Background
Self-care is essential for treating hypertension by lowering and controlling blood pressure, to ultimately reduce cardiovascular disease. A valid and reliable hypertension self-care measure is needed for the Thai population.
Objective
The aim of this study was to translate a cross-cultural adaptation of the Self-care of Hypertension Inventory (SC-HI) into Thai and conduct a pretest of the Thai SC-HI (version 2.0).
Methods
We performed a methodological study. The stepped approach included translation of the original version of the SC-HI into Thai (forward), synthesis of translation, translation of the Thai version back to English, expert committee review, and pretesting. Pretest phase for feasibility, interobserver agreement, and temporal stability tests were performed in 140 patients with hypertension.
Results
Translation equivalence was obtained between the Thai and the original US versions. The item-level content validity index was rated by 9 experts; the relevance, clarity, simplicity, and ambiguity criteria were all 1.00. Similarly, the scale-level content validity indices were 1.00 for the overall instrument and the self-care maintenance, self-care management, and self-care confidence scales. The item-level intraclass correlation coefficients (ICCs) had a range of 0.97 to 1.00 for interobserver agreement and 0.95 to 1.00 for test-retest, respectively. The interobserver ICCs were 0.99 for the total scale and 3 separate scales. The test-retest ICCs were 0.99 for the total scale, with a range of 0.97 to 0.99 for the three separate scales.
Conclusion
The process of cross-cultural adaptation warranted validity and reliability testing of the Thai SC-HI. Psychometric testing of this instrument is needed for evaluation in a large sample of individuals with hypertension.
KEY WORDS: cross-cultural, hypertension, measurement, self-care
Hypertension is a substantial risk factor for cardiovascular disease globally.1,2 Thailand is witnessing an upsurge in hypertension due to longer life expectancy, affecting 1 in 4 people. Those with cardiometabolic risk factors (CMRFs) had a prevalence of 30% to 40%, and fewer than 20% achieved the target blood pressure (BP).3 Self-care is essential in hypertension treatment to lower and control BP. Improving self-care is one of the hypertension lifestyle change recommendations.1,4–7 Self-care efforts (eg, dietary change, physical activity, exercise, weight management, medication, and stress reduction) are linked to lower BP4,8–13 and CMRFs,14–17 which is a result of decreased risk of major adverse cardiovascular events.16,18,19
Self-care is crucial in chronic conditions such as hypertension. Self-care is the process of maintaining health and managing illness.20 Regular self-care and situation-specific action are required to control BP and eliminate hypertension-related symptoms. It is essential to have a validated instrument for assessing hypertension self-care across cultures. None of the well-known hypertension self-care instruments21,22 has recently been adapted for Thais. The Self-care of Hypertension Inventory (SC-HI)22 is critical in terms of trustworthy, quantitative, and thorough theoretical constructions within hypertension-specific treatment regimens. Three measurement scales including self-care maintenance, self-care management, and self-care confidence were generated to assess adherence, symptom management, and influence of self-care.22
The SC-HI is presently used in several countries.23–26 The scale, however, has not been adapted for the Thai context, where the living environment and healthcare facilities differ from that of other Asian countries including China.26 Therefore, cross-cultural translation and adaptation procedures are required to identify deficiencies and gaps in the SC-HI for Thais. Because Thailand is not an English-speaking nation, language and cultural background are considered to avoid bias.27 There may be various benefits to a well-developed SC-HI, including theoretical background, scaling methodology and items examined, and cost-benefit. The modified version, on the other hand, must be cross-culturally appropriate, legitimate, and dependable. To adequately describe and quantify self-care as a more culturally relevant term, a clearer self-care notion with examples of acts is required. Given the relevance of this instrument in numerous countries, we used a standard methodological framework to examine the efficacy of a cross-cultural adaptation of the SC-HI, Thai version. The content validity, feasibility, interobserver agreement, and test-retest reliability were investigated in this study.
Theoretical Framework
Self-care is a naturalistic health-maintenance and illness-management decision-making process.20,28 The SC-HI was derived from the situation-specific theory of heart failure self-care28 and the middle-range theory of self-care of chronic illness.20 Self-care maintenance, self-care management, and self-confidence are 3 distinct but intertwined aspects of self-care. The SC-HI consists of 23 items that fall within the 3 components including self-care of hypertension maintenance, self-care of hypertension management, and self-care of hypertension confidence.22 Self-care maintenance is defined as the deliberate actions undertaken to promote one's well-being, preserve health, and maintain physical and emotional stability. Self-care maintenance demands long-term consistency, dedication, and adherence behaviors. Self-care management refers to symptom management entailing monitoring changes in physical and emotional signs and symptoms. Symptoms of elevated or uncontrolled BP must be addressed quickly and effectively. Self-care confidence is not self-care per se, but the motivation for self-care and a combination of self-care and health outcomes.20 Appropriate diet, physical activity and exercise, weight management, stress reduction, BP checkup, follow-up, and medication are required self-care for hypertension.22
Methods
Study Design
We used cross-cultural methodological approaches29–31 with these following steps: translation of the SC-HI original version into Thai (forward), translation synthesis, translation of the Thai version back to English, expert committee evaluation, and pretesting. The previous Thai version 1.0 was derived from the first version of Riegel's Self-care of High Blood Pressure Index and was used in earlier research.32,33 After the current SC-HI22 was released, we began work on an adapted version of the Thai SC-HI (version 2.0) in 2017. The feasibility, interobserver agreement, and temporal stability of the pretest phase were reported in this study.
Instruments
The Self-care of Hypertension Inventory
Self-care maintenance (11 items), self-care management (6 items), and self-care confidence (6 items) are 3 scale measures totaling 23 items.22 Items are scored on a Likert-type scale ranging from 0 to 4 or from 1 to 4. The lowest ratings indicate poor self-care, whereas the highest scores suggest better self-care. The self-care management scale should be given only to individuals who have had increased BP-related symptoms or uncontrolled BP in the preceding 4 weeks. Each scale is standardized to a range of 0 to 100, with a score of 70 or higher being considered adequate self-care.22
Forward Translation
Two doctorally prepared nurses with expertise in instrument development methodology created 2 independent translated versions.
Synthesis of the Translated Versions
Two investigators then evaluated the 2 translated versions and synthesized them into 1 standard version. Two English literature PhDs from the United States and United Kingdom blindly translated this version into English. Any discrepancies between the versions were identified. This step was performed to ensure that the translated Thai SC-HI had the same meaning as the original.
Back-translation
Two translators independently retranslated the Thai SC-HI into English. This step is completed by a Thai-English doctorally prepared nurse and an English native speaker.
Synthesis of the Back-translated Versions
The back-translators and 2 investigators then synthesized the back-translated English versions. All of the wording, phrasing, grammar, meaning equivalency, and relevancy were clarified.
Cross-cultural Adaptation Process
Comparability of the Thai and original SC-HI measures was evaluated. The initial versions were verified by an expert group including all translators, 2 investigators, 2 advanced practice nurses with PhDs in cardiovascular nursing, and 1 Master of Nursing with specialties in hypertension and chronic illness management. The content validity of the prefinal version was assessed during the cross-cultural adaptation process.
Pretesting
Content Validity
Instructions, items, and responder scales were evaluated by the committee members. The appropriateness, sensitivity, and relevance of the prefinal version were discussed and agreed upon.34 To ensure content validity, the basic structure and individual items were extensively evaluated. A 4-point Likert scale was used to determine whether the instrument met 4 criteria: relevance (1, not relevant; 4, very relevant); clarity (1, not clear; 4, very clear); simplicity (1, not simple; 4, very simple); and ambiguity (1, doubtful; 4, meaning is clear).35 The content validity index (CVI) was calculated by multiplying the total of items with replies of 3 and 4 by the number of 9 committee members. Items with a CVI of 0.75 to 0.90 were modified by the committee, whereas items with a CVI of 0.90 or higher were accepted. Finally, the committee determined whether the original SC-HI and the prefinal Thai SC-HI were semantically, idiomatically, experientially, and conceptually equivalent.30 The following criteria were used to evaluate the prefinal draft: (1) identifying any grammatical difficulties in translation and any words or phrases with multiple meanings, (2) formulating equivalence in expressions, (3) asking the committee members to discuss whether items capture their own experience or their clinical experience with hypertension and fixing the text for the Thai adaptation, and (4) evaluating the meaning of similar words or phrases. After the final expert committee meeting, only minor adjustments were made to the instructions. The final format was established by 2 investigators, and the creator, B. Riegel, approved the back-translated version of the Thai SC-HI (website: https://self-care-measures.com).
Feasibility Test
During the feasibility test, the participants with hypertension were asked to clarify their understanding of each item. They were asked whether any terms (item 4: Thai word “mho” to refer to healthcare providers) or examples of behaviors (item 3: physical activity vs item 6: exercise) needed to be modified, clarified, or added. Then, we finished the final version before running the reliability test.
Interobserver Agreement
Interobserver reliability represents the difference between many raters who assess the same set of patients.36 Two investigators independently rated self-care in the same patient within a 2- to 4-hour interval.
Test-Retest Reliability
Test-retest reliability is the variance in measurements gathered by an instrument on the same subject under the same conditions.36 One investigator conducted 2 within-subject tests within 12 to 16 days apart.
Pretest Participants
Pretest participants included 40 cases for feasibility testing, 40 cases for interobserver agreement, and 60 cases for test-retest reliability. Participants might self-administer or have the instrument administered (researcher, relative). We conducted this work under the designation of the Identification of Complex Care Needed in Patients with Hypertension Treated at Primary Care study. Approval was obtained from the Walailak University Ethics Board Committee (code number: 59/075). In brief, the Identification of Complex Care Needed in Patients with Hypertension Treated at Primary Care study included people with hypertension from May 2017 to April 2019 with the goal of discovering multiple CMRFs and self-care. Those receiving antihypertensive medication for at least 6 months at the Health Promotion Hospital (HPH) were eligible. This health center provides primary care in rural communities and subdistricts in Thailand. The pretest participants came from 3 of the 15 study settings. We obtained sociodemographic data, hypertension treatment information, and CMRFs from electronic health records. All data were collected using the following standard procedures: BP was measured twice in the sitting position, an overnight fasting blood sample was taken for glycemic and lipid profiles, body mass index was calculated using body weight in kilograms divided by height in meters squared, a waist circumference measurement was taken between the lowest rib and the iliac crest, and we assessed self-reported daily or occasional cigarette smoking and alcohol consumption within the last 6 months.
Data Analysis
We analyzed the intraclass correlation coefficients (ICCs) based on established recommendations.36 Statistical analyses were performed using SPSS version 18.0. We used the ICC(3, k) model for interobserver reliability, 2-way mixed-effects, consistency, and multiple raters. The 2-way mixed-effects model, absolute agreement, and multiple measurements were selected for test-retest reliability. Correlations (r) and 95% confidence intervals between 2 observers and between time 1 and time 2 ratings of the same participants were analyzed. The correlation values toward 1.00 revealed outstanding reliability. Additional item response analyses, including a description of frequency (percentage), mean (SD), and median (interquartile range), were gathered for the item scores and total scores of the scales at the first-time rating by the overall participants. Raw and standard scores of separated scales, as well as SC-HI, were reported.
Results
Overall, pretest participants were mostly female (70.7%), older adults (63.6%), those who had finished primary school (78.6%), those who had a spouse (72.1%), those who lived with spouse or family members (92.1%), and those who worked in agriculture (84.3%) (Table 1). The mean (SD) age was 69.34 (12.14) years (range, 39–93 years); the mean (SD) duration of hypertension treatment was 5.64 (3.44) years (median, 5 years; range, 0.5–15 years). The median number of CMRFs was 3 (interquartile range, 2.0–4.0), whereas only 6.4% of the participants had none.
TABLE 1.
The Characteristics of the Pretest Sample
| Characteristics | Overall | Feasibility Test | Interobserver Test | Test-Retest |
|---|---|---|---|---|
| Participant, n (%) | 140 (100) | 40 (28.57) | 40 (28.57) | 60 (42.86) |
| Sociodemographic | ||||
| Women | 99 (70.7) | 27 (67.5) | 28 (70.0) | 44 (73.3) |
| Age, mean (SD), y | 69.34 (12.14) | 71.38 (10.25) | 67.08 (13.84) | 69.50 (12.03) |
| Age range, y | 39–93 | 51–86 | 46–93 | 39–92 |
| Age ≥ 65 y | 89 (63.3) | 30 (75.0) | 21 (52.5) | 38 (63.3) |
| Living with spouse or partner | 101 (72.1) | 36 (90.0) | 22 (55.0) | 43 (71.7) |
| Living with family members | 129 (92.1) | 36 (90.0) | 35 (87.5) | 58 (96.7) |
| Primary education | 110 (78.6) | 29 (72.5) | 25 (62.5) | 56 (93.3) |
| Illiterate | 18 (12.9) | 8 (20.0) | 8 (20.0) | 2 (3.3) |
| Agriculture | 118 (84.3) | 29 (72.5) | 31 (77.5) | 58 (96.7) |
| Not working or retired | 81 (57.9) | 28 (70.0) | 27 (67.5) | 26 (43.3) |
| Family income insufficiency | 24 (17.1) | 3 (7.5) | 9 (22.5) | 12 (20.0) |
| Cardiometabolic risk factor | ||||
| SBP ≥ 140 mm Hg | 41 (29.3) | 10 (25.0) | 16 (40.0) | 15 (25.0) |
| DBP ≥ 90 mm Hg | 10 (7.1) | 4 (10.0) | 5 (12.5) | 1 (1.7) |
| SBP or DBP ≥ 140/90 mm Hg | 44 (31.4) | 12 (30.0) | 16 (40.0) | 16 (26.7) |
| FPG > 125 mg/dL or known diabetes | 40 (28.6) | 14 (35.0) | 13 (32.5) | 13 (21.7) |
| Total cholesterol ≥ 200 mg/dL | 74 (52.9) | 18 (45.0) | 19 (47.5) | 37 (61.7) |
| Triglycerides ≥ 150 mg/dL | 52 (37.1) | 20 (50.0) | 16 (40.0) | 16 (26.7) |
| HDL-C < 40 mg/dL | 23 (16.4) | 12 (30.0) | 5 (12.5) | 6 (10.0) |
| LDL-C ≥ 130 mg/dL | 59 (42.1) | 17 (42.5) | 14 (35.0) | 28 (46.7) |
| Body mass index ≥ 25.0 kg/m2 | 45 (32.1) | 10 (25.0) | 19 (47.5) | 16 (26.7) |
| Abdominal obesity | 86 (61.4) | 23 (57.5) | 28 (70.0) | 35 (58.3) |
| Current smoking | 10 (7.1) | 3 (7.5) | 2 (5.0) | 5 (8.3) |
| Current alcohol drinking | 8 (5.7) | 1 (2.5) | 5 (12.5) | 2 (3.3) |
| Blood pressure–lowering medication | 140 (100) | 40 (100) | 40 (100) | 60 (100) |
| Blood glucose–lowering medication | 32 (22.9) | 12 (30.0) | 9 (22.5) | 11 (18.3) |
| Lipid-lowering medication | 56 (40.0) | 9 (22.5) | 0 (0.0) | 47 (78.3) |
| CMRF number, median (IQR) | 3.0 (2.0, 4.0) | 3.0 (2.0, 5.0) | 3.5 (2.0, 4.0) | 3.0 (2.0, 4.0) |
| None | 9 (6.4) | 4 (10.0) | 1 (2.5) | 4 (6.7) |
| 1 | 15 (10.7) | 4 (10.0) | 2 (5.0) | 9 (15.0) |
| 2 | 32 (22.9) | 8 (20.0) | 11 (27.5) | 13 (21.7) |
| 3 | 84 (60.0) | 24 (60.0) | 26 (65.0) | 34 (56.7) |
| Duration of HTN, median (IQR), y | 5.0 (3.0, 7.7) | 6.0 (3.2, 8.0) | 5.0 (2.2, 7.0) | 5.0 (3.0, 7.0) |
| ≤2 | 26 (18.6) | 6 (15.0) | 10 (25.0) | 10 (16.7) |
| >2 | 114 (81.4) | 34 (85.0) | 30 (75.0) | 50 (83.3) |
Values are n (%), mean (SD), and median (IQR).
Abbreviations: DBP, diastolic blood pressure; FPG, fasting plasma glucose; HDL-C, high-density lipoprotein cholesterol; HTN, hypertension; IQR, interquartile range; LDL-C, low-density lipoprotein cholesterol; SBP, systolic blood pressure.
Cross-cultural Adaptation
Tables 2–4 indicate how items and instructions were modified to better fit healthcare contexts and cultures. We added self-care examples to demonstrate certain acts or habits. Only 4 items (1, 7, 18, and 22) required no adaptations. All responses of the scale were clear in meaning, understandability, and agreement. Because not all Thai people knew English, the parts “A, B, and C” were substituted with numerical “1, 2, and 3,” To encompass all self-care linked to hypertension, the term “feeling” was substituted with “manage your hypertension.” In section 1, the phrases “self-care actions the persons with hypertension should do routinely” and “during the last month” were added to indicate self-care maintenance and time frame. The word “routinely” was replaced with “frequently.” In section 2, the term “or symptoms occurred” was added to denote any symptoms patients had as a signal of elevated BP (eg, headache, dizziness, flushing, vision problem, and irregular heartbeat).
TABLE 2.
Original Version and Cross-cultural Adapted Version of the Thai Self-care of Hypertension Inventory: Hypertension Maintenance Scale
| Original Version | Translated, Back-translated, and Adapted Version | Rationale |
|---|---|---|
| 2. Eat lots of fruits and vegetables? | Eat a variety of vegetables, fruits, and grains (especially greens, local vegetables and herbs, a little sweet fruit, rich in fibers, and whole grains, clover, and seeds)? | In both spoken and written Thai, “vegetable” came before “fruit.” So “vegetables and fruits” was used. According to hypertension guidelines, “grains” were added to the items. Eating a variety of vegetables and fruits is recommended. Then, “variety” was added. |
| 3. Do some physical activity? | Exert on doing daily busy activity, nonsedentary (eg, do housework, gardening, farmhand, go elsewhere on foot or bicycle instead of a motorcycle, use stairs rather an elevator) | “Exert on doing” was used instead of “physical activity,” and “daily busy activity” was used instead of “do some.” The word “nonsedentary” is a phrasal modifier to characterize an active lifestyle. Examples of everyday routines activities were included in the adapted version. |
| 4. Keep doctor or nurse appointments? | Attend hospital for routine hypertension follow-up on the date appointed? | The term “keep doctor or nurse” was replaced with “attend hospital.” In Thai words, “hospital” is commonly referred to as a place providing medical care and a person who provided care. Commonly, the hospital is an umbrella term covering all levels of the hospital, hypertension clinic, and healthcare provider. In other words, we say “go to the hospital” in a sense of “to meet doctor/nurse.” A phase “for routine hypertension follow-up…” was also added to specify. Patients were advised to attend on a specified day of the month, and then the term “date appointed” was used. |
| 5. Eat a low salt diet? | Eat a less salty foodstuff? | The word “less salty” is commonly used to express individual experience on the taste sensation and refers to a low-sodium diet. The word “diet” was replaced with “foodstuff” referring to all eatable foods. The meaning covered eatable things such as ready meal, raw food diet, seasoning, fast food, snack, and types and forms of foodstuff containing high sodium. |
| 6. Exercise for 30 minutes? | Exercise for at least a half-hour? | The word “regular” was added to express daily routine, frequency, continuity, and adherence to exercise. The phrase “for 30 minutes” was replaced with “for at least” and “a half-hour.” A counting of duration time in a curtained minute was not a common word used by the patient and healthcare provider; they round up into a half and full hour. |
| 8. Ask for low salt items when eating out or visiting others? | Selected less salty food choices when eating out, visiting others, or bought food (eg, social gathering, merit-making ceremony, visiting others, restaurant, food court, food truck, curry and rice shop, ready meals, course eaten with rice or bag curry) | The item aims at measuring individual's “low salt items” choices on certain situations where they cook by themselves or homemade, and other options for food that is not homemade or “eating out or visiting others.” In general, the word “eating out” was used to capture any places to eat outside the home including “visiting others.” Therefore, the word “ask” was replaced by the word “selected” and “bought food.” Bought food is referred to as not homemade food in general. Several options of eating out and bought food were added to the example to express the Thai context. |
| 9. Use a system (pillbox, reminders) to help you remember your medicines? | Use a system to help you remember your medicines? (eg, family members, friends' group, daily pill box, reminders, mobile phone application) | Family members are a very close network, strong, and important system involving supportive care for older adults and chronically ill people in the Thai context.37 Studied in the US context found that social support had an indirect effect on self-care management through self-care confidence.38 Smartphone-based applications (eg, mobile apps, Line group) are a recent technological system supporting self-care including daily medication reminders.39 |
| 10. Eat a low-fat diet? | Avoiding high-fatty foodstuff? | The original item is difficult to translate to capture a sentence of daily food consumption. “What to eat/good for hypertension” and “what not to eat/bad for hypertension” were listed in self-care manual and treatment guidelines. High-fat and high-cholesterol foods are well known to be prohibited. Both patients and providers kept awareness on “high-fatty…high cholesterol” rather than “eat a diet low….” Thus, the term “eat…” was replaced with “avoiding…” as a common word of awareness. |
| 11. Try to lose weight or control your body weight? | Try to lower your weight or keep control healthy weight, neither gaining weight nor becoming thinner? | Healthy weight is an ideal and target for the weight management of hypertension. Patients who are overweight and obese are recommended to lose some weight. Those with normal weight require stable weight control, whereas gaining some weight is recommended for underweight patients. The phase “lower-your-weight” was used to capture weight management for overweight/obese persons, “keep control” in a commonsense of having a routine, and “healthy weight” to capture a target of weight management for all of the patients. |
TABLE 4.
Original Version and Cross-cultural Adapted Version of the Thai Self-care of Hypertension Inventory: Hypertension Confidence Scale
| Original Version | Translated, Back-translated, and Adapted Version | Rationale |
|---|---|---|
| 19. Follow your treatment regimen? | Follow your hypertension treatment regimen? | The word “hypertension” was added to emphasize the certain regimen. |
| 20. Recognize changes in your health? | Recognize when your health is out of the ordinary? | According to the state of health, the term “changes” is used to determine an improvement or getting better; on the other hand, it more likely refers to deterioration or getting worse including the occurring of symptoms.26 The item was generated toward a negative change in health; therefore, we clarified by adding the phrase “when your health is out of the ordinary.” |
| 21. Evaluate changes in your blood pressure? | Evaluate whether either your blood pressure was up or symptoms occurred? | Similar to item 20, “changes” referred to worsen or “blood pressure was up.” The phrase “or symptoms occurred” was added in item 13. |
| 23. Evaluate how well an action works? | Evaluate how well a self-care action works? | The word “self-care” was added to acquire all of the actions taken to manage hypertension. |
TABLE 3.
Original Version and Cross-cultural Adapted Version of the Thai Self-care of Hypertension Inventory: Hypertension Management Scale
| Original Version | Translated, Back-translated, and Adapted Version | Rationale |
|---|---|---|
| 12. If you had trouble controlling your blood pressure in the past month… | If you had trouble controlling your blood pressure in the past month or had symptoms in the past month. | The phrase “had symptoms” was added. |
| How quickly did you recognize that your blood pressure was up? | How quickly did you recognize that your blood pressure was up or symptoms occurred? | We added the phrase “or symptoms occurred” similar to the above sentence. |
| 13. Reduce the salt in your diet | Reduce the salt or salty recipes in your meal (eg, sodium, fish sauce, soy source, seasoning, monosodium glutamate, fermented fish sauce, shrimp paste, salty sauce, pickled) | There are several “salty recipes” added to the daily meal. The meal is a common word that captured the food eaten on regular occasions. Common recipes that contained high sodium are an example. |
| 14. Reduce your stress level | Mindful relaxation, be aware of stress or overthinking (eg, recreational activities, meditation, to do good things, pray, religious ceremony, consult others, accept things as they are) | Stress and anxiety are the state of an uncomfortable mind, where mindful relaxation is a target and strategy of comfort. In our context, patients do practice a duality of “mindful relaxation” and are “aware of stress” and the principles of Buddhism in general terms.40,41 We also described an uncomfortable mind as a common word “dukkha” in the meaning of suffering exists, when referring to a universal stressor involving body, cognition, and emotion.40,41 The word “overthinking” is a commonly used expression to describe anxiety. Both stress and anxiety are expressed as the individual experience psychosocial wellness that promotes the elevation of blood pressure.42 |
| 15. Be careful to take your prescription medicines more regularly | Be strict on taking your blood pressure–lowering medicines more regularly | The word “be careful” and the phrase “prescription medications” were replaced with “be strict” and “blood pressure lowering,” respectively. Words used to indicate how crucial it is to take medicines and specify to lower blood pressure. |
| 16. Call for doctor/nurse for guidance | Contact your healthcare provider (nurse/doctor), hospital, or hypertension clinic visit for guidance | Patients use several ways to get guidance from healthcare providers. Thus “contact” represents overall action including call, text message via social media or patients' group, personal contact, or walk-in at the hospital/hypertension clinic. A nurse is the first contact. In Thai, “healthcare provider” is an umbrella term referring to those who treated you. |
| 17. Think of an action you tried the last time your blood pressure was up | Think of an action you tried the last time your blood pressure was up or symptoms occurred | We added the phrase “or symptoms occurred” similar to the above sentence. |
| How sure were you that the action helped or did not help? | How sure were you that the action helped or did not help to reduce your blood pressure? | The phrase “to reduce your blood pressure” was added to specify the considered outcome. |
Content Validity
Nine experts gave each item a score of 3 to 4. The relevance, clarity, simplicity, and ambiguity CVIs of the item level were all 1.0. The summation of CVIs for the overall instrument, as well as the maintenance, management, and confidence scales, was 1.0.
Feasibility
The interview lasted 8 to 15 minutes. As expected, older patients who were unable to read and had lower levels of education needed more time during the interview. Well-educated patients finished the interview in 8 to 10 minutes on average.
Interobserver Agreement and Test-Retest Reliability
Table 5 shows the Thai SC-HI interobserver agreement and test-retest reliability. The item-level ICCs among observers ranged from 0.99 to 1.00 and 0.95 to 1.00 for the test-retest reliability. The scale-level ICCs were 0.99 among observers for 3 separate scales and their summation. For self-care maintenance, self-care management, and summation, the test-retest ICCs were 0.99 and 0.97 for self-care confidence.
TABLE 5.
Interobserver Agreement and Test-Retest Reliability of the Thai Self-care of Hypertension Inventory
| Interobserver Agreement | Test-Retest Reliability | ||||
|---|---|---|---|---|---|
| ICC(3, k) | (95% CI) | ICC | (95% CI) | ||
| Item level | |||||
| Self-care of hypertension maintenance | |||||
| 01. | Check your blood pressure? | 1.00 | (1.00–1.00) | 0.98 | (0.98–0.99) |
| 02. | Eat a variety of vegetables, fruits, and grains in moderation (especially greens, local vegetables and herbs, a little sweet fruit, rich in fibers, and whole grains, clover, and seeds)? | 0.99 | (0.98–0.99) | 0.99 | (0.98–0.99) |
| 03. | Exert on doing daily busy activity, nonsedentary (eg, do housework, gardening, farmhand, go elsewhere on foot or bicycle instead of motorcycle, use stairs rather elevator) | 0.99 | (0.98–0.99) | 0.99 | (0.98–0.99) |
| 04. | Attend hospital for routine hypertension follow-up on the date appointed? | 1.00 | (1.00–1.00) | 1.00 | (1.00–1.00) |
| 05. | Eat a less salty foodstuff? | 1.00 | (1.00–1.00) | 0.99 | (0.99–1.00) |
| 06. | Exercise for at least a half-hour? | 1.00 | (1.00–1.00) | 1.00 | (1.00–1.00) |
| 07. | Take medicines as prescribed? | 1.00 | (1.00–1.00) | 1.00 | (1.00–1.00) |
| 08. | Selected less salty food choices when eating out, visiting others, or bought food (eg, social gathering, merit-making ceremony, visiting others, restaurant, food court, food truck, curry and rice shop, ready meals, course eaten with rice or bag curry) | 0.99 | (0.99–0.99) | 0.98 | (0.97–0.98) |
| 09. | Use a system to help you remember your medicines? (eg, family members, friends' group, daily pill box, reminders, mobile phone application) | 1.00 | (1.00–1.00) | 1.00 | (1.00–1.00) |
| 10. | Avoiding high-fatty foodstuff? | 1.00 | (1.00–1.00) | 0.99 | (0.98–0.99) |
| 11. | Try to lower your weight or keep control healthy weight, neither gaining weight nor becoming thinner? | 1.00 | (1.00–1.00) | 0.98 | (0.94–0.99) |
| Self-care of hypertension management | |||||
| 12. | How quickly did you recognize that your blood pressure was up or symptoms occurred? | 1.00 | (1.00–1.00) | 0.99 | (0.98–0.99) |
| 13. | Reduce the salt or salty recipes in your meal (eg, sodium, fish sauce, soy source, seasoning, monosodium glutamate, fermented fish sauce, shrimp paste, salty sauce, pickled) | 1.00 | (1.00–1.00) | 0.99 | (0.99–0.99) |
| 14. | Mindful relaxation, be aware of stress or overthinking (eg, recreational activities, meditation, to do good things, pray, religious ceremony, consult others, accept things as they are) | 0.97 | (0.95–0.98) | 1.00 | (1.00–1.00) |
| 15. | Be strict on taking your blood pressure–lowering medicines more regularly | 1.00 | (1.00–1.00) | 1.00 | (1.00–1.00) |
| 16. | Contact your healthcare provider (nurse/doctor), hospital, or hypertension clinic visit for guidance | 0.99 | (0.98–0.99) | 0.99 | (0.98–0.99) |
| 17. | How sure were you that the action helped or did not help to reduce your blood pressure? | 1.00 | (1.00–1.00) | 0.99 | (0.98–0.99) |
| Self-care of hypertension confidence | |||||
| 18. | Control your blood pressure? | 1.00 | (1.00–1.00) | 0.96 | (0.94–0.97) |
| 19. | Follow your hypertension treatment regimen? | 0.99 | (0.98–0.99) | 0.97 | (0.96–0.98) |
| 20. | Recognize when your health is out of the ordinary? | 1.00 | (1.00–1.00) | 0.99 | (0.98–0.99) |
| 21. | Evaluate whether either your blood pressure was up or symptoms occurred? | 1.00 | (1.00–1.00) | 0.97 | (0.96–0.98) |
| 22. | Take action that will control your blood pressure? | 1.00 | (1.00–1.00) | 0.98 | (0.97–0.99) |
| 23. | Evaluate how well a self-care action works? | 0.99 | (0.98–0.99) | 0.95 | (0.92–0.97) |
| Scale level | |||||
| Self-care of Hypertension Maintenance scale | 0.99 | (0.99–1.00) | 0.99 | (0.99–0.99) | |
| Self-care of Hypertension Management scale | 0.99 | (0.99–0.99) | 0.99 | (0.99–0.99) | |
| Self-care of Hypertension Confidence scale | 0.99 | (0.99–0.99) | 0.97 | (0.95–0.98) | |
| Self-care of Hypertension Inventory total scale | 0.99 | (0.99–1.00) | 0.99 | (0.99–0.97) | |
Abbreviations: CI, confidence interval; ICC, intraclass correlation coefficient.
Item Response
Overall, 19 of the 23 items were given a score of 2 or 3. Four remaining items were rated at the lowest possible scores of 0 or 1 (item 1) or the highest possible scores of 4 (items 4, 7, and 15). Most of the items (52%–88%) were ranked at the median scores of 2 or 3 on the scale. Self-care maintenance, self-care management, self-care confidence, and total SC-HI mean (SD) standard scores were 63.64 (10.32), 62.80 (13.21), 62.14 (14.39), and 63.40 (9.61), respectively. Table 6 contains more details on the item analysis.
TABLE 6.
Self-care of Hypertension Item Response
| Self-care of Hypertension Maintenance Items | |||||||
|---|---|---|---|---|---|---|---|
| Never or Rarely | Sometimes | Frequently | Always or Daily | Mean (SD) | Median (IQR) | ||
| Item 01. | 59.3% | 29.3% | 7.1% | 4.3% | 1.56 (0.80) | 1 (1, 4) | |
| Item 02. | 0.7% | 38.6% | 41.1% | 18.6% | 2.79 (0.74) | 3 (2, 3) | |
| Item 03. | 8.6% | 37.9% | 28.6% | 25.0% | 2.70 (0.94) | 3 (2, 3) | |
| Item 04. | 0.0% | 7.1% | 10.7% | 82.1% | 3.75 (0.57) | 4 (4, 4) | |
| Item 05. | 20.7% | 39.3% | 25.0% | 15.0% | 2.34 (0.97) | 2 (2, 3) | |
| Item 06. | 15.7% | 45.0% | 18.6% | 20.7% | 2.44 (0.99) | 2 (2, 3) | |
| Item 07. | 2.1% | 3.6% | 10.7% | 83.6% | 3.76 (0.62) | 4 (4, 4) | |
| Item 08. | 21.4% | 47.1% | 19.3% | 12.1% | 2.22 (0.92) | 2 (2, 3) | |
| Item 09. | 37.9% | 18.6% | 17.9% | 25.7% | 2.31 (1.22) | 2 (2, 3) | |
| Item 10. | 16.4% | 40.7% | 32.1% | 10.8% | 2.37 (0.88) | 2 (2, 3) | |
| Item 11. | 30.7% | 39.3% | 20.0% | 10.0% | 2.09 (0.95) | 2 (1, 3) | |
| Self-care of Hypertension Management Items | |||||||
|---|---|---|---|---|---|---|---|
| I Did Not Recognize It/Try Anything | Not Quickly/Likely/Sure | Somewhat Quickly/Likely/Sure | Quickly/Likely/Sure | Very Quickly/Likely/Sure | Mean (SD) | Median (IQR) | |
| Item 12. | 17.9% | 21.4% | 30.0% | 4.3% | 3.6% | 1.41 (1.05) | 1 (1, 2) |
| Item 13. | — | 10.7% | 32.1% | 40.0% | 17.1% | 2.64 (0.89) | 3 (2, 3) |
| Item 14. | — | 8.6% | 28.6% | 40.7% | 22.1% | 2.76 (0.89) | 3 (2, 3) |
| Item 15. | — | 0.7% | 12.9% | 19.3% | 67.1% | 3.53 (0.74) | 4 (3, 4) |
| Item 16. | — | 32.9% | 27.9% | 24.3% | 15.0% | 2.21 (1.06) | 2 (1, 3) |
| Item 17. | 10.8% | 12.9% | 59.3% | 12.1% | 5.0% | 1.88 (0.93) | 2 (2, 2) |
| Self-care of Hypertension Confidence Items | |||||||
|---|---|---|---|---|---|---|---|
| Not Confident | Somewhat Confident | Confident | Very Confident | Mean (SD) | Median (IQR) | ||
| Item 18. | 6.4% | 50.7% | 34.3% | 8.6% | 2.44 (0.74) | 2 (2, 3) | |
| Item 19. | 1.4% | 51.4% | 37.1% | 10.0% | 2.54 (0.69) | 2 (2, 3) | |
| Item 20. | 7.9% | 44.3% | 42.9% | 5.0% | 2.44 (0.71) | 2 (2, 3) | |
| Item 21. | 10.0% | 45.7% | 38.6% | 5.7% | 2.39 (0.74) | 2 (2, 3) | |
| Item 22. | 3.6% | 47.9% | 36.4% | 12.1% | 2.55 (0.76) | 2 (2, 3) | |
| Item 23. | 4.3% | 47.1% | 39.3% | 9.3% | 2.56 (0.73) | 2 (2, 3) | |
| Scale level | Raw Scores of the Scales | Standard Scores of the Scales | ||||
|---|---|---|---|---|---|---|
| Lower-Upper | Mean (SD) | Median (IQR) | Lower-Upper | Mean (SD) | Median (IQR) | |
| SCMT Scale | 16–39 of 44 | 28.34 (4.54) | 28 (25, 32) | 15.15–84.85 | 52.55 (13.76) | 51 (42, 63) |
| SCMN Scale | 6–24 of 24 | 14.69 (3.09) | 15 (13, 16) | 10–100 | 53.42 (15.49) | 45 (55, 60) |
| SCSC Scale | 6–24 of 24 | 14.91 (3.45) | 14 (12, 17) | 0–100 | 49.52 (19.19) | 47 (33, 61) |
| SC-HI Total | 34–81 of 92 | 58.20 (8.74) | 58 (53, 65) | 18.31–84.51 | 52.39 (12.31) | 52 (45, 61) |
Abbreviations: IQR, interquartile range; SC-HI, Self-care of Hypertension Inventory; SCSC, Self-care of Hypertension Confidence; SCMN, Self-care of Hypertension Management; SCMT, Self-care of Hypertension Maintenance.
Discussion
The Thai SC-HI was created under the global framework for instrument translations and cross-cultural adaption. This instrument was legitimate and reliable. The good relevance, clarity, simplicity, and ambiguity were reflected by the larger CVIs. Like the original,22 we used a simple term, phrase, and sentence to represent self-care to allow patients and healthcare professionals to communicate their situation congruently. Throughout the procedure, the Thai language was compared with English word by word. A list of synonyms, antonyms, and related words was compiled. Translators, back-translators, and synthesists worked together to select terms that expressed hypertension self-care in Thai context and were easy to understand. The prefinal Thai version incorporated standard Thai terms used by people with hypertension, care providers, and the general public after a consensus was established. Only 1 item was changed (item 10: avoiding high-fatty foodstuff), and examples were added (item 2: local and herbs; item 3: go elsewhere on foot or bicycle instead of a motorcycle; item 8: merry-making ceremony, curry and rice shop, the course has eaten with rice or bag curry) in the final version, which were suggested by participants during the pretest phase.
Three features of the Thai SC-HI support a conceptual equivalence. All scales and items are constructed in accordance with the middle-range theories of Self-Care of Chronic Illness20 and the situation-specific theory of Self-Care of Heart Failure.28 The instrument's synthesists meticulously examined all assumptions, attributions, constructions, conceptions, terminologies, contents, and essential elements. Inquiries regarding the theories were shared, discussed, and clarified during the expert panel phase. Three basic theoretical constructions represent each group of items under the 3 scales. Different assumptions were made to distinguish self-care maintenance, self-care management, and self-confidence. When adjusting items, we used a basic assumption of each theoretical construct to create measurements. The self-care management scale, for example, refers to the deliberate action with aggravation of symptoms.20 Blood pressure measurement is the only clinical way to determine whether hypertension is under control, elevated, or uncontrolled. Only a few patients have home BP monitoring equipment. However, patients typically report symptoms related to BP elevation such as headache, dizziness, and vision problems.43,44 Thus, recognizing the change in bodily symptoms is crucial for people who cannot measure their BP. Patients should intensify regular self-care if their BP is elevated or their health worsens. The Thai version now contains words or phrases describing symptoms and activities. Moreover, terms with 2 or more aspects were thoroughly described based on the self-care of chronic disease theory (eg, the self-care confidence scale items 20, “recognize changes in your health,” and 21, “evaluate changes in your blood pressure”).20 To put it another way, “changes” might mean either something good or something bad depending on how they are accomplished. When it comes to the negative aspects of physical and emotional symptoms, a theoretical term has been used to explain how they evolve as the disease progresses.20
Content validity is the second criterion of conceptual equivalency. Like the Self-care of Heart Failure Index, items measuring hypertension self-care are grounded on situation-specific theory. Maintaining or lowering BP could be achieved by diet, physical activity, exercise, weight control, stress management, and medication. The recommendations for hypertension treatment, diet, and exercise have been carefully evaluated and fitted to Thai culture. A low-salt, low-fat diet is also recommended for BP control. For patients with hypertension, high-fat and high-cholesterol meals such as lard, pig belly, red meat, lean meat, organ meats, chicken skin, processed meats, seafood, egg yolk, fried foods, full-fat dairy products, cooking oil, coconut cream, sweets, and trans fats are all restricted.42 Vegetables, fruits, and grains are suggested in a portion-controlled serving and vary in terms of kind, fiber content, and glycemic index. Reduced BP,12 weight,45 total and low-density lipoprotein cholesterol,15 and a lower risk of developing diabetes,25 metabolic syndrome,14 and cardiovascular disease16 benefit from dietary self-care for individuals with hypertension.
Regular physical activity is a broad term that refers to a person who participates in everyday activities or expends energy doing daily routines. Sedentary habits, on the other hand, are those in which the bulk of waking time is spent on a screen or sitting.37 Household work, skilled labor, recreation, outdoor activity, exercise, and sedentism are all forms of physical activity. Exercise is a formal or scheduled physical exercise with a certain length and intensity. Increased physical activity and exercise are related to lower BP,8 cardiovascular mortality,18 and all-cause mortality.37 A healthy weight is ideal for managing hypertension. Individual attained gains and losses are considered in proportion to their optimal body weight. Even if the target weight is not reached, gradual weight reduction over time reduces BP.9 Dietary restriction, increased physical activity, or a combination of the two are self-care maintenance for weight sustaining.9,45 For stress management, studies have shown a link between psychological stress38 and anxiety39 with an increased risk of hypertension. Blood pressure is lowered through practicing mindfulness (eg, transcendental meditation) and relaxation (eg, biofeedback, yoga, music).6,7 The higher CVI value for these items on the relevance criteria35 is reflected in the entire agreement with the methods mentioned previously of hypertension self-care. Consequently, the Thai version achieved functional equivalence.
Finally, the model for cross-cultural translating instruments was refined to improve efficiency and reinforce the integrity of the desired cultural equivalence.31 The concept analysis is used to conduct an in-depth examination of various cultural diversities. The measured items are characterized as emic, etic, and derived etic perspectives. For illustration, the concepts of “taken medicine” and “checking blood pressure” are universally understood without an adaptation, whereas the “system” they use to remind themselves to take medicine has both etic and emic interpretations. A close-knit family is a unique “system” to Thai and other cultures outside the United States.24,40 Social support41 and daily communication technology46 are essential to support systems for chronically ill individuals. Another example of cultural variations may be seen in stress management. The terms “dukkha” and “overthinking” are often used to refer to an unpleasant condition, a general stressor, or an unpleasant sensation. These 2 terms are deeply ingrained in Thai culture, tradition, and religion.47,48
Diet and physical activity, including exercise, are 2 critical hypertension self-care behaviors. Although eating and moving are essential human necessities, individuals in various cultures may have diverse lifestyles. We discovered that eating is more diversified and intricate than physical lifestyle patterns throughout the translation and adaptation processes. Rice or sticky rice, for example, is the traditional dish of Thais and other Asians, but not of Westerners. At least 1 to 2 courses to be eaten with rice are prepared or purchased by families and individuals. Foods rich in salt and fat are often eaten with rice in Thai culture. A well-known local Thai food cuisine includes Northeast dishes (eg, spicy papaya salad, pork and rice sausage, pickled fish, spicy minced, spicy shredded bamboo-shoot salad, spicy fruit salad), Northern dishes (eg, Hang-le curry, streaky pork with crispy crackling, Thai sausage), Southern dishes (eg, pickled fish organs, spicy curry, sour spicy curry made of tamarind paste, stir-fried pork in shrimp paste), and typical dishes (eg, fried rice with shrimp paste, Chinese sausage, shrimp paste sauce, stir-fried), which are typically high in salt. A variety of seafood is accessible and widely available, including fresh, frozen, salted and dried, pickled, and fermented. Many of the most popular seafood dishes in Thailand are made using ordinary ingredients, including oil, coconut milk, and salty condiments mix such as sea salt, fish source, soy sauce, shrimp paste, seasoning powder, and monosodium glutamate. As a result, people with hypertension should be concerned about their diet with excessive salt and fat. Maintaining a low-sodium, low-fat diet and regulating portion sizes are crucial steps in controlling BP.
The items used to measure healthcare utilization, on the other hand, differ in terms of wording and action. Meeting healthcare providers or visiting the hospital in the Thai context of chronic care follow-up usually entails having a physician or nurse appointment for treatment. Thai words vary from English words in many ways. For example, “doctor” is a word used to refer to a specific medical doctor, but “healthcare providers” include all healthcare professionals. In Thai, the common term “healer” refers to all “healthcare providers.” A “doctor” is a person who has achieved a doctorate, but a “hmo” or “phaeth” is a doctor of medicine. In general, “phaeth” is a standard term used to refer to a physician. The word “hmo” is a common term with a broad connotation that refers to anyone else who provides care, including healthcare professionals (eg, dentists, nurses, pharmacists, physicians, physiotherapists, public health, Thai medicine) and folk medicine practitioners (eg, alternative, complementary, ethnomedicine, herbal, traditional unconventional). According to the semantic criteria, the English word “healthcare provider” is used instead of “doctor” or “nurse” to refer to healthcare professionals who treat patients with hypertension. As a result, the word “healers” is not used in the Thai version to avoid being deceived.
Similar to the Brazilian Portuguese24 and Chinese26 versions, an item “call for doctor/nurse for guidance” was adapted into “contact your provider nurse/doctor or hospital/hypertension clinic for guidance,” to grasp the culture of healthcare. Most patients with hypertension in our country are treated in public healthcare facilities. According to their catchment areas, the residents of the inner-district, inner-city, and urban area or municipality partake in the district, provincial, and university hospitals. They generally contact nurses at the hypertension clinic for information and assistance via phone, walk-in contact, or text message if they need it. Patients in the rural area, on the other hand, may simply walk in to the HPH and meet their primary nurse whenever they choose. They only contact the physician as a last resort because they prefer not to call the physician. Most hypertension clinics, but not all, allow patients to phone a nurse or physician directly; however, all clinics offer the ability to make an official call. The nurses at HPH offered phone numbers and used social media to maintain personal contact with patients in a group setting. In comparison with the United States,22 Thailand and other countries24,26 have a somewhat different approach to patient-provider interactions, including self-care while seeking medical care and consultation.
The Thai SC-HI was found to be feasible and reliable based on the pretest findings. The SC-HI items had a good distribution score at average points. Only 1 item favors the lowest score, whereas the other 3 prefer the highest. However, we were unable to determine the presence of floor and ceiling effects because the principal goals of the pretest were not to discover the scale attenuation. Notably, the highest and lowest score distributions underlined the significance of self-care rather than response bias. We concluded this based on the mean score and the degree of inadequate self-care. The standard mean scores of the scales were approximately identical to the median, suggesting that the distribution was symmetrical. Furthermore, the fact that the mean scores of the 3 scales, as well as the overall SC-HI score, were both less than 70 implies poor self-care. Although these scores were inaccessible from the original test,22 the inadequate self-care found in our study is consistent with that of the Polish.25
Considering self-care, sociodemographics are essential. Pretest participants were indeed chosen depending on age, sex, and educational background. The self-administered instrument was delivered effectively by participants. As anticipated, participants who were older, were less educated, and preferred to have the test administered by someone else took longer to finish. After the pretest, minor word improvements and examples were necessary. The test-retest reliability was measured within a suitable time interval. We assumed self-care behavior remained constant during 2 weeks. Overall, the Thai SC-HI was proven to be valid, feasible, and reliable. The primary characteristics of the present study participants, such as their age, sex, primary education, and multiplex CMRF, are representative of the population with hypertension in Thailand3 and other low- and middle-income countries.2
Limitations and Strengths
The pretest sample was drawn from 3 rural villages with distinct HPH facilities. Although the HPH included vital care services for patients with hypertension all across the nation, the adapted items may not be sufficient to accommodate the urbanized lifestyle. To close the gap created by the constraint, participants who live in the city or are treated at higher levels of healthcare services must be engaged. In addition, we only offered a basic test of the instrument with a limited sample. Furthermore, the internal consistency, construct validity, criterion validity, and floor and ceiling effects should be considered in the psychometric assessment. In addition, the large-scale research requires an understanding of the similarities and variations in hypertension self-care across countries. The panel's cultural knowledge is a general strength. Eight of 9 members had studied in Western environments throughout their doctorates. Our pretest was composed of women, seniors, low-educated individuals, and individuals with CMRFs. The use of the Thai SC-HI may be inferred based on these comparable characteristics.
Conclusions
The Thai SC-HI was translated and cross-culturally adapted in accordance with the international framework for research instruments. A translation process and the appointment of a judging committee were carried out to ensure cultural appropriateness. The Thai SC-HI proved the theoretical construct, hypertension care regimens, self-care culture, and healthcare service. This instrument has been found to be valid and trustworthy in patients with a wide range of socioeconomic backgrounds.
What’s New and Important
We conducted the first cross-cultural adaptation of the SC-HI in Southeast Asia, where hypertension incidence and unfavorable health outcomes significantly increased.
A universal concept of self-care provides a specific framework to measure self-care actions across cultures. Our study delivers a trustworthy, valid, feasible, and reliable instrument.
Acknowledgments
The authors thank research assistants for their contribution to data collection. The research team is grateful to the developer of the SC-HI, Barbara Riegel, PhD, RN, FAHA, FHFSA, FAAN, for her review of the final back-translation of the SC-HI Thai version. The corresponding author would like to acknowledge Dr Riegel for her lifelong mentoring. Finally, they would also like to thank Editage (www.editage.com) for English-language editing.
Footnotes
The research was financially supported by Walailak University under the National Research Council of Thailand (NRCT grant #WU60115), the Excellent Center of Community Health Promotion of Walailak University, and the new strategies research project (P2P), Walailak University, Thailand.
The authors have no conflicts of interest to disclose.
Contributor Information
Chennet Phonphet, Email: chennet.p@gmail.com.
Ladda Thiamwong, Email: ladda.thiamwong@ucf.edu.
Chidchanok Mayurapak, Email: cmayurapak@gmail.com.
Putrada Ninla-aesong, Email: putrada.ni@mail.wu.ac.th.
REFERENCES
- 1.Mills KT, Stefanescu A, He J. The global epidemiology of hypertension. Nat Rev Nephrol. 2020;16(4):223–237. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Sarki AM, Nduka CU, Stranges S, Kandala NB, Uthman OA. Prevalence of hypertension in low- and middle-income countries: a systematic review and meta-analysis. Medicine (Baltimore). 2015;94(50):e1959. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Aekplakorn W Sangthong R Kessomboon P, et al. Changes in prevalence, awareness, treatment and control of hypertension in Thai population, 2004–2009: Thai National Health Examination Survey III–IV. J Hypertens. 2012;30(9):1734–1742. [DOI] [PubMed] [Google Scholar]
- 4.Barnason S White-Williams C Rossi LP, et al. Evidence for therapeutic patient education interventions to promote cardiovascular patient self-management: a scientific statement for healthcare professionals from the American Heart Association. Circ Cardiovasc Qual Outcomes. 2017;10(6):e000025. [DOI] [PubMed] [Google Scholar]
- 5.Chobanian AV Bakris GL Black HR, et al. The seventh report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure: the JNC 7 report. JAMA. 2003;289(19):2560–2572. [DOI] [PubMed] [Google Scholar]
- 6.Umemura S Arima H Arima S, et al. The Japanese Society of Hypertension guidelines for the management of hypertension (JSH 2019). Hypertens Res. 2019;42(9):1235–1481. [DOI] [PubMed] [Google Scholar]
- 7.Williams B Mancia G Spiering W, et al. 2018 ESC/ESH guidelines for the management of arterial hypertension. Eur Heart J. 2018;39(33):3021–3104. [DOI] [PubMed] [Google Scholar]
- 8.Börjesson M, Onerup A, Lundqvist S, Dahlöf B. Physical activity and exercise lower blood pressure in individuals with hypertension: narrative review of 27 RCTs. Br J Sports Med. 2016;50(6):356–361. [DOI] [PubMed] [Google Scholar]
- 9.Horvath K Jeitler K Siering U, et al. Long-term effects of weight-reducing interventions in hypertensive patients: systematic review and meta-analysis. Arch Intern Med. 2008;168(6):571–580. [DOI] [PubMed] [Google Scholar]
- 10.Nagele E Jeitler K Horvath K, et al. Clinical effectiveness of stress-reduction techniques in patients with hypertension: systematic review and meta-analysis. J Hypertens. 2014;32(10):1936–1944. [DOI] [PubMed] [Google Scholar]
- 11.Rainforth MV Schneider RH Nidich SI, et al. Stress reduction programs in patients with elevated blood pressure: a systematic review and meta-analysis. Curr Hypertens Rep. 2007;9(6):520–528. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Saneei P, Salehi-Abargouei A, Esmaillzadeh A, Azadbakht L. Influence of Dietary Approaches to Stop Hypertension (DASH) diet on blood pressure: a systematic review and meta-analysis on randomized controlled trials. Nutr Metab Cardiovasc Dis. 2014;24(12):1253–1261. [DOI] [PubMed] [Google Scholar]
- 13.Semlitsch T Jeitler K Hemkens LG, et al. Increasing physical activity for the treatment of hypertension: a systematic review and meta-analysis. Sports Med. 2013;43(10):1009–1023. [DOI] [PubMed] [Google Scholar]
- 14.Azadbakht L, Mirmiran P, Esmaillzadeh A, Azizi T, Azizi F. Beneficial effects of a Dietary Approaches to Stop Hypertension eating plan on features of the metabolic syndrome. Diabetes Care. 2005;28(12):2823–2831. [DOI] [PubMed] [Google Scholar]
- 15.Obarzanek E Sacks FM Vollmer WM, et al. Effects on blood lipids of a blood pressure-lowering diet: the Dietary Approaches to Stop Hypertension (DASH) trial. Am J Clin Nutr. 2001;74(1):80–89. [DOI] [PubMed] [Google Scholar]
- 16.Schwingshackl L, Hoffmann G. Diet quality as assessed by the Healthy Eating Index, the Alternate Healthy Eating Index, the Dietary Approaches to Stop Hypertension score, and health outcomes: a systematic review and meta-analysis of cohort studies. J Acad Nutr Diet. 2015;115(5):780–800.e5. [DOI] [PubMed] [Google Scholar]
- 17.Shirani F, Salehi-Abargouei A, Azadbakht L. Effects of Dietary Approaches to Stop Hypertension (DASH) diet on some risk for developing type 2 diabetes: a systematic review and meta-analysis on controlled clinical trials. Nutrition. 2013;29(7–8):939–947. [DOI] [PubMed] [Google Scholar]
- 18.Pescatello LS Buchner DM Jakicic JM, et al. Physical activity to prevent and treat hypertension: a systematic review. Med Sci Sports Exerc. 2019;51(6):1314–1323. [DOI] [PubMed] [Google Scholar]
- 19.Rossi A, Dikareva A, Bacon SL, Daskalopoulou SS. The impact of physical activity on mortality in patients with high blood pressure: a systematic review. J Hypertens. 2012;30(7):1277–1288. [DOI] [PubMed] [Google Scholar]
- 20.Riegel B, Jaarsma T, Strömberg A. A middle-range theory of self-care of chronic illness. ANS Adv Nurs Sci. 2012;35(3):194–204. [DOI] [PubMed] [Google Scholar]
- 21.Han HR, Song HJ, Nguyen T, Kim MT. Measuring self-care in patients with hypertension: a systematic review of literature. J Cardiovasc Nurs. 2014;29(1):55–67. [DOI] [PubMed] [Google Scholar]
- 22.Dickson VV, Lee C, Yehle KS, Abel WM, Riegel B. Psychometric testing of the Self-care of Hypertension Inventory. J Cardiovasc Nurs. 2017;32(5):431–438. [DOI] [PubMed] [Google Scholar]
- 23.Alsaqer K, Bebis H. Cross-cultural adaptation, validity, and reliability of the Arabic version of the Self-care of Hypertension Inventory scale among older adults. J Cardiovasc Nurs. 2021;36(5):430–436. [DOI] [PubMed] [Google Scholar]
- 24.Silveira LCJ, Rabelo-Silva ER, Ávila CW, Beltrami Moreira L, Dickson VV, Riegel B. Cross-cultural adaptation of the Self-care of Hypertension Inventory into Brazilian Portuguese. J Cardiovasc Nurs. 2018;33(3):289–295. [DOI] [PubMed] [Google Scholar]
- 25.Świątoniowska-Lonc N, Polański J, Jankowska-Polańska B. Psychometric properties of the Polish version of the Self-care of Hypertension Inventory. J Cardiovasc Nurs. 2021;36(5):437–445. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Zhao Q, Guo Y, Gu Y, Yang L. Translation and cross-cultural adaptation of the Chinese version of the Self-care of Hypertension Inventory in older adults. J Cardiovasc Nurs. 2019;34(2):124–129. [DOI] [PubMed] [Google Scholar]
- 27.Saengsiri A, Hacker ED. Conducting quality of life research in people with coronary artery disease in non–English-speaking countries: conceptual and operationalization issues. J Cardiovasc Nurs. 2015;30(1):74–84. [DOI] [PubMed] [Google Scholar]
- 28.Riegel B, Dickson VV, Faulkner KM. The situation-specific theory of heart failure self-care: revised and updated. J Cardiovasc Nurs. 2016;31(3):226–235. [DOI] [PubMed] [Google Scholar]
- 29.Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine J. 2000;25(24):3186–3191. [DOI] [PubMed] [Google Scholar]
- 30.Beaton D, Bombardier C, Guillemin F, Ferraz MB. Recommendations for the Cross-Cultural Adaptation of the DASH & Quick DASH Outcome Measures. Toronto, ON: Institute for Work and Health; 2007. [Google Scholar]
- 31.Jones PS, Lee JW, Phillips LR, Zhang XE, Jaceldo KB. An adaptation of Brislin's translation model for cross-cultural research. Nurs Res. 2001;50(5):300–304. [DOI] [PubMed] [Google Scholar]
- 32.Pantong U. Predictive Factors of Micro-albuminuria in People with Hypertension at a Primary Care Unit [unpublished thesis]. Nakhon Si Thammarat, Thailand: Walailak University School of Nursing; 2015. [Google Scholar]
- 33.Panthong U, Suwanno J, Petsirasan R, Sameanphet T. Prevalence of microalbuminuria among hypertensive persons attending primary care service. J Nurs Health Sci. 2016;34(1):93–102. [Google Scholar]
- 34.Hardesty DM, Bearden WO. The use of expert judges in scale development: implications for improving face validity of measures of unobservable constructs. J Bus Res. 2004;57(2):98–107. [Google Scholar]
- 35.Yaghmaie F. Content validity and its estimation. J Med Edu. 2003;3(1):25–27. [Google Scholar]
- 36.Koo TK, Li MY. A guideline of selecting and reporting intraclass correlation coefficients for reliability research. J Chiropr Med. 2016;15(2):155–163. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37.Ekelund U Steene-Johannessen J Brown WJ, et al. Does physical activity attenuate, or even eliminate, the detrimental association of sitting time with mortality? A harmonised meta-analysis of data from more than 1 million men and women. Lancet. 2016;388(10051):1302–1310. [DOI] [PubMed] [Google Scholar]
- 38.Liu MY, Li N, Li WA, Khan H. Association between psychosocial stress and hypertension: a systematic review and meta-analysis. Neurol Res. 2017;39(6):573–580. [DOI] [PubMed] [Google Scholar]
- 39.Pan Y, Cai W, Cheng Q, Dong W, An T, Yan J. Association between anxiety and hypertension: a systematic review and meta-analysis of epidemiological studies. Neuropsychiatr Dis Treat. 2015;11:1121–1130. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 40.Klainin P, Ounnapiruk L. A meta-analysis of self-care behavior research on elders in Thailand. Nurs Sci Q. 2010;23(2):156–163. [DOI] [PubMed] [Google Scholar]
- 41.Salyer J, Schubert CM, Chiaranai C. Supportive relationships, self-care confidence, and heart failure self-care. J Cardiovasc Nurs. 2012;27(5):384–393. [DOI] [PubMed] [Google Scholar]
- 42.Sacks FM Lichtenstein AH Wu JHY, et al. Dietary fats and cardiovascular disease: a presidential advisory from the American Heart Association. Circulation. 2017;136(3):e1–e23. [DOI] [PubMed] [Google Scholar]
- 43.Erickson SR, Williams BC, Gruppen LD. Relationship between symptoms and health-related quality of life in patients treated for hypertension. Pharmacotherapy. 2004;24(3):344–350. [DOI] [PubMed] [Google Scholar]
- 44.Hagen K, Stovner LJ, Vatten L, Holmen J, Zwart JA, Bovim G. Blood pressure and risk of headache: a prospective study of 22 685 adults in Norway. J Neurol Neurosurg Psychiatry. 2002;72(4):463–466. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 45.Soltani S, Shirani F, Chitsazi MJ, Salehi-Abargouei A. The effect of dietary approaches to stop hypertension (DASH) diet on weight and body composition in adults: a systematic review and meta-analysis of randomized controlled clinical trials. Obes Rev. 2016;17(5):442–454. [DOI] [PubMed] [Google Scholar]
- 46.Kumar N, Khunger M, Gupta A, Garg N. A content analysis of smartphone–based applications for hypertension management. J Am Soc Hypertens. 2015;9(2):130–136. [DOI] [PubMed] [Google Scholar]
- 47.Sumedho (born R.K. Jackman) . The Four Noble Truths. Hertfordshire, United Kingdom: Amaravati; 1992. [Google Scholar]
- 48.Van Gordon W, Shonin E, Griffiths M, Singh N. Mindfulness and the four noble truths. In: Shonin E., Gordon W., Singh NN, eds. Buddhist Foundations of Mindfulness. New York, NY: Springer International Publishing; 2015:9–27. [Google Scholar]