The effects of Self-care, Self-efficacy, and Health Literacy on Health-related Quality of Life in Patients with Hypertension

doi:10.21203/rs.3.rs-4944574/v1

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The effects of Self-care, Self-efficacy, and Health Literacy on Health-related Quality of Life in Patients with Hypertension

https://doi.org/10.21203/rs.3.rs-4944574/v1

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Background: Hypertension is a chronic disease that can deteriorate patients' health-related quality of life (Hr-QoL). In this study, we aim to investigate the variables associated with Hr-QoL, including self-care, self-efficacy, and health literacy in patients with hypertension.

Methods: In this cross-sectional study, data on 427 randomely selected patients from March 2023 to March 2024 in community and private sectors were collected through interviews in different clinics affiliated with Shiraz University of Medical Sciences, Shiraz, Iran. A linear regression model was used for multivariate data analysis.

Results: The mean age of the participants in the study was 60.05± 11.06, and most (68.4%) were women. The mean total Hr-QoL, self-care, self-efficacy and health literacy scores were 62.47%±15.75, 87.14%±10.76, 68.69%±14.90, and 81.15% ± 17.19, respectively. Based on the linear regression model, every one score change in self-care total score, self-efficacy total score, and health literacy total score was associated with -0.471 (CI:-0.792 - -0.150), 0.306 (CI:0.140-0.473), and 0.283(CI:0.206-0.360) change in Hr-QoL total score, respectively. The model also demonstrated that having an occupation and good income was associated with 7.415 (CI:4.262-10.568) and 6.330 (CI:3.818-8.843) more Hr-QoL scores, respectively. Also, patients who did not have diabetes mellitus and renal disease had 3.407 (CI:0.802-6.012) and 4.071 (CI:1.109-7.032) more Hr-QoL scores, respectively—based on the model, health literacy (β=0.375) had the strongest effect on the Hr-QoL.

Conclusion: In conclusion, self-care, self-efficacy, and health literacy can positively predict Hr-QoL in patients with hypertension. Moreover, health literacy is the strongest predictive factor of Hr-QoL in patients with hypertension.

Health sciences/Health care/Public health

Health sciences/Health care/Quality of life

Health sciences/Medical research/Epidemiology

Health sciences/Diseases/Cardiovascular diseases

Self Care

Self Efficacy

Health Literacy

Quality of Life

Essential Hypertension

Worldwide, cardiovascular disease is the leading cause of death (1). Hypertension is a chronic disease considered a major risk factor for cardiovascular diseases (2). Globally, approximately one-third of adults aged 30 to 79 years old are suffering from hypertension (3). It is also estimated that about one-fourth of adults in Iran have hypertension (4). If it remains undiagnosed or uncontrolled, hypertension can lead to mortality or morbidities, deteriorating patients' well-being and diminishing their health-related quality of life (Hr-QoL) (5, 6).

Hr-QoL assesses patients' overall subjective health and function in the context of disease treatment (7). Hr-QoL is highly affected in patients coping with chronic diseases (8–10).

Improving Hr-QoL is not only a treatment goal in chronic diseases such as hypertension but also a validated tool to assess the effectiveness of different therapeutic methods (11).

Promoting patients' self-care behaviors, including smoking cessation, decrease in alcohol intake, adopting a low-sodium diet, regular exercise, maintaining a healthy weight, and adherence to medication, plays an important role in the treatment of hypertension. Optimal self-care in patients with hypertension has been associated with a significant reduction in their blood pressure level (12). However, based on previous studies, patients with hypertension are mostly ignorant of this factor (13).

Self-efficacy means a person's belief in their ability to behave in a way that leads to a specific goal. It is a sense of control over a difficult situation by one's competent behavior that creates the necessary motivation to obtain health-promoting behaviors such as adhering to treatment, enhancing doctor-patient communication, and actively participating in recommended therapeutic interventions (14, 15). Self-efficacy increases the amount of self-care behaviors in patients and the probability of treatment success (16).

Health literacy is the ability to obtain information, understand it, and use it to improve one's health (17). Health literacy leads to patients' participation in making decisions about their treatment and establishing good rapport with their caregivers. Adequate health literacy is associated with prevention of cardiovascular diseases and better blood pressure control in patients with hypertension (18, 19).

Due to the lack of comparable research focusing on the Hr-QoL among patients with hypertension in our setting and discrepancies in the findings of previous studies worldside, we aimed to investigate the variables associated with Hr-QoL, including self-care, self-efficacy, and health literacy in patients with hypertension.

Study design and participants

This study is a cross-sectional study that was conducted on a sample size of 427 patients. Random sampling was done among people from the community and private sectors, family medicine doctors' networks, and cardiovascular disease clinics affiliated with the Shiraz University of Medical Sciences, Fars Province, Shiraz, Iran, from March 2023 to March 2024. The inclusion criteria were the age of 18 years and older, previous diagnosis of high blood pressure by a doctor at least in the past six months before the study, taking blood pressure medication prescribed by a doctor, the ability to communicate with the researcher to complete the questionnaire (no cognitive problems) and consent to participation in the study. Data were gathered through questionnaires completed by researchers who interviewed the patients in the clinics.

The sample size was determined using Cochran's formula. A total of 550 hypertensive patients were randomly selected. Out of 550 patients, 77 were excluded due to lack of consent to participate in the study. Also, 46 patients who could not answer all the questions were excluded. Therefore, 427 patients were included in the study.

Measurements

Demographic information

demographic information such as age, gender, marital status, comorbidities, Family history of hypertension, job, economic status, residency, types of blood pressure drugs, number of tablets taken daily, time since diagnosis with hypertension, education, and lipid profile were collected.

Blood pressure

According to American Heart Association guidelines, controlled blood pressure includes maintaining systolic blood pressure below 140 mmHg and diastolic blood pressure below 90 mmHg. In this study, uncontrolled blood pressure was defined as systolic blood pressure ≥ 140 mmHg or diastolic blood pressure ≥ 90 mmHg based on the mean blood pressure measured two times in the clinic.

In the clinic, blood pressure measurements followed a standard protocol using a digital sphygmomanometer. The patients were prohibited from consuming caffeine, smoking, and drinking alcohol for at least 30 minutes before measuring blood pressure. The patients' blood pressure was measured twice in the clinic with a 15-minute interval between measurements. Before each measurement, the patients rested for 5 minutes. The blood pressure used in this study was the average of the two measurements for each patient. The patients with high mean systolic blood pressure, high mean diastolic blood pressure, or both were classified as uncontrolled blood pressure.

Health-related quality of life (Hr-QoL):

WHOQOL-BREF (20, 21) is a 26-item instrument with a 5-point Likert scale that includes physical health, mental health, social relationships, and environmental health. It also includes public health issues. Physical health includes energy, fatigue, pain, discomfort, sleep, and rest. The psychological domain includes body image and appearance, negative emotions, positive emotions, self-esteem, thinking, learning, memory and concentration, religion/spirituality/personal beliefs. The social domain includes personal relationships, social support, and sexual activity, and finally, the environmental domain includes financial resources, freedom, physical safety and security, health and social care, access and quality of the house environment, opportunities to acquire new information and share skills and opportunities for recreation/leisure, environment (pollution/noise/weather) and transportation.

Outcomes with this tool can be shown using different scales: the raw one and those ranging from 0 to 20 and from 0 to 100. We opted for a scale of 0–100, where 0 stands for extremely poor and 100 for exceptionally good QoL. Fifty can be considered the cutoff score at which the outcome is neither good nor poor.

Self-care:

Hill bone self-care questionnaire (22, 23) is a 14-item scale. The questionnaire is on a 4-point Likert scale to assess patient behaviors for three important behavioral domains of hypertension treatment: 3 items of keeping doctor's appointments (questions 3-13-14), three items of diet (questions 10-11-12), eight items of medication adherence (questions 1-2-4-5 6-7-8-9). Each item is on a 4-point scale, stating 4. always, 3. most of the time, 2. sometimes, and 1. never. After summing up the points, The Hill-Bone Compliance to High Blood Pressure Therapy (HBCHBPT) scale ranges from 14 (perfect adherence) to 56 (nonadherent). A cutoff score of 22 was used to distinguish high and low adherence.

Self-Efficacy:

HBP- SCP questionnaire (24, 25) was used to evaluate self-efficacy. This questionnaire contains 20 items and three dimensions, including diet (questions 2 to 13), compliance with treatment (questions 16-17-20), and treatment management (questions 1-14-15-18-19). This questionnaire is based on a four-point Likert scale: I am entirely sure (4 points), I am sure (3 points), I am somewhat sure (2 points), and I am not sure (1 point). The obtained score varies between 0 and 100; a higher score means more self-efficacy.

Health literacy:

Health Literacy for Iranian Adults (HELIA) (26) is a short version of a 9-item survey instrument with a 5-point Likert scale designed and psychometrically evaluated by Montazeri et al. in 2014. This questionnaire includes two sub-dimensions of health Literacy: basic skills (5 items) and decision-making skills (4 items). In the HELIA instrument, participants agree with statements on a Likert scale (5 = completely easy, 4 = easy, 3 = neither easy nor difficult, 2 = difficult, and 1 = completely difficult). The higher the score, the more health literacy the person has. Then, each patient's score is converted to a 0 to 100 scale, and a score of 0 to 50 is considered insufficient health literacy, 50 to 66 as insufficient health literacy, 66 to 84 as adequate health literacy, and 84 to 100 as excellent health literacy (27).

Statistical analysis

Mean and standard deviation were used to describe quantitative data, and relative comparison was used to classify qualitative variables. In this study, a one-way analysis of variance and an independent t-test were used for bivariate analysis. Pearson's correlation was calculated to assess the correlations between the main continues variables.

Linear regression was performed for multivariate analysis. Durbin–Watson test was used to evaluate the autocorrelation in residual before the conduction of regression. The test acceptance level is for the values of 1.5–2.5. Multivariate normality assumption on residuals was evaluated using a standard P-P plot of regression standardized residual. Cook's distance index was used for data screening if there were an outlier or influential. The values of less than 1 were considered for the acceptance level of the index. The multicollinearity of predictor variables was evaluated by variance inflation factor (VIF), with values of less than three as the acceptance level.

A p-value (p) of less than 0.05 was considered statistically significant. IBM SPSS Statistics 26.0 software was used for data analysis.

The mean age of the participants in the study was 60.05 ± 11.06. Most of them (68.4%) were women. Of all patients, 77.3% had a partner, 85.7% were educated up to a high school diploma, and 79.1% were unemployed. Of all patients, 88.5% lived in urban areas. Only 2.1% and 7.7% of the study population reported alcohol consumption and smoking, respectively. The mean duration of living with hypertension and the number of pills consumed by the patients were 8.42 ± 7.42 and 1.74 ± 0.97, respectively. Of all patients, 36.5% had a history of hypertension over ten years, and 63.7% used only one type of blood pressure medication. The mean systolic and diastolic blood pressure was 129.84 ± 13.82 and 80.06 ± 9.05, respectively, and 27.9% had uncontrolled blood pressure. The mean BMI of the patients was 28.09 ± 4.65, and 30.7% had obesity. Regarding comorbidities, 31.7%, 33%, 17.4%, and 15% developed with renal disease, diabetes melitus, hyperlipidemia, and myocardial infarction, respectively. (Table 1).

Table 1

Descriptive information and results of bivariate analyses of factors affecting health-related quality of life, self-care, self-efficacy, and health literacy
Variable	Sub Group	Number (percent)	Self Care	Self Efficacy	Health Literacy	Quality Of Life
Variable	Sub Group		Mean(SD)	Mean(SD)	Mean(SD)	Mean(SD)
Sex	Male	135(31.6)	19.76(5.37)	60.75(9.08)	85.47(14.37)	65.40(15.55)
	Female	292(68.4)	19.22(4.06)	61.42(8.88)	79.15(18.03)	61.12(15.69)
	P value		0.306	0.471	< 0.001	0.009
Education	Less than a high school diploma	366(85.7)	19.32(4.44)	60.87(8.77)	79.35(17.64)	60.96 (15.72)
	more than a high school diploma	61(14.3)	19.81(4.96)	63.24(9.69)	91.93(8.26)	71.56 (12.69)
	P value		0.432	0.055	< 0.001	< 0.001
Occupation	unemployed	338(79.1)	18.89(3.81)	62.2(8.47)	79.77(17.94)	60.93(15.58)
	employed	89(20.9)	21.32(6.19)	58.14(10.01)	86.39(12.75)	68.34(15.09)
	P value		< 0.001	0.001	< 0.001	< 0.001
Residence	Rural area	49(11.5)	18.44(4.04)	61.57(8.03)	75.45(17.81)	60.89(15.94)
	Urban area	378(88.5)	19.52(4.57)	61.16(9.06)	81.89(16.99)	62.68(15.74)
	P value		0.118	0.767	0.013	0.454
Smoker	Yes	33(7.7)	22.15(6.21)	54.33(9.24)	81.22(16.63)	61.24(12.58)
	No	394(92.3)	19.16(4.28)	61.79(8.68)	81.14(17.26)	62.58(16.01)
	P value		0.011	< 0.001	0.979	0.570
Family history of hypertension	Yes	337(78.9)	19.57(4.62)	60.84(9.14)	81.71(16.55)	62.29(15.52)
	No	90(21.1)	18.73(4.07)	62.60(8.03)	79.07(19.38)	63.18(16.67)
	P value		0.117	0.076	0.240	0.634
Relationship status	Single	97(22.7)	18.77(3.74)	62.16(8.52)	77.97(20.33)	60.53(15.63)
	Not single	330(77.3)	19.58(4.71)	60.93(9.05)	82.08(16.07)	63.05(15.76)
	P value		0.08	0.235	0.07	0.167
Economic status	Poor income	202(47.3)	19.47(4.72)	60.44(8.97)	76.33(18.67)	57.21(15.09)
	Good income	225(52.7)	19.32(4.34)	61.91(8.87)	85.48(14.48)	67.21(14.83)
	P value		0.739	0.090	< 0.001	< 0.001
Renal disease	Yes	93(31.7)	19.43(4.22)	59.26(9.38)	78.58(17.50)	58.04(15.53)
	No	333(78.2)	19.40(4.60)	61.74(8.76)	81.81(17.06)	63.71(15.63)
	P value		0.963	0.018	0.109	0.002
Diabetes mellitus	Yes	141(33)	19.13(4.33)	61.62(8.57)	78.56(17.14)	59.00(15.48)
	No	285(66.7)	19.52(4.61)	61.01(9.12)	82.43(17.10)	64.19(15.62)
	P value		0.399	0.508	0.029	0.001
Hyperlipidemia	Yes	74(17.4)	19.10(4.41)	61.95(8.98)	83.55(16.58)	64.78(18.24)
	No	353(82.6)	19.45(4.54)	61.05(8.93)	80.65(17.30)	61.99(15.16)
	P value		0.545	0.432	0.186	0.222
Myocardial infarction	Yes	64(15)	18.59(4.44)	61.12(8.79)	76.08(19.09)	59.26(15.71)
	No	363(85)	19.53(4.52)	61.23(8.97)	82.04(16.71)	63.04(15.71)
	P value		0.123	0.930	0.021	0.077
Obesity	Yes	131(30.7)	19.57(4.09)	59.67(8.43)	81.91(15.47)	61.74(15.31)
	No	296(69.3)	19.32(4.07)	61.89(9.08)	80.81(17.91)	62.80(15.96)
	P value		0.597	0.017	0.522	0.515
Alcohol consumption	Yes	9(2.1)	23.55(5.98)	57.00(10.59)	86.11(8.44)	69.33(9.07)
	No	418(97.9)	19.30(4.45)	61.30(8.89)	81.04(17.32)	62.33(15.84)
	P value		0.005	0.153	0.117	0.187
Uncontrolled blood pressure	Yes	119 (27.9)	21.14(4.99)	58.84(8.95)	81.79(17.35)	62.34(15.48)
	No	308(72.1)	18.72(4.13)	62.13(8.78)	80.90(17.15)	62.53(15.88)
	P value		< 0.001	< 0.001	0.634	0.914

The results showed that only 24.1% of the patients had high Hr-QoL. The mean of the overall Hr-QoL score was 62.47%±15.75.

Overall, 79.8% of the patients had high adherence to self-care behaviors, with a mean score of 87.14%±10.76. The total self-efficacy mean was 68.69%±14.90, and 60% had a poor level of self-efficacy. Of all patients, 51.8% benefited from excellent health literacy. The overall mean health literacy was 81.15% ± 17.19.

Bivariate analysis revealed that male gender (65.40 ± 15.55 Vs. 61.12 ± 15.69, P < 0.001), education more than a high school diploma (71.56 ± 12.69 Vs. 60.96 ± 15.72, P < 0.001), being employed (68.34 ± 15.09 Vs. 60.93 ± 15.58, P < 0.001), having good income (67.21 ± 14.83 Vs. 57.21 ± 15.09, P < 0.001) are associated with higher Hr-QoL mean score. Also, it demonstrated that patients with renal disease (58.04 ± 15.53 Vs. 63.71 ± 15.63, P = 0.002) and diabetes mellitus (59.00 ± 15.48 Vs. 64.19 ± 15.62, P = 0.001) had lower H-QoL mean score (Table 1).

Hr-QoL was inversely correlated with self-care (r = 0.217, P < 0.001). It also had a direct correlation with self-efficacy (r = 0314, P < 0.001) and health literacy (r = 0.469, P < 0.001) (Fig. 1). Also, there was an indirect correlation among self-care and self-efficacy total scores(r = -0.534, P < 0.001), self-care and health literacy total scores (r = -0.1, P < 0.001), and a direct correlation between self-efficacy and health literacy (r = 0.246, P < 0.001).

The results confirmed the applicability of multivariate linear regression analysis. Durbin–Watson test value was 1.883, and residuals were normally distributed. The residual mean was 0, the maximum Cook’s distance index was 0.027, and the maximum VIF was 1.56. Based on the multivariate linear regression analysis, every one score change in self-care total score, self-efficacy total score, and health literacy total score was associated with − 0.471 (CI:-0.792 - -0.150), 0.306 (CI:0.140–0.473), and 0.283(CI:0.206–0.360) change in Hr-QoL total score, respectively. The model also demonstrated that having an occupation and good income was associated with 7.415 (CI:4.262–10.568) and 6.330 (CI:3.818–8.843) more Hr-QoL scores, respectively. Also, patients who did not have diabetes mellitus and renal disease had 3.407 (CI:0.802–6.012) and 4.071 (CI:1.109–7.032) more Hr-QoL scores, respectively. Based on the model, health literacy (β = 0.375) had the strongest effect on the Hr-QoL (Table 2).

Table 2

Multivariate analysis of factors affecting health-related quality of life
Model		Unstandardized Coefficients		Standardized Coefficients	t	Sig.	95% Confidence Interval for B
Model		B	Std. Error	Beta	t	Sig.	Lower Bound	Upper Bound
	(Constant)	-1.730	7.991		-0.217	0.829	-17.437	13.976
	Self-care Total Score	-0.471	0.163	-0.135	-2.883	0.004	-0.792	-0.150
	Self-efficacy Total Score	0.306	0.085	0.174	3.615	< 0.001	0.140	0.473
	Health Literacy Total Score	0.283	0.039	0.309	7.229	< 0.001	0.206	0.360
	Occupation	7.415	1.604	0.191	4.623	< 0.001	4.262	10.568
	Economic status	6.330	1.278	0.201	4.953	< 0.001	3.818	8.843
	Diabetes Mellitus	3.407	1.325	0.102	2.571	0.010	0.802	6.012
	Renal disease	4.071	1.507	0.108	2.702	0.007	1.109	7.032
Dependent Variable: Health-related quality of life

In this study, we aimed to investigate the variables affecting Hr-QoL, including self-care, self-efficacy, and health literacy in patients with hypertension. Concerning our results, about one-fourth of the patients had high Hr-QoL, and the majority had high adherence to treatment regarding self-care behaviors; however, most patients had low levels of self-efficacy. We also found that while most of the patients were not well-educated, about half had excellent health literacy. Moreover, based on our results, education level, occupation, and good economic status positively affected Hr-QoL, while having diabetes mellitus and renal disease decreased patients' Hr-QoL. In addition, we found that self-care, self-efficacy, and health literacy can positively predict Hr-QoL in patients with hypertension. Regarding association among predictive factors, self-care, self-efficacy, and health literacy were correlated.

Previous research tried to unravel the roles of various predictive factors of Hr-QoL in patients with hypertension.

Based on a recent study, Hr-QoL was significantly lower among patients with hypertension in comparison to the normal population (28). Another study stated that even among patients with hypertension, those with uncontrolled hypertension have poorer Hr-QoL (29). Low educational level, low income, presence of comorbidities, low occupational status, female gender, and age were introduced as negative determinants of Hr-QoL in patients with hypertension (6, 30–32). These results were in line with our findings.

Regarding self-care and its effect on Hr-QoL in patients with hypertension, Du et al. claimed that self-care ability was low among older adults with hypertension. They also found a positive association between self-care ability and Hr-QoL (33). Two other studies revealed that medication non-adherence results in poorer Hr-QoL in patients with hypertension (34, 35). It has also been found that self-care training can significantly improve Hr-QoL in patients with hypertension (36). These findings also concorded with our results.

Concerning self-efficacy and health literacy, Lee et al. showed that self-efficacy was positively correlated with Hr-QoL in patients with hypertensive nephropathy (37). Another study by Chen et al. claimed that self-efficacy was the most critical predictor of Hr-QoL. They also reported that disease knowledge is positively associated with self-efficacy and Hr-QoL in patients with hypertensive nephropathy (38). Two recent studies show a positive correlation between health literacy and Hr-QoL in patients with hypertension (39, 40). According to our model, health literacy is the most important predictive factor of Hr-QoL in patients with hypertension. This result was approved by another study conducted by Zhang et al. (41). Another study by Darvishpour et al. reported that most patients with hypertension had adequate health literacy, excellent self-efficacy, and desirable self-care. According to their findings, higher health literacy was independently associated with better self-efficacy and self-care (16). These results were comparable to ours as well.

In the past few decades, the prevalence of multimorbidities has increased due to improved life expectancy—a factor that exacerbates patients' Hr-QoL (42). Hypertension, as one of the most prevalent chronic diseases, affects many people worldwide. As a result, any try to improve Hr-QoL in these patients is noteworthy. As discussed, although many behavioral, physical, and psychosocial factors can affect Hr-QoL in patients with hypertension, self-care, self-efficacy, and health literacy are among the most important predictive factors.

Limitations and strengths

Although the current study had some strengths, including an adequate cohort of patients, numerous important independent variables, and sampling from private and community clinics, it had some limitations. The patient selection was done only in one urban area, and the majority of patients lived in the city. Also, the study was cross-sectional and could not measure the effects of the variables on patients' Hr-QoL over a specific time period.

In conclusion, self-care, self-efficacy, and health literacy can positively predict Hr-QoL in patients with hypertension. Also, self-care, self-efficacy, and health literacy positively affect one another. Moreover, health literacy is the strongest predictive factor of Hr-QoL in patients with hypertension. It is recommended that a cohort study on Hr-QoL of patients with hypertension be conducted, including more variables such as patients' self-esteem and sleep quality in the future.

Ethics approval and consent to participate

This study was approved by the Ethics Committee of the Shiraz University of Medical Sciences (IR.SUMS.MED.REC.1403.057), and written informed consent was obtained from the subjects. All methods were carried out in accordance with relevant guidelines and regulations.

Consent for publication

Not applicable

Availability of data and materials

Data of the patients can be requested from the authors. Please write to the corresponding author if you are interested in such data.

Competing interests

The authors declare no competing interests.

Funding

No financial support was received for this study.

Author Contribution:

N.S and A.S convenience the idea for the manuscript. N.S, S.N, A.S and A.Z collected data. N.S, A.S, M.R and M.R.S analyzed and interpreted the data. N.S, S.N, M.R, M.R.S, A.Z and H.B.D drafted the manuscript. A.S also revised the manuscript critically and stood as a Guarantor of the manuscript. All authors read and approved the final version of the manuscript. All authors confirm that all methods were carried out in accordance with relevant guidelines and regulations.

Acknowledgement

Not Applicable

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The effects of Self-care, Self-efficacy, and Health Literacy on Health-related Quality of Life in Patients with Hypertension

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