Effect of an educational program for patients with hypertension in communities : a pilot randomized controlled trial

Abstract

Background: Hypertension is a global health concern affecting more than 1 billion people worldwide. Although guidelines for the effective treatment of hypertension have been developed, only 50% of the treated patients achieve a controlled blood pressure. Nonadherence to hypertension management was revealed to be the major cause of inability to achieve a controlled blood pressure. Educational intervention was found to effectively improve adherence to hypertension management as well as reduce blood pressure. The use of text messaging as a supportive method supporting hypertension management has been demonstrated in some hypertension-related studies. However, the extent of educational intervention and text messaging required for the management of patients with hypertension has not been identified in previously. Aims and objectives: The study aim was to develop and test an evidence-based educational program for hypertensive patients. The study objectives were as follows: 1) to develop an evidence-based educational program; 2) to examine the preliminary effects of the program on blood pressure, pulse pressure, self-efficacy, and adherence to hypertension management; and 3) to assess the feasibility and acceptability of the newly developed program in two cites in the Greater Bay Area. Methods: This study was conducted in two phases. In Phase I, the evidence-based educational program was developed and validated; systematic reviews were conducted to identify the effective dosage of educational intervention and text messaging for patients with hypertension. The newly developed program was then reviewed by experts using the content validity index. In Phase II, the program's preliminary effect was assessed; a pilot parallel randomized controlled trial was conducted to assess the preliminary effect, feasibility, and acceptability of the program. People aged 45 and over, having a blood pressure over 130/80 mmHg, and diagnosis of hypertension were invited to participate in the study. The program comprised one session of group health education on hypertension management, a summary leaflet, and 12 weekly text messages. Patients in the control group received usual care, which included a routine health education on hypertension management and a leaflet from the government. To minimize the arousal of group allocation, weekly text messages on general health (i.e., not related to hypertension management) were sent to the participants in the control group for 12 weeks. Data were collected at community centers at baseline (T0), week 8 (T1), and week 12 (T2) to assess the outcomes of blood pressure, pulse pressure, self-efficacy, and adherence to hypertension management. Data were analyzed using a generalized estimating equation based on the intention-to-treat principle. Feasibility and acceptability were assessed on the basis of a numeric rating scale. Results: In Phase I, findings from systematic reviews indicated that a 45-min group health education session and weekly 1-way text messaging could effectively improve adherence to hypertension management and reduce blood pressure. The newly developed educational program employed the findings from the reviews, based on which the extent of intervention required was determined. The overall content validity index was good. In Phase II, 69 patients with hypertension were recruited; 56 (81.15%) of them completed follow-up at T2. Using the generalized estimating equation, the educational program was found to significantly reduce pulse pressure at T2 (β = -8.203, p = 0.007); in contrast, no statistically significant difference was noted in terms of blood pressure, self-efficacy, and adherence to hypertension management. However, the program did have a small-to-moderate effect on the reduction of systolic blood pressure (Effect size = -0.450) and pulse pressure (Effect size = -0.667); self-efficacy was low but improved after the program at T2 (Effect size = 0.230). The program was noted to be satisfactorily feasible, and the participants were highly satisfied with the educational program with a range of mean scores of 8.37 to 9.40. Conclusion: Our findings indicate that the educational program (a health education session, a leaflet, and weekly text messaging) could reduce the pulse pressure of patients with hypertension. The program also has the potential to reduce blood pressure and enhance self-efficacy. The program's satisfactory feasibility and acceptability warrant the progression of main study in the Greater Bay Area. The entire study, including Phase I and II, provides evidence that it is plausible to develop an educational program for patients with hypertension in communities and utilize it in clinical practice to reduce the risk profile of cardiovascular events and stroke. The reported outcomes of the pilot study provide a basis for future studies.