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Hypertension is a serious health issue and a significant risk factor for cardiovascular disease and stroke. Although various health education models have been used to improve lifestyle in patients with hypertension, the findings have been inconsistent.
This study aims to assess the effects of a lifestyle intervention program using a modified Beliefs, Attitude, Subjective Norms, Enabling Factors (BASNEF) model among nonadherent participants with hypertension in managing elevated blood pressure (BP) levels.
This study reports a quantitative quasi-experimental research work, particularly using a repeated-measures design of the within-subjects approach on the 50 nonadherent patients who received a diagnosis of essential hypertension in Cebu, Philippines. The research participants received 5 sessions of training based on a modified BASNEF model. An adherence instrument was used as an evaluation platform. The first phase gathers participants' relevant profiles and background, and the final phase gathers participants' systolic BP, diastolic BP, heart rate, and adherence scores.
The results indicate that the phase 1 mean systolic readings (146.50, SD 19.59) differ significantly from the phase 4 mean systolic readings (134.92, SD 15.24). They also suggest that the lifestyle intervention based on session III or phase IV behavioral intention in the BASNEF model microgroup sessions positively affects BP readings among the research participants.
This study has established that the BASNEF model approach can be a good BP management technique.
The third goal (ie, goal 3, to ensure healthy lives and promote well-being for all ages) of the United Nations Sustainable Development Goals targets reducing premature deaths from noncommunicable diseases by one-third through prevention and treatment by the year 2030 [
Hypertension is the most common cardiovascular disease, often resulting in stroke, heart attack, kidney disease, and aneurysm [
The traditional approach in managing hypertension involves following health guidelines to prevent adverse health issues. Despite these guidelines, encouraging patients to modify their lifestyle over time remains a considerable challenge in hypertension management. How health education is implemented is crucial in helping patients change their lifestyle over the long term [
Various literature models were offered as supportive behavioral change tools and current sociocultural contexts [
As a healthy lifestyle is widely believed to be a critical factor in reducing disease incidence, severity, and complications, particularly in hypertension, the BASNEF model addresses a significant gap. As a framework, the BASNEF model considers environmental and social norms in changing behavior, in addition to the knowledge and attitude of patients. A prerequisite for an effective health education model is an understanding of the factors underlying the behavior of a person. Conceptually, the BASNEF model is a simplified behavioral understanding approach based on the Predisposing, Reinforcing, and Enabling Constructs in Educational/Environmental Diagnosis and Evaluation model and value expectation theory. Applying the BASNEF strategy involves assessing the group outlook for behavior with adequately defined actions. In addition to adequately defined actions, it is also essential to pay attention to the facilities and knowledge that a motivated person needs to ensure that all enabling factors are available for a motivated person. With these factors in place and a good understanding of the immediate community, it is possible to use the BASNEF model to design health education interventions.
Few studies have explored the BASNEF model to improve the lifestyle of patients with hypertension. The model has been used to develop lifestyle changes in different domains, including investigations for several interventions [
In patients with hypertension, health education has been shown to have a significant impact on self-care behaviors. The prevalence of precautionary measures via health education is a robust tool for healthier lifestyles while safeguarding from complications of hypertension. It was also found that the use of these preventive procedures in educating self-care behaviors in patients with hypertension without a holistic educational structure is less vital than conventional teaching, considering the long history of design and educational structures in global health systems and given that these approaches are preferred educational instruments [
This study aims to determine if there is significant evidence to support the following research hypotheses (RH):
The different phases of medication significantly differ in systolic BP readings (RH1), diastolic BP readings (RH2), and HR readings (RH3).
Sex classifications of the participants differ significantly in systolic BP readings (RH4), diastolic BP readings (RH5), HR readings (RH6), and Morisky Scale (MS) scores (RH7).
Age classifications of the participants differ significantly in systolic BP readings (RH8), diastolic BP readings (RH9), HR readings (RH10), and MS scores (RH11).
Medication adherence (ie, MS scores) of the participants differs significantly in systolic BP readings (RH12), diastolic BP readings (RH13), and HR readings (RH14).
The age of the participants significantly relates to systolic BP readings (RH15), diastolic BP readings (RH16), HR readings (RH17), and MS scores (RH18).
Medication adherence (ie, MS scores) of the participants significantly relates to systolic BP readings (RH19), diastolic BP readings (RH20), and HR readings (RH21).
This study is a quantitative quasi-experimental research work, particularly using a repeated-measures design of the within-subjects approach [
This study was conducted on 120 nonadherent patients diagnosed with stage 1 or stage 2 hypertension listed in the Rural Health Unit-Hypertension Club. The participants are currently living in a mountain village in the municipality of Moalboal, Cebu (Philippines). The sampling design followed the approach in Arani et al [
In this study, the MS determines the level of medication adherence of the participants with hypertension. MS is a standardized measure intended to measure the risk of nonadherence to medication [
The intervention was given every Friday afternoon in 5 sessions after collecting their BP and HR readings. Every session had a design that integrated various aspects of a lifestyle change program. Participants received printed materials containing Microsoft PowerPoint slides included in the sessions expressed in the local dialect (ie, Cebuano) for reference. The relevance and internal validity of the educational materials draw parallel to the work of Arani et al [
Phase 1 (month 1): This phase covers activities such as orientation to the session design, signing of the informed consent document, finishing the research tool (ie, MS), and carrying out the baseline measurements (ie, BP and HR readings).
Session I, phase 2 (month 2): This phase aims to enhance the knowledge and transform the behavior, attitudes, and beliefs of the participants based on the BASNEF model. It also provides 45-60 min/week lecture on hypertension (eg, the definition of hypertension, its causes, and several contributing factors).
Session II, phase 3 (month 3): This phase discusses the cumulative and salient effects of high BP and the consequences of smoking, alcohol, and caffeine. It also elucidates the side effects of antihypertensive drugs.
Session III, phase 4 (month 4): This phase highlights the behavioral intention of the BASNEF model (ie, via microgroups). It aims to educate the participants on what action is anticipated and how to do it (eg, practical tips on keeping the ideal weight considering the BMI, methods for reducing salt consumption, and practical stress management methods).
Session IV, phase 5 (month 5): This phase elucidates subjective norms. It includes a session for individuals who would help improve the lifestyle of the participant and thus help reduce hypertension, such as their partner and children, in a way that explains their role in behavioral modification and hypertension management.
Session V, phase 6 (month 6): This phase emphasizes the enabling factors. At meetings, all participants were provided with a pamphlet to keep the training fluid. The participants were informed of how to use health care center services and access the necessary treatment.
Phase 7 (month 7): This phase includes the necessary evaluation activities, such as reviewing the previous education sessions, conducting the posttest and BP readings, and taking a post–lifestyle intervention program for the participants.
Categorical variables, particularly the sex and age of participants, were expressed as frequencies and percentages. Continuous variables, such as systolic BP, diastolic BP, HR readings, and MS scores, were defined as mean (SD). Repeated-measures one-way analysis of variance (ANOVA) was used for testing RH1 to RH14, except for RH4 to RH7, in which a 2-tailed independent
The distribution of research participants in terms of sex and age are presented in
Profile of the participants (N=50).
Profile | Frequency, n (%) | |
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Female | 39 (78) |
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Male | 11 (22) |
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80-89 | 4 (8) |
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70-79 | 13 (26) |
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60-69 | 8 (16) |
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50-59 | 7 (14) |
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40-49 | 12 (24) |
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30-39 | 6 (12) |
Blood pressure and heart rate readings of the participants.
Phases | Blood pressure readingsa | Heart rate readingsb | |||
|
Systolic, mean (SD) | Diastolic, mean (SD) | Interpretation | Heart rate, mean (SD) | Interpretation |
1 | 146.50 (19.59) | 84.60 (12.59) | Hypertension stage 2 | 77.76 (11.65) | Normal |
2 | 136.64 (18.42) | 80.36 (11.83) | Hypertension stage 1 | 76.92 (10.71) | Normal |
3 | 136.80 (16.37) | 79.26 (9.90) | Hypertension stage 1 | 76.08 (9.93) | Normal |
4 | 134.92 (15.24) | 78.76 (10.81) | Hypertension stage 1 | 77.94 (12.43) | Normal |
5 | 137.88 (19.18) | 79.96 (11.24) | Hypertension stage 1 | 79.16 (12.01) | Normal |
6 | 136.86 (15.14) | 79.58 (10.76) | Hypertension stage 1 | 77.06 (11.32) | Normal |
aMean systolic blood pressure, 138.27 (SD13.31); mean diastolic blood pressure, 80.42 (SD 7.97).
bMean heart rate, 77.49 (SD 7.70); interpretation: normal.
As presented in
A summary of the results of the tests for RH1 to RH14 (numerical values and descriptive entries on the differences in systolic BP, diastolic BP, and HR readings based on the phases of medication, sex, age, and MS scores) is presented in
Using repeated-measures ANOVA, all
The
Summary of inferences on systolic BPa, diastolic BP, and HRb readings, and MSc scores based on the phases of medication, sex, age, and MS scores.
Comparison bases | RHd | Critical valuee | Test value | Decision on H0 | Difference | ||||||||
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Systolic BP readings | RH1 | 2.42 | 0.41 | .80 | Not rejected | Not significant | ||||||
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Diastolic BP readings | RH2 | 2.42 | 0.27 | .90 | Not rejected | Not significant | ||||||
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HR readings | RH3 | 2.42 | 0.90 | .46 | Not rejected | Not significant | ||||||
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Systolic BP readings | RH4 | 2.11 | 2.59 | .02 | Rejected | Significant | ||||||
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Diastolic BP readings | RH5 | 2.10 | 4.85 | <.001 | Rejected | Significant | ||||||
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HR readings | RH6 | 2.13 | 0.59 | .56 | Not rejected | Not significant | ||||||
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MS scores | RH7 | 2.08 | 1.18 | .25 | Not rejected | Not significant | ||||||
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Systolic BP readings | RH8 | 2.43 | 5.10 | <.001 | Rejected | Significant | ||||||
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Diastolic BP readings | RH9 | 2.43 | 1.30 | .28 | Not rejected | Not significant | ||||||
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HR readings | RH10 | 2.43 | 1.40 | .24 | Not rejected | Not significant | ||||||
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MS scores | RH11 | 2.43 | 1.28 | .29 | Not rejected | Not significant | ||||||
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Systolic readings | RH12 | 2.58 | 2.21 | .08 | Not rejected | Not significant | ||||||
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Diastolic readings | RH13 | 2.58 | 2.02 | .11 | Not rejected | Not significant | ||||||
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HR readings | RH14 | 2.58 | 0.71 | .59 | Not rejected | Not significant |
aBP: blood pressure.
bHR: heart rate.
cMS: Morisky Scale.
dRH: research hypothesis.
eThe critical values used were
The
The
Significance of differences in systolic BPa, diastolic BP, and heart rate readings based on Morisky Scale scores.
|
Critical |
Computed |
Decision on H0 | Difference | |
Systolic BP readings | 2.58 (4) | 2.21 (45) | .08 | Not rejected | Not significant |
Diastolic BP readings | 2.58 (4) | 2.02 (45) | .11 | Not rejected | Not significant |
Heart rate readings | 2.58 (4) | 0.71 (45) | .59 | Not rejected | Not significant |
aBP: blood pressure.
bSignificance level
Significance of relationships between the readings with MSa scores and age and between the readings and MS scores.
Relationship bases | Correlation coefficient ( |
Decision on H0 | Relationship | ||||||
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|||||||||
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Systolic | 0.42 | .002 | Rejected | Significant | ||||
|
Diastolic | 0.10 | .49 | Not rejected | Not significant | ||||
|
Heart rate | 0.11 | .43 | Not rejected | Not significant | ||||
|
MS scores | 0.25 | .08 | Not rejected | Not significant | ||||
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|||||||||
|
Systolic | 0.26 | .07 | Not rejected | Not significant | ||||
|
Diastolic | 0.21 | .14 | Not rejected | Not significant | ||||
|
Heart rate | 0.10 | .51 | Not rejected | Not significant |
aMS: Morisky Scale.
In contrast, because the
This study assessed the effects of a lifestyle intervention program on nonadherent patients with hypertension using a modified BASNEF model. The results suggest that the lifestyle intervention based on session III or phase IV behavioral intention in the BASNEF model microgroup sessions positively affects BP readings among the research participants. The descriptive results indicate that the BP readings of the population under consideration were not significantly different from their MS scores.
In the last 3 months of the implementation of the program, our study found significant modifications in systolic and diastolic BP and improvements in all behavioral factors. Participants had reduced dietary sodium intake, had taken their maintenance antihypertensive medications if available, and if budget warranted, and had limited their alcohol and cigarette consumption. Our findings indicate that lifestyle change interventions have effectively decreased BP levels by having participants take steps such as reducing salt consumption, taking prescribed medicines, and limiting alcohol and cigarette consumption [
Our results are also consistent with studies that used the BASNEF model to manage anxiety disorders in patients with hypertension [
This study established that the BASNEF model approach can be an effective BP management technique. A significant change in BP was observed in sessions III or phase IV of the program, where behavioral intention in the BASNEF model (ie, microgroups) was implemented. The results of this study are relevant for patients with hypertension without comorbidities such as diabetes mellitus and physical or mental disorders. For future work, a longitudinal study may be conducted to determine the significant difference between the BP and HR readings among the respondents and emphasize the essentiality of medical adherence in managing hypertension using health education models.
analysis of variance
Beliefs, Attitude, Subjective Norms, Enabling Factors
blood pressure
heart rate
Morisky Scale
research hypothesis
The General Appropriations Act of the Cebu Technological University funded this research project. The authors would like to thank Cebu Technological University President, Dr Rosein A Ancheta Jr, the late Cebu Technological University Director for Internationalization and ASEAN Integration, Dr Doris O Gascon, and Cebu Technological University-Moalboal Campus, and Dr Eldie V Abenido for their inspiration and generosity. The authors are grateful to Dr Raymond R Tan and Dr Kathleen B Aviso of De La Salle University for their profound wisdom and insights that polished the manuscript into fruition. The final stages of manuscript preparation were supported by the United States Agency for International Development via the Science, Technology, Research and Innovation for Development program’s skills in technical and advanced research training courses.
RTV, CAA, MCT, and MLV conceived the idea. RTV, CAA, MLV, RB, LO, and PB developed the theory and performed the computations. RB, LO, and PB verified the analytical methods. RTV, CAA, MCT, MLV, RB, LO, and PB supervised the findings of this study. All authors have discussed the results and contributed to the final manuscript.
None declared.