| BMI (kg/m2) | X10 | X1 < 18.50, X2 = 18.50–24.99, X3 = 25.00–29.99, X4 ≥ 30.00 |
| Disease duration (years) | X11 | X1 < 1, X2 = 1–5, X3 > 5–10, X4 > 10–20, X5 > 20–30, X6 > 30 |
| Classification of hypertension | X12 | X1 = Stage I hypertension, X2 = Stage II hypertension, X3 = Stage III hypertension |
| Maximum systolic blood pressure (mmHg) | X13 | X1 ≤ 159, X2 = 160–179, X3 = 180–199, X4 ≥ 200 |
| Maximum diastolic blood pressure (mmHg) | X14 | X1 < 90, X2 = 90–99, X3 = 100–109, X4 = 110–119, X5 ≥ 120 |
| Stable systolic blood pressure after medication (mmHg) | X15 | X1 < 100, X2 = 100–119, X3 = 120–139, X4 = 140–159, X5 ≥ 160 |
| Stable diastolic blood pressure after medication (mmHg) | X16 | X1 < 60, X2 = 60–79, X3 = 80–99, X4 = 100–120, X5 > 120 |
| Family history of hypertension | X17 | X1 = Yes, X2 = No |
| Co‐morbidity | X18 | X1 = 0, X2 = 1, X3 = 2, X4 ≥ 3 |
| Receiving self‐care education | X19 | X1 = Often, X2 = Seldom, X3 = Never |
| Self‐assessment of health | X20 | X1 = Good, X2 = Average, X3 = Poor |
4.3.1. GLM univariate analysis of predictors of self‐care maintenance
The results showed that participants being married, being institution staff members, having light or average economic burden, living with the spouse, having the maximum diastolic blood pressure of 90–99, having the stable diastolic blood pressure of 60–79, 80–99 and 100–120, having family history of hypertension, often receiving self‐care education and their primary caregivers being spouse or children, the self‐assessment of health being good had the statistically significant difference comparing with control group (p < .05), as shown in Table 5.
TABLE 5.
GLM univariate analysis of predictors of self‐care maintenance
| Variables | B | Wald | p | 95% CI | |
|---|---|---|---|---|---|
| Upper bound | Lower bound | ||||
| Gender (referring to females) | −0.286 | 2.911 | .088 | −0.615 | 0.043 |
| Age (years) (referring to ≥90) | |||||
| 60–74 | 0.384 | 0.490 | .484 | −0.692 | 1.461 |
| 75–89 | 0.271 | 0.249 | .617 | −0.792 | 1.334 |
| Marital status (referring to single/divorced/widowed) | −0.741 | 5.168 | .023* | −1.380 | −0.102 |
| Education level (years) (referring to college degree or above) | |||||
| Primary school or below | −0.079 | 0.049 | .825 | −0.778 | 0.621 |
| Middle school | 0.216 | 0.431 | .511 | −0.429 | 0.860 |
| High school/secondary school | 0.100 | 0.104 | .747 | −0.506 | 0.706 |
| Pre‐retirement occupations (referring to others) | |||||
| Farmers | 0.168 | 0.280 | .597 | −0.455 | 0.792 |
| Workers | 0.392 | 1.665 | .197 | −0.204 | 0.988 |
| Institution staff members | 1.157 | 11.834 | .001** | 0.498 | 1.817 |
| Economic burden (referring to heavy) | |||||
| Light | −0.935 | 11.985 | .001** | −1.464 | −0.406 |
| Average | −0.538 | 5.619 | .018* | −0.982 | −0.093 |
| Coverage of medical insurance (referring to none) | |||||
| Partial | 0.166 | 0.286 | .593 | −0.442 | 0.773 |
| Full | −0.187 | 0.143 | .705 | −1.156 | 0.782 |
| Family model (referring to others) | |||||
| Living alone | −0.088 | 0.031 | .861 | −1.067 | 0.891 |
| Living with the spouse | 1.051 | 5.586 | .018* | 0.179 | 1.922 |
| Living with children | 0.217 | 0.222 | .638 | −0.687 | 1.122 |
| Living with the spouse and children | 0.561 | 1.712 | .191 | −0.280 | 1.402 |
| Primary caregiver (referring to others) | |||||
| Spouse | −0.651 | 5.895 | .015* | −1.176 | −0.125 |
| Children | −0.848 | 9.404 | .002** | −1.390 | −0.306 |
| Nanny | 0.337 | 0.352 | .553 | −0.775 | 1.448 |
| BMI (kg/m2) (referring to ≥30.00) | |||||
| <18.50 | 0.186 | 0.171 | .679 | −0.698 | 1.071 |
| 18.50–24.99 | 0.210 | 0.470 | .493 | −0.391 | 0.811 |
| 25.00–29.99 | 0.479 | 2.499 | .114 | −0.115 | 1.072 |
| Disease duration (years) (referring to >30) | |||||
| <1 | −0.851 | 1.830 | .176 | −2.083 | 0.382 |
| 1–5 | −0.157 | 0.152 | .696 | −0.945 | 0.631 |
| >5–10 | 0.111 | 0.077 | .782 | −0.676 | 0.898 |
| >10–20 | −0.392 | 1.004 | .316 | −1.158 | 0.375 |
| >20–30 | 0.354 | 0.634 | .426 | −0.517 | 1.224 |
| Classification of hypertension (referring to stage III hypertension) | |||||
| Stage I hypertension | 0.396 | 1.304 | .253 | −0.283 | 1.075 |
| Stage II hypertension | −0.019 | 0.007 | .933 | −0.471 | 0.432 |
| Maximum systolic blood pressure (mmHg) (referring to ≥200) | |||||
| ≤159 | −0.159 | 0.193 | .661 | −0.866 | 0.549 |
| 160–179 | −0.123 | 0.173 | .678 | −0.702 | 0.456 |
| 180–199 | −0.216 | 0.628 | .428 | −0.751 | 0.318 |
| Maximum diastolic blood pressure (mmHg) (referring to ≥120) | |||||
| <90 | −0.590 | 2.531 | .112 | −1.317 | 0.137 |
| 90–99 | −0.704 | 4.828 | .028* | −1.332 | −0.076 |
| 100–109 | −0.264 | 0.758 | .384 | −0.859 | 0.330 |
| 110–119 | −0.308 | 0.791 | .374 | −0.988 | 0.371 |
| Stable systolic blood pressure after medication (mmHg) (referring to ≥160) | |||||
| <100 | −0.264 | 0.017 | .896 | −4.234 | 3.705 |
| 100–119 | 0.297 | 0.203 | .652 | −0.996 | 1.591 |
| 120–139 | 0.072 | 0.017 | .895 | −0.997 | 1.142 |
| 140–159 | 0.216 | 0.160 | .689 | −0.843 | 1.275 |
| Stable diastolic blood pressure after medication (mmHg) (referring to >120) | |||||
| <60 | 1.547 | 1.330 | .249 | −1.082 | 4.175 |
| 60–79 | 2.435 | 4.682 | .030* | 0.229 | 4.640 |
| 80–99 | 2.231 | 4.000 | .046* | 0.045 | 4.417 |
| 100–120 | 2.998 | 5.897 | .015* | 0.578 | 5.417 |
| Family history of hypertension (referring to no) | 0.324 | 3.946 | .047* | 0.004 | 0.644 |
| Co‐morbidity (referring to ≥3) | |||||
| 0 | −0.071 | 0.037 | .847 | −0.792 | 0.650 |
| 1 | 0.300 | 0.693 | .405 | −0.406 | 1.005 |
| 2 | 0.200 | 0.234 | .628 | −0.610 | 1.009 |
| Receiving self‐care education (referring to never) | |||||
| Often | 0.895 | 12.933 | .000** | 0.407 | 1.382 |
| Seldom | 0.000 | 0.000 | 1.000 | −0.433 | 0.432 |
| Self‐assessment of health (referring to poor) | |||||
| Good | 0.579 | 4.183 | .041* | 0.024 | 1.135 |
| Average | 0.340 | 1.818 | .178 | −0.154 | 0.833 |
**p < .01; *p < .05.
4.3.2. GLM univariate analysis of predictors of self‐care management
The results showed that participants having light or average economic burden, having the maximum systolic blood pressure of ≤159, 160–179 and 180–199 and their primary caregivers being spouse had the statistically significant difference comparing with control group (p < .05), as shown in Table 6.
TABLE 6.
GLM univariate analysis of predictors of self‐care management
| Variables | B | Wald | p | 95% CI | |
|---|---|---|---|---|---|
| Upper bound | Lower bound | ||||
| Gender (referring to females) | −0.136 | 0.441 | .506 | −0.538 | 0.266 |
| Age (years) (referring to ≥90) | |||||
| 60–74 | 0.649 | 0.922 | .337 | −0.676 | 1.975 |
| 75–89 | −0.103 | 0.024 | .877 | −1.410 | 1.204 |
| Marital status (referring to single/divorced/widowed) | −0.297 | 0.568 | .451 | −1.068 | 0.475 |
| Education level (years) (referring to college degree or above) | |||||
| Primary school or below | 0.341 | 0.677 | .411 | −0.471 | 1.153 |
| Middle school | 0.209 | 0.293 | .588 | −0.547 | 0.965 |
| High school/secondary school | 0.234 | 0.379 | .538 | −0.511 | 0.979 |
| Pre‐retirement occupations (referring to others) | |||||
| Farmers | −0.216 | 0.344 | .558 | −0.938 | 0.506 |
| Workers | −0.133 | 0.147 | .702 | −0.816 | 0.549 |
| Institution staff members | 0.692 | 3.388 | .066 | −0.045 | 1.428 |
| Economic burden (referring to heavy) | |||||
| Light | −0.575 | 2.752 | .097 | −1.255 | 0.104 |
| Average | −0.855 | 7.740 | .005** | −1.457 | −0.253 |
| Coverage of medical insurance (referring to none) | |||||
| Partial | 0.514 | 1.558 | .212 | −0.293 | 1.320 |
| Full | −0.009 | 0.000 | .989 | −1.233 | 1.216 |
| Family model (referring to others) | |||||
| Living alone | 1.103 | 3.239 | .072 | −0.098 | 2.305 |
| Living with the spouse | 0.916 | 2.755 | .097 | −0.166 | 1.997 |
| Living with children | 0.569 | 1.001 | .317 | −0.545 | 1.682 |
| Living with the spouse and children | 0.623 | 1.375 | .241 | −0.418 | 1.665 |
| Primary caregiver (referring to others) | |||||
| Spouse | −0.700 | 4.998 | .025* | −1.314 | −0.086 |
| Children | −0.736 | 5.246 | .022* | −1.365 | −0.106 |
| Nanny | 0.525 | 0.542 | .461 | −0.873 | 1.923 |
| BMI (kg/m2) (referring to ≥30.00) | |||||
| <18.50 | −0.076 | 0.020 | .887 | −1.129 | 0.977 |
| 18.50–24.99 | 0.247 | 0.401 | .527 | −0.517 | 1.010 |
| 25.00–29.99 | 0.487 | 1.529 | .216 | −0.285 | 1.260 |
| Disease duration (years) (referring to >30) | |||||
| <1 | 0.026 | 0.001 | .970 | −1.298 | 1.350 |
| 1–5 | −0.520 | 1.284 | .257 | −1.420 | 0.379 |
| >5–10 | −0.136 | 0.087 | .768 | −1.039 | 0.768 |
| >10–20 | −0.140 | 0.100 | .751 | −1.009 | 0.728 |
| >20–30 | 0.446 | 0.730 | .393 | −0.577 | 1.469 |
| Classification of hypertension (referring to stage III hypertension) | |||||
| Stage I hypertension | 0.313 | 0.547 | .460 | −0.516 | 1.142 |
| Stage II hypertension | 0.047 | 0.025 | .874 | −0.528 | 0.621 |
| Maximum systolic blood pressure (mmHg) (referring to ≥200) | |||||
| ≤159 | −1.231 | 7.253 | .007** | −2.126 | −0.335 |
| 160–179 | −0.984 | 7.366 | .007** | −1.695 | −0.273 |
| 180–199 | −0.677 | 4.687 | .030* | −1.289 | −0.064 |
| Maximum diastolic blood pressure (mmHg) (referring to ≥120) | |||||
| <90 | −0.284 | 0.397 | .529 | −1.166 | 0.598 |
| 90–99 | −0.072 | 0.034 | .854 | −0.838 | 0.694 |
| 100–109 | −0.105 | 0.079 | .779 | −0.837 | 0.627 |
| 110–119 | 0.093 | 0.049 | .824 | −0.731 | 0.917 |
| Stable systolic blood pressure after medication (mmHg) (referring to ≥160) | |||||
| <100 | −2.966 | 1.887 | .170 | −7.198 | 1.266 |
| 100–119 | 0.103 | 0.020 | .889 | −1.339 | 1.545 |
| 120–139 | −0.145 | 0.060 | .806 | −1.299 | 1.009 |
| 140–159 | −0.427 | 0.532 | .466 | −1.574 | 0.720 |
| Stable diastolic blood pressure after medication (mmHg) (referring to >120) | |||||
| <60 | −0.066 | 0.002 | .964 | −2.951 | 2.819 |
| 60–79 | 0.456 | 0.153 | .695 | −1.827 | 2.740 |
| 80–99 | −0.043 | 0.001 | .970 | −2.301 | 2.215 |
| 100–120 | −0.101 | 0.006 | .938 | −2.634 | 2.432 |
| Family history of hypertension (referring to no) | 0.067 | 0.114 | .736 | −0.321 | 0.454 |
| Co‐morbidity (referring to ≥3) | |||||
| 0 | 0.114 | 0.059 | .808 | −0.804 | 1.033 |
| 1 | 0.475 | 1.018 | .313 | −0.448 | 1.397 |
| 2 | 0.475 | 0.783 | .376 | −0.577 | 1.527 |
| Receiving self‐care education (referring to never) | |||||
| Often | 0.454 | 2.253 | .133 | −0.139 | 1.046 |
| Seldom | −0.345 | 1.684 | .194 | −0.867 | 0.176 |
| Self‐assessment of health (referring to poor) | |||||
| Good | 0.281 | 0.559 | .455 | −0.455 | 1.016 |
| Average | −0.040 | 0.014 | .905 | −0.706 | 0.625 |
**p < .01; *p < .05.
4.3.3. GLM univariate analysis of predictors of self‐care confidence
The results showed that participants having 0 or 1 co‐morbidity, using partial, and their self‐assessment of health being average had the statistically significant difference comparing with control group (p < .05), as shown in Table 7.
TABLE 7.
GLM univariate analysis of predictors of self‐care confidence
| Variables | B | Wald | p | 95% CI | |
|---|---|---|---|---|---|
| Upper bound | Lower bound | ||||
| Gender (referring to females) | 0.191 | 1.290 | .256 | −0.138 | 0.520 |
| Age (years) (referring to ≥90) | |||||
| 60–74 | −0.056 | 0.010 | .919 | −1.135 | 1.023 |
| 75–89 | −0.569 | 1.096 | .295 | −1.635 | 0.496 |
| Marital status (referring to single/divorced/widowed) | 0.099 | 0.093 | .760 | −0.538 | 0.737 |
| Education level (years) (referring to college degree or above) | |||||
| Primary school or below | −0.350 | 0.955 | .328 | −1.051 | 0.352 |
| Middle school | −0.175 | 0.283 | .595 | −0.821 | 0.470 |
| High school/secondary school | −0.089 | 0.082 | .775 | −0.696 | 0.519 |
| Pre‐retirement occupations (referring to others) | |||||
| Farmers | 0.294 | 0.852 | .356 | −0.330 | 0.919 |
| Workers | 0.140 | 0.213 | .644 | −0.456 | 0.736 |
| Institution staff members | 0.603 | 3.238 | .072 | −0.054 | 1.260 |
| Economic burden (referring to heavy) | |||||
| Light | 0.183 | 0.467 | .495 | −0.343 | 0.709 |
| Average | −0.153 | 0.456 | .500 | −0.597 | 0.291 |
| Coverage of medical insurance (referring to none) | |||||
| Partial | −0.811 | 6.750 | .009** | −1.423 | −0.199 |
| Full | −0.770 | 2.402 | .121 | −1.744 | 0.204 |
| Family model (referring to others) | |||||
| Living alone | 0.073 | 0.021 | .884 | −0.907 | 1.054 |
| Living with the spouse | −0.151 | 0.116 | .734 | −1.021 | 0.718 |
| Living with children | −0.183 | 0.156 | .693 | −1.089 | 0.723 |
| Living with the spouse and children | −0.092 | 0.046 | .830 | −0.933 | 0.749 |
| Primary caregiver (referring to others) | |||||
| Spouse | −0.333 | 1.550 | .213 | −0.858 | 0.191 |
| Children | −0.497 | 3.254 | .071 | −1.038 | 0.043 |
| Nanny | −0.956 | 2.820 | .093 | −2.071 | 0.160 |
| BMI (kg/m2) (referring to ≥30.00) | |||||
| <18.50 | 0.136 | 0.090 | .764 | −0.750 | 1.021 |
| 18.50–24.99 | −0.072 | 0.055 | .815 | −0.673 | 0.530 |
| 25.00–29.99 | 0.424 | 1.957 | .162 | −0.170 | 1.019 |
| Disease duration (years) (referring to >30) | |||||
| <1 | −0.762 | 1.462 | .227 | −1.996 | 0.473 |
| 1–5 | −0.345 | 0.734 | .392 | −1.135 | 0.445 |
| >5–10 | −0.349 | 0.753 | .385 | −1.138 | 0.440 |
| >10–20 | −0.088 | 0.051 | .821 | −0.856 | 0.679 |
| >20–30 | 0.237 | 0.284 | .594 | −0.635 | 1.109 |
| Classification of hypertension (referring to stage III hypertension) | |||||
| Stage I hypertension | 0.022 | 0.004 | .949 | −0.658 | 0.702 |
| Stage II hypertension | −0.347 | 2.260 | .133 | −0.800 | 0.106 |
| Maximum systolic blood pressure (mmHg) (referring to ≥200) | |||||
| ≤159 | −0.158 | 0.192 | .662 | −0.868 | 0.551 |
| 160–179 | −0.037 | 0.016 | .900 | −0.617 | 0.543 |
| 180–199 | −0.223 | 0.665 | .415 | −0.758 | 0.313 |
| Maximum diastolic blood pressure (mmHg) (referring to ≥120) | |||||
| <90 | 0.127 | 0.117 | .733 | −0.600 | 0.854 |
| 90–99 | −0.126 | 0.156 | .693 | −0.754 | 0.501 |
| 100–109 | −0.202 | 0.440 | .507 | −0.797 | 0.394 |
| 110–119 | −0.423 | 1.483 | .223 | −1.104 | 0.258 |
| Stable systolic blood pressure after medication (mmHg) (referring to ≥160) | |||||
| <100 | −3.691 | 3.156 | .076 | −7.762 | 0.381 |
| 100–119 | 0.416 | 0.396 | .529 | −0.880 | 1.712 |
| 120–139 | 0.298 | 0.298 | .585 | −0.773 | 1.370 |
| 140–159 | 0.041 | 0.006 | .940 | −1.020 | 1.102 |
| Stable diastolic blood pressure after medication (mmHg) (referring to >120) | |||||
| <60 | 2.296 | 2.917 | .088 | −0.339 | 4.932 |
| 60–79 | 1.633 | 2.109 | .146 | −0.571 | 3.838 |
| 80–99 | 1.589 | 2.029 | .154 | −0.597 | 3.775 |
| 100–120 | −0.226 | 0.034 | .854 | −2.641 | 2.189 |
| Family history of hypertension (referring to no) | 0.108 | 0.437 | .509 | −0.212 | 0.427 |
| Co‐morbidity (referring to ≥3) | |||||
| 0 | 0.810 | 4.802 | .028* | 0.086 | 1.535 |
| 1 | 1.086 | 8.971 | .003** | 0.375 | 1.796 |
| 2 | 0.329 | 0.632 | .427 | −0.482 | 1.140 |
| Receiving self‐care education (referring to never) | |||||
| Often | 0.139 | 0.319 | .572 | −0.345 | 0.624 |
| Seldom | −0.411 | 3.441 | .064 | −0.845 | 0.023 |
| Self‐assessment of health (referring to poor) | |||||
| Good | 0.260 | 0.840 | .359 | −0.296 | 0.815 |
| Average | −0.533 | 4.441 | .035* | −1.028 | −0.037 |
**p < .01; *p < .05.
4.3.4. GLM univariate analysis of predictors of self‐care
The results showed that participants being institution staff members, living with the spouse, having the maximum systolic blood pressure of ≤159, 160–179 and 180–199, having 0 or 1 co‐morbidity and their primary caregivers being spouse or children, the self‐assessment of health being good had the statistically significant difference comparing with control group (p < .05), as shown in Table 8.
TABLE 8.
GLM univariate analysis of predictors of self‐care
| Variables | B | Wald | p | 95% CI | |
|---|---|---|---|---|---|
| Upper bound | Lower bound | ||||
| Gender (referring to females) | −0.009 | 0.003 | .958 | −0.337 | 0.319 |
| Age (years) (referring to ≥90) | |||||
| 60–74 | 0.543 | 0.978 | .323 | −0.533 | 1.619 |
| 75–89 | −0.036 | 0.004 | .947 | −1.098 | 1.026 |
| Marital status (referring to single/divorced/widowed) | −0.300 | 0.852 | .356 | −0.936 | 0.337 |
| Education level (years) (referring to college degree or above) | |||||
| Primary school or below | 0.137 | 0.149 | .700 | −0.561 | 0.836 |
| Middle school | 0.298 | 0.823 | .364 | −0.346 | 0.942 |
| High school/secondary school | 0.355 | 1.318 | .251 | −0.251 | 0.961 |
| Pre‐retirement occupations (referring to others) | |||||
| Farmers | −0.177 | 0.311 | .577 | −0.800 | 0.446 |
| Workers | −0.046 | 0.023 | .880 | −0.640 | 0.549 |
| Institution staff members | 0.680 | 4.140 | .042* | 0.025 | 1.336 |
| Economic burden (referring to heavy) | |||||
| Light | 0.098 | 0.135 | .714 | −0.426 | 0.623 |
| Average | −0.104 | 0.213 | .645 | −0.547 | 0.338 |
| Coverage of medical insurance (referring to none) | |||||
| Partial | 0.015 | 0.002 | .962 | −0.592 | 0.622 |
| Full | −0.475 | 0.922 | .337 | −1.444 | 0.494 |
| Family model (referring to others) | |||||
| Living alone | 0.674 | 1.820 | .177 | −0.305 | 1.653 |
| Living with the spouse | 0.952 | 4.599 | .032* | 0.082 | 1.822 |
| Living with children | 0.654 | 2.009 | .156 | −0.251 | 1.559 |
| Living with the spouse and children | 0.485 | 1.283 | .257 | −0.354 | 1.325 |
| Primary caregiver (referring to others) | |||||
| Spouse | −1.028 | 14.538 | .000** | −1.556 | −0.499 |
| Children | −1.138 | 16.787 | .000** | −1.682 | −0.594 |
| Nanny | −0.174 | 0.094 | .759 | −1.284 | 0.936 |
| BMI (kg/m2) (referring to ≥30.00) | |||||
| <18.50 | 0.398 | 0.780 | .377 | −0.486 | 1.282 |
| 18.50–24.99 | 0.249 | 0.661 | .416 | −0.351 | 0.849 |
| 25.00–29.99 | 0.557 | 3.387 | .066 | −0.036 | 1.151 |
| Disease duration (years) (referring to >30) | |||||
| <1 | −0.116 | 0.034 | .854 | −1.346 | 1.115 |
| 1–5 | −0.547 | 1.848 | .174 | −1.335 | 0.242 |
| >5–10 | −0.225 | 0.314 | .575 | −1.011 | 0.562 |
| >10–20 | −0.334 | 0.733 | .392 | −1.100 | 0.431 |
| >20–30 | −0.055 | 0.016 | .901 | −0.925 | 0.814 |
| Classification of hypertension (referring to Stage III hypertension) | |||||
| Stage I hypertension | 0.322 | 0.864 | .353 | −0.357 | 1.000 |
| Stage II hypertension | −0.119 | 0.267 | .606 | −0.570 | 0.332 |
| Maximum systolic blood pressure (mmHg) (referring to ≥200) | |||||
| ≤159 | −1.277 | 12.315 | .000** | −1.991 | −0.564 |
| 160–179 | −0.826 | 7.745 | .005** | −1.408 | −0.244 |
| 180–199 | −0.626 | 5.241 | .022* | −1.162 | −0.090 |
| Maximum diastolic blood pressure (mmHg) (referring to ≥120) | |||||
| <90 | 0.184 | 0.246 | .620 | −0.542 | 0.909 |
| 90–99 | 0.055 | 0.030 | .863 | −0.570 | 0.680 |
| 100–109 | −0.058 | 0.036 | .849 | −0.651 | 0.536 |
| 110–119 | −0.076 | 0.048 | .826 | −0.755 | 0.602 |
| Stable systolic blood pressure after medication (mmHg) (referring to ≥160) | |||||
| <100 | −2.082 | 1.057 | .304 | −6.051 | 1.887 |
| 100–119 | −0.029 | 0.002 | .966 | −1.321 | 1.264 |
| 120–139 | −0.273 | 0.251 | .616 | −1.342 | 0.796 |
| 140–159 | −0.479 | 0.786 | .375 | −1.537 | 0.580 |
| Stable diastolic blood pressure after medication (mmHg) (referring to >120) | |||||
| <60 | 0.906 | 0.458 | .498 | −1.717 | 3.528 |
| 60–79 | 1.146 | 1.047 | .306 | −1.049 | 3.341 |
| 80–99 | 0.955 | 0.740 | .390 | −1.221 | 3.131 |
| 100–120 | 0.750 | 0.374 | .541 | −1.655 | 3.156 |
| Family history of hypertension (referring to no) | 0.215 | 1.752 | .186 | −0.104 | 0.535 |
| Co‐morbidity (referring to ≥3) | |||||
| 0 | 0.766 | 4.316 | .038* | 0.043 | 1.489 |
| 1 | 0.880 | 5.942 | .015* | 0.172 | 1.587 |
| 2 | 0.463 | 1.258 | .262 | −0.346 | 1.272 |
| Receiving self‐care education (referring to never) | |||||
| Often | 0.473 | 3.663 | .056 | −0.011 | 0.957 |
| Seldom | −0.324 | 2.148 | .143 | −0.756 | 0.109 |
| Self‐assessment of health (referring to poor) | |||||
| Good | 0.681 | 5.775 | .016* | 0.126 | 1.237 |
| Average | 0.204 | 0.658 | .417 | −0.289 | 0.697 |
**p < .01; *p < .05.
4.4. The optimal scaling regression analysis of predictors of self‐care
Although we had the results of the GLM univariate analyses, we still could not discriminate the combined effects and gradient effects of various factors on self‐care, self‐care maintenance, self‐care management and self‐care confidence. Therefore, we used the optimal scaling regression analysis for further analysing predictors. The results of the optimal scaling regression analysis showed that the regression models were statistically significant. However, the multiple correlation coefficient, coefficient of determination and adjusted coefficient of determination of the models were not very ideal, indicating that there may be other predictors that had not yet been included in the equation and should be investigated in future research.
4.4.1. The predictors of self‐care maintenance
The results of the optimal scaling regression analysis showed that the coverage of medical insurance and disease duration were the important predictors of self‐care maintenance (p < .05). By combining the partial regression coefficients and the meaning of assignments of original variables, it could be known that participants having long disease duration and no medical insurance had better self‐care maintenance, as shown in Table 9.
TABLE 9.
The results of partial regression analysis and significance test of predictors of self‐care maintenance
| Variables | B | SE | t | p |
|---|---|---|---|---|
| Gender | −2.947 | 2.068 | −1.425 | .155 |
| Age (years) | −3.921 | 2.114 | −1.854 | .064 |
| Marital status | −1.616 | 3.088 | −0.523 | .601 |
| Education level (years) | 1.765 | 1.244 | 1.418 | .157 |
| Pre‐retirement occupations | −1.314 | 1.224 | −1.073 | .284 |
| Economic burden | −2.540 | 1.638 | −1.551 | .122 |
| Coverage of medical insurance | 4.560 | 1.764 | 2.584 | .010* |
| Family model | −0.531 | 0.952 | −0.558 | .577 |
| Primary caregiver | 0.060 | 1.074 | 0.056 | .956 |
| BMI (kg/m2) | 2.275 | 1.403 | 1.622 | .105 |
| Disease duration (years) | 1.825 | 0.890 | 2.051 | .041* |
| Classification of hypertension | 0.515 | 2.024 | 0.255 | .799 |
| Maximum systolic blood pressure (mmHg) | 1.267 | 1.412 | 0.898 | .370 |
| Maximum diastolic blood pressure (mmHg) | −0.548 | 1.012 | −0.541 | .589 |
| Stable systolic blood pressure after medication (mmHg) | −3.124 | 1.789 | −1.746 | .081 |
| Stable diastolic blood pressure after medication (mmHg) | −1.945 | 2.065 | −0.942 | .347 |
| Family history of hypertension | −0.488 | 1.992 | −0.245 | .807 |
| Co‐morbidity | −1.212 | 1.264 | −0.959 | .338 |
| Receiving self‐care education | −2.760 | 1.524 | −1.811 | .071 |
| Self‐assessment of health | −1.594 | 1.681 | −0.948 | .343 |
**p < .01; *p < .05.
4.4.2. The predictors of self‐care management
The results of the optimal scaling regression analysis showed that age, maximum systolic blood pressure and receiving self‐care education were the significant predictors of self‐care management (p < .05). By combining the partial regression coefficients and the meaning of assignments of original variables, it could be known that participants would have better self‐care management if they were younger, often received self‐care education and their maximum systolic blood pressure were higher, as shown in Table 10.
TABLE 10.
The results of partial regression analysis and significance test of predictors of self‐care management
| Variables | B | SE | t | p |
|---|---|---|---|---|
| Gender | −0.382 | 2.323 | −0.164 | .870 |
| Age (years) | −4.906 | 2.377 | −2.065 | .040* |
| Marital status | 0.606 | 3.515 | 0.173 | .863 |
| Education level (years) | −0.228 | 1.362 | −0.167 | .867 |
| Pre‐retirement occupations | 0.918 | 1.312 | 0.699 | .485 |
| Economic burden | 0.404 | 1.886 | 0.214 | .831 |
| Coverage of medical insurance | −2.213 | 2.108 | −1.050 | .295 |
| Family model | −1.840 | 1.079 | −1.705 | .089 |
| Primary caregiver | 2.187 | 1.162 | 1.882 | .061 |
| BMI (kg/m2) | 1.742 | 1.583 | 1.101 | .272 |
| Disease duration (years) | 1.690 | 0.986 | 1.714 | .087 |
| Classification of hypertension | −2.443 | 2.276 | −1.073 | .284 |
| Maximum systolic blood pressure (mmHg) | 5.234 | 1.652 | 3.169 | .002** |
| Maximum diastolic blood pressure (mmHg) | 0.658 | 1.113 | 0.591 | .555 |
| Stable systolic blood pressure after medication (mmHg) | −1.235 | 1.969 | −0.628 | .531 |
| Stable diastolic blood pressure after medication (mmHg) | −3.380 | 2.261 | −1.495 | .136 |
| Family history of hypertension | −1.028 | 2.247 | −0.458 | .648 |
| Co‐morbidity | 1.000 | 1.419 | 0.705 | .481 |
| Receiving self‐care education | −4.418 | 1.711 | −2.582 | .010* |
| Self‐assessment of health | 0.011 | 1.975 | 0.005 | .996 |
**p < .01; *p < .05.
4.4.3. The predictors of self‐care confidence
The results of the optimal scaling regression analysis showed that education level, economic burden, family model, primary caregiver, family history of hypertension and receiving self‐care education were the significant predictors of self‐care confidence (p < .05). By combining the partial regression coefficients and the meaning of assignments of original variables, it could be known that participants would have better self‐care confidence if they had higher education level, had heavier economic burden, lived alone, had other primary caregivers, had family history of hypertension and often received self‐care education, as shown in Table 11.
TABLE 11.
The results of partial regression analysis and significance test of predictors of self‐care confidence
| Variables | B | SE | t | p |
|---|---|---|---|---|
| Gender | 1.797 | 1.588 | 1.132 | .258 |
| Age (years) | −0.850 | 1.624 | −0.524 | .601 |
| Marital status | −0.165 | 2.372 | −0.069 | .945 |
| Education level (years) | 2.215 | 0.956 | 2.318 | .021* |
| Pre‐retirement occupations | 0.981 | 0.940 | 1.043 | .297 |
| Economic burden | 3.381 | 1.258 | 2.688 | .007** |
| Coverage of medical insurance | −0.882 | 1.355 | −0.651 | .515 |
| Family model | −1.710 | 0.731 | −2.341 | .020* |
| Primary caregiver | 1.781 | 0.825 | 2.158 | .031* |
| BMI (kg/m2) | 0.953 | 1.077 | 0.885 | .377 |
| Disease duration (years) | 0.715 | 0.683 | 1.047 | .296 |
| Classification of hypertension | −0.270 | 1.554 | −0.174 | .862 |
| Maximum systolic blood pressure (mmHg) | −0.353 | 1.084 | −0.326 | .745 |
| Maximum diastolic blood pressure (mmHg) | 1.034 | 0.777 | 1.330 | .184 |
| Stable systolic blood pressure after medication (mmHg) | 0.916 | 1.374 | 0.667 | .505 |
| Stable diastolic blood pressure after medication (mmHg) | −1.327 | 1.586 | −0.837 | .403 |
| Family history of hypertension | −3.016 | 1.530 | −1.972 | .049* |
| Co‐morbidity | 1.313 | 0.970 | 1.353 | .177 |
| Receiving self‐care education | −5.288 | 1.170 | −4.518 | .000** |
| Self‐assessment of health | −1.866 | 1.291 | −1.445 | .149 |
**p < .01; *p < .05.
4.4.4. The predictors of self‐care
The results of the optimal scaling regression analysis showed that age, family model, primary caregiver, maximum systolic blood pressure and receiving self‐care education were the significant predictors of self‐care (p < .05). By combining the partial regression coefficients and the meaning of assignments of original variables, it could be known that participants would have better self‐care if they were younger, lived alone, had other primary caregivers, often received self‐care education and their maximum systolic blood pressure were higher, as shown in Table 12.
TABLE 12.
The results of partial regression analysis and significance test of predictors of self‐care
| Variables | B | SE | t | p |
|---|---|---|---|---|
| Gender | −1.240 | 4.444 | −0.279 | .780 |
| Age (years) | −10.695 | 4.544 | −2.354 | .019* |
| Marital status | −4.300 | 6.637 | −0.648 | .517 |
| Education level (years) | 2.773 | 2.674 | 1.037 | .300 |
| Pre‐retirement occupations | 4.187 | 2.631 | 1.592 | .112 |
| Economic burden | −3.018 | 3.520 | −0.857 | .392 |
| Coverage of medical insurance | −0.603 | 3.792 | −0.159 | .874 |
| Family model | −5.837 | 2.045 | −2.854 | .004** |
| Primary caregiver | 7.073 | 2.309 | 3.063 | .002** |
| BMI (kg/m2) | 2.401 | 3.014 | 0.797 | .426 |
| Disease duration (years) | 2.868 | 1.912 | 1.500 | .134 |
| Classification of hypertension | −2.383 | 4.349 | −0.548 | .584 |
| Maximum systolic blood pressure (mmHg) | 11.124 | 3.034 | 3.666 | .000** |
| Maximum diastolic blood pressure (mmHg) | −1.056 | 2.176 | −0.486 | .627 |
| Stable systolic blood pressure after medication (mmHg) | −3.212 | 3.846 | −0.835 | .404 |
| Stable diastolic blood pressure after medication (mmHg) | −6.464 | 4.439 | −1.456 | .146 |
| Family history of hypertension | −4.208 | 4.281 | −0.983 | .326 |
| Co‐morbidity | −3.819 | 2.715 | −1.406 | .160 |
| Receiving self‐care education | −10.176 | 3.276 | −3.107 | .002** |
| Self‐assessment of health | −5.954 | 3.613 | −1.648 | .100 |
**p < .01; *p < .05.
4.4.5. Summary of related predictors
This study indicated that age, family model, primary caregiver, maximum systolic blood pressure, receiving self‐care education are the predictors of self‐care. Participants would have better self‐care if they were younger, lived alone, had other primary caregivers, often received self‐care education and had higher maximum systolic blood pressure. Coverage of medical insurance and disease duration are the predictors of self‐care maintenance. They would have better self‐care maintenance if they had none of medical insurance and long disease duration. Age, high systolic blood pressure and receiving self‐care education are the predictors of self‐care management. They would have better self‐care management if they were younger, had higher maximum systolic blood pressure and often received self‐care education. Education level, economic burden, family model, primary caregiver, family history of hypertension and receiving self‐care education are the predictors of self‐care confidence. They would have better self‐care confidence if they had higher education level, had heavier economic burden, lived alone, had other primary caregivers and had family history of hypertension and often received self‐care education. In order to compare all the predictors of self‐care, self‐care maintenance, self‐care management and self‐care confidence, we summarized all the predictors in one table, as shown in Table 13.
TABLE 13.
Summary of predictors of SC‐HI and three domains
| Variables | SC‐HI | Self‐care maintenance | Self‐care management | Self‐care confidence |
|---|---|---|---|---|
| Age (years) | + | + | ||
| Education level (years) | + | |||
| Economic burden | + | |||
| Coverage of medical insurance | + | |||
| Family model | + | + | ||
| Primary caregiver | + | + | ||
| Disease duration (years) | + | |||
| Maximum systolic blood pressure (mmHg) | + | + | ||
| Family history of hypertension | + | |||
| Receiving self‐care education | + | + | + |
5. DISCUSSION
5.1. Overall evaluation of self‐care status
According to Orem's opinion, the ultimate goal of nursing is to maximize the maintenance and promotion of self‐care for clients (Orem, 2001). In order to promote the self‐care ability of elderly patients with hypertension in China, a cross‐sectional study was performed to investigate the status of self‐care among 544 elderly patients with hypertension in China using the Chinese version of SC‐HI. The median and inter‐quartile range of total scores of self‐care was 140.00 ± 67 that of total scores of self‐care maintenance was 50 ± 24.76, that of total scores of self‐care management was 56.25 ± 29.41 and that of total scores of self‐care confidence was 54.79 ± 29.17. According to the classification criteria of the original scale, the self‐care status of patients is good when the score of each dimension is >70 (Silveira et al., 2018). Therefore, according to the scale, the results of this study showed that the status of self‐care among older adults with hypertension in China is poor. This result is consistent with Ademe et al.’s (2019) research, which indicates that self‐care of older adults with hypertension needs to be improved urgently. In this study, the score of self‐care maintenance was the lowest, which indicates that elderly patients lack awareness of long‐term disease management. The medical staff should cultivate older adults with hypertension knowledge of long‐term disease and belief of lifelong self‐care. Self‐care confidence refers to the patient's confidence in controlling symptoms and treatment compliance (Riegel & Dickson, 2008). In this study, participants got the highest scores in this dimension. The reasons might be that the participants were all inpatients who could receive good professional support and felt safe enough.
5.2. Analysis of the self‐care maintenance status
In the subscale of self‐care maintenance, participants got the highest scores of item 7 “Take medicines as prescribed?” Of participants, 331 (60.85%) were able to take medicines daily, and it indicates good medication adherence, which was consistent with Ma et al.’s (2019) research. The possible reason is that with the popularization of health education, most elderly patients have realized the importance of taking medicine during the hypertension treatment and are able to stick to doing it. The lowest scoring item was item 8 “Ask for low salt items when eating out or visiting others?” Of participants, 267 (49.08%) answered “never or rarely.” About item 5 “Eat a low‐salt diet”, 208 (38.42%) participants could not guarantee the daily salt intake <6 g, which was consistent with Li et al.’s (2014) research. The reasons might be related to Chinese food culture and individuals’ eating habits. The food in Chinese restaurant often has heavy taste. Some of elderly people like eating pickled food.
5.3. Analysis of the self‐care management status
In this study, 378 participants had elevated blood pressure in the past 1 month. The highest scoring item was “Be careful to take your prescription medicines more regularly”. Of participants, 339 (89.68%) answered that they would take antihypertensive drugs more regularly, while only 2 (0.53%) participants would not take antihypertensive drugs, which was consistent with Ma et al.’s (2019) research. Taking anti‐hypertensive drugs as prescribed by doctors is the most important measure to control hypertension, stabilize the range of blood pressure fluctuations and reduce the incidence of cardiovascular diseases. In recent years, almost all antihypertensive drugs had been included into the scope of medical insurance, which greatly reduced the financial burden of patients and improved medication adherence. In this study, only 91 (16.73%) elderly patients were always or daily able to measure their blood pressure, which was lower than that reported by Fu‐wai Hospital Chinese Academy of Medical Sciences (Lu et al., 2017). The possible reason is that the participants in the study were all older adults, who were far less familiar with sphygmomanometers than younger patients. Therefore, the low self‐test rate, improper use of the blood pressure meter and inaccurate measurement would lead to miss recognizing fluctuations of blood pressure. In the item of “Evaluate how well an action works?,” 19 (5.03%) participants did not take any measures to deal with elevated blood pressure and others were certain or very certain that the measures taken would reduce blood pressure effectively. It indicates that there is still some room for further improvement.
5.4. Analysis of the self‐care confidence status
In this study, the highest scoring item was “Follow your treatment regimen.” Of the participants, 445 (81.80%) chose “very confident” or “extremely confident,” and only 2 (0.37%) participants chose “not confident.” The lowest scoring item was “Evaluate changes in your blood pressure.” Of the patients, 41.91% had poor confidence in identifying changes in blood pressure. The results showed that older patients have higher self‐efficacy on treatment adherence, but they have difficulties when their blood pressure changes. However, compared with the results of Chen (2015) research, the self‐care confidence in this study was slightly lower. The possible reason is that elderly patients, whose body function, cognitive ability and state of mind were often worse than those of younger patients. Therefore, we should understand the physical and mental characteristics of elderly patients and promote their management of diseases proactively.
5.5. Analysis of predictors of self‐care and related interventions
5.5.1. Predictors of self‐care and related interventions
In this study, we found that the predictors of self‐care among older adults with hypertension in China include age, family model, primary caregiver, maximum systolic blood pressure and receiving self‐care education. In this study, the older the participant was, the worse the self‐care was, as Haveman‐Nies et al. (2003) and Niriayo et al. (2019) reported. It indicates that medical staff should pay more attention to the high‐age elderly with hypertension. Family model refers to the members with whom the older adults live. The results showed that elderly hypertensive patients who lived alone had better self‐care, which may be related to solitude makes people more independent and self‐care aware, as Han et al. (2013) reported. On the contrary, the elderly who lived with spouse and children or with nanny had relatively poor self‐care, probably because they can get more care from others. The results showed that the elderly people who had people other than family members as the primary caregiver had better self‐care, probably because they become more independent, which is consistent with Han et al.’s (2013) research. Therefore, older adults should be encouraged to self‐care even if their primary caregivers are spouse or children. In this study, patients with higher maximum systolic blood pressure had better self‐care, which is consistent with Zhao et al.’s (2019) research. The possible reason is that these patients always have obvious symptoms and are more likely to notice the symptoms affecting their life quality and take self‐care measures. We found that elderly patients who often receive self‐care education had better self‐care, which is consistent with Ademe et al.’s (2019) research. It indicates that hypertension self‐care education should be carried out regularly.
Therefore, to enhance the self‐care of older adults with hypertension, medical staff should pay close attention to high‐age elderly, and give more considerate self‐care guidance. Self‐care should be encouraged for those living with family and have family members as primary caregivers.
5.5.2. Predictors of subscale of self‐care and related interventions
In the subscale domain, we found that predictors of coverage of medical insurance, disease duration would influence self‐care maintenance, which is consistent with Niriayo et al.’s (2019) research. Predictors of age, maximum systolic blood pressure and receiving self‐care education would influence self‐care management, which is consistent with Ademe et al.’s (2019) research. Predictors of education level, economic burden, family model, disease duration, family history of hypertension and receiving self‐care education would influence self‐care confidence, which is consistent with Han et al. (2013), Ademe et al. (2019) and Lee and Park (2017) research.
Participants with higher education levels had better self‐care confidence, which is consistent with Feng et al. (2015), Koukouli et al. (2002) and Darrat et al. (2018) research. Highly educated patients often have better learning abilities, as Visanuyothin et al. (2018) reported that patients with good knowledge and literacy have a lower incidence of hypertension. Participants with family history of hypertension had better self‐care maintenance, which is consistent with Fan et al. (2010) research. The reason might be that these patients’ families have more awareness of disease‐related knowledge and give more care and supervision to patients.
The predictors mentioned earlier indicate that medical staff should pay more attention to the patients having full coverage of medical insurance and having long disease duration who have less self‐care maintenance. Moreover, patients with lower systolic blood pressure should strengthen blood pressure monitoring and timely detect blood pressure fluctuation. Health education should be provided through various forms to improve self‐care management. Patients having lower education level, heavy economic burden, family members as spouse and children, long disease duration and having no family history of hypertension often have lower level of self‐care confidence, who need to be paid special attention.
5.6. Limitations
In this study, 544 participants were all convenience sampled from one city in China due to the constraints of manpower, without fully considering the regional difference. We performed the preliminary analysis of the predictors of self‐care from the perspective of general information among older patients with hypertension, without full consideration of other factors. This study was a cross‐sectional study that we could not confirm the causal relationship between variables.
6. CONCLUSIONS
A cross‐sectional questionnaire survey was conducted in a convenience sampling of 544 older adults with hypertension using the Chinese version of SC‐HI. SPSS25.0 software was used for statistical analysis of the data. We found that the status of self‐care among older adults with hypertension in China is poor and needs more attention. The predictors from this study suggest which groups need special attention to improve self‐care and individualized intervention measures should be performed for older adults with hypertension.
7. RELEVANCE TO CLINICAL PRACTICE
In future study, we hope that multi‐regional and multi‐centre research can improve the representativeness of study results. It is necessary to expand the age stratification of the participants, considering factors including psychological, family and society, to explore more comprehensive predictors of self‐care. In addition, the action paths between variables should be explored on the basis of this study and experimental study should be carried out to identify the casual relationship between variables.
CONFLICT OF INTEREST
The authors have no conflicts of interest to disclose.
AUTHOR CONTRIBUTIONS
All authors have agreed on the final version and meet at least one of the following criteria [recommended by the ICMJE (http://www.icmje.org/recommendations/)]:
substantial contributions to conception and design, acquisition of data or analysis and interpretation of data;
drafting the article or revising it critically for important intellectual content.
ETHICAL APPROVAL
This study was approved by the institutional review board of the Affiliated Hospital of Nantong University (Nantong University Ethical Review 2016‐K142).
Supporting information
File S1
ACKNOWLEDGEMENT
This study was supported by the funding from the Natural Science Foundation of Jiangsu Province (BK 20191447).
Guo, Y.‐J. , Hu, X.‐Y. , Ji, H.‐J. , Zhao, Q. , Wang, L.‐Y. , Zhou, X.‐Y. , Tang, J. , & Sun, X.‐C. (2022). The status and predictors of self‐care among older adults with hypertension in China using the Chinese version of Self‐Care of Hypertension Inventory – A cross‐sectional study. Nursing Open, 9, 1241–1261. 10.1002/nop2.1165
Yu‐Jie Guo, Xiao‐Yun Hu, Hong‐Juan Ji & Qiao Zhao contributed equally to this work and should be considered co‐first authors.
Funding information
Natural Science Foundation of Jiangsu Province (BK 20191447)
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the corresponding author upon reasonable request.
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Associated Data
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Supplementary Materials
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Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.