The effect of Leventhal’s Self-Regulatory Intervention on the hypertensive patients’ Illness Perception and Lifestyle: A randomized controlled trial

Material And Methods

Design and participants

The present randomized parallel-controlled trial study was registered on Iranian Registry of Clinical Trials Website (IRCT); ID: IRCT20141222020401N6 on 8/5/2019. The present study was conducted on ninety eligible hypertensive patients referring to Yasuj Shahid Dastgheib Health Center, Iran, from May 2019 to October 2019. A total of 41 participants were calculated as the sample size for each group considering α = 0.05, z_1−α/2=1.96, β = 0.2, 1-β = 0.8, z_1−β=0.85, lifestyle standard deviations of S₁ = 26.59 and S₂ = 16.96, and lifestyle means of µ₁ = 21.8 and µ₂ = 41.2 (16), using the following formula:

$$\text{n}=\frac{2\times \left[{\left({\text{z}}_{1-\frac{{\alpha }}{2}}+{\text{z}}_{1-{\beta }}\right)}^{2}\right]\times \left({\text{S}}_{1}^{2}+{\text{S}}_{2}^{2}\right)}{{\text{d}}^{2}={\left({{\mu }}_{1}-{{\mu }}_{2}\right)}^{2}}$$

Considering a 10% attrition rate, a total of 90 participants, each group comprising 45 patients, were considered. They were selected through convenience sampling. However, they randomly were assigned to one of the two groups of intervention (n = 45) and control (n = 45), using randomized block allocation method as follow: Initially, by multiplying the number of study groups by two (an intervention group and a control group), four people were assigned to each group. At that point, twenty-four blocks were calculated using the factorial rule (24 = 1×2×3×4=!4). The members of each block were marked with the letters A, B, C, D. Subsequently, letters A and B were assigned to the control group, and letters C and D were randomly assigned to the intervention group. A total of twenty-four blocks with possible layouts were identified. Allocation was done by random selection of each block by an individual outside the research team. Furthermore, the samples were selected based on the sequence of blocks and based on the time priority of the participants' entry. Randomization continued until 45 patients were in the intervention group and 45 patients were in the control group. Blinding was not done in the present study.

Inclusion criteria consisted of definitive diagnosis of primary HTN, stage 1 or 2 HTN, age range of 18–65 years, at least six months of HTN, informed consent to participate in the study, and lifestyle score of ≤ 105. Patients’ unwillingness to participate in the study, not having other chronic diseases or sever complications following the hypertension, and lack of inclusion criteria were considered as exclusion criteria.

Instrument And Data Gathering

The outcomes were Lifestyle and Illness Perception, the formerly measured by the Lifestyle Questionnaire (LSQ) and the latter by the Revised Illness Perception Questionnaire (IPQ-R) two times։ the baseline (week 0), and 12 weeks following the intervention (week 17). The IPQ-R was originally developed by Moss-Morris et al. (17) to assess patients̓ illness perception. This questionnaire comprises 70 items which are divided into nine subscales: identity (attributing unrealistic symptoms to the disease), consequences (belief in negative consequences of the disease), timeline acute/chronic (patients’ perception of the illness chronicity), timeline cyclical (believing that the disease is cyclical until its stability), personal control (belief in more control), treatment control (belief in more treatment), emotional representations, illness coherence (higher level of illness perception), and perception of the causes. The score of the identity subscale was obtained by adding up the positive answers to symptoms. Furthermore, the subscales of 2 to 9 were based on a 5-point Likert scale (strongly disagree: 1, disagree: 2, neither agree nor disagree: 3, agree: 4, and strongly agree: 5). A lower score in the subscales of identity, consequence, timeline cyclical and emotional representations indicates a higher perception. On the contrary, higher scores in the subscales of timeline acute/chronic, personal control, treatment control, and illness coherence indicate a higher perception of the disease.

The validity and reliability of the IPQ-R had previously been confirmed (17). The validity and reliability of the Persian version of the questionnaire had likewise been established (18).

Lifestyle was assessed by LSQ. The LSQ consists of 70 items divided into 10 subscales։ physical health, exercise and fitness, weight control and nutrition, illness prevention, psychological health, spiritual health, social health, avoidance of drugs, opiates and alcohol, prevention of accidents and environmental health. The LSQ score is based on a four-point Likert scale (never = 0, sometimes = 1, usually = 2, and always = 3). Global score of the LSQ ranges from zero to 210. Cronbach’s alpha for the whole questionnaire was 0.87. The validity and reliability of LSQ had been established through content validity, factor analysis, and convergence validity (19).

The data which were collected one week prior to the intervention as the baseline and 12 weeks after the intervention

Interventions

Due to the large number of patients in the intervention group, they were divided into three groups. Consistent with Leventhal’s self-regulatory intervention, on a weekly basis (5 weeks), five 60-minute sessions were held for the intervention group whereas the control group received routine interventions.

The intervention protocol was based on Leventhal’s self-regulatory model and the literature review (14, 20). Based on Leventhal’s model, intervention was performed by one of the researchers (master’s student in Community Health Nursing), a psychologist, and a nutritionist consistent with the subscales of illness perception and lifestyle in Shahid Dastgheib Health Center.

In the first session, the patients’ perception of the illness identity was discussed by asking a number of questions about the symptoms, the cause (s) of the disease, and lifestyle factors believed to have contributed to the disease. In this session, the patients’ perception of the illness identity and causes was determined and the pathophysiology, causes, and symptoms of hypertension were discussed. The intention was to increase the perception of the illness identity and causes, especially those related to lifestyle.

In the second session, patients’ views on the effect of the disease on their life and the disease consequences, the disease duration, personal control, and treatment control were evaluated by asking the following open-ended questions: How long do you think it will take to recover? Do you think your disease can be controlled and cured? What will be the consequences of this disease for you? Misconceptions of the relevant issues were clarified through discussion between the patients and the researcher. The use of drugs and their side effects were also discussed.

In the third session, the patients and the researcher discussed the illness coherence and the necessity of avoidance of drugs, opiates, and alcohol. Following that, the psychologist talked about emotional representations as well as psychological, spiritual, and social health, using counseling techniques and provided the necessary training.

In the fourth session, the participants were asked about their perception of and adherence to weight control and nutrition in hypertension and were advised about proper diet. Moreover, the researcher discussed the importance of maintaining physical health.

The fifth session was devoted to the patients’ perception of the importance and benefits of physical activity, environmental health, and prevention of accidents and illness. Meanwhile, proper educational interventions were provided. At the end of the fifth session, an educational pamphlet containing a summary of the educational content provided during the sessions was handed over to the patients.

Data Analysis

The data which were collected one week prior to the intervention as the baseline and 12 weeks after the intervention were analyzed, using inferential statistics. The nominal data were analyzed by running Chi Square test or Fisher’s Exact test. For quantitative data with normal distribution, use was made of Independent Sample t- test and Paired Sample t- test. P- value < 0.05 was considered to be a significant difference for all data analyses. The data analyzer was blind to the allocation of the patients to the groups.

Results

Ninety hypertensive patients initially consented to participate in the present study. However, seven patients either withdrew or failed to complete the intervention (Fig. 1). Mean value of the participants’ age was 53 ± 6.5 years (Range 37–65). All of the hypertensive patients were married, and were taking oral antihypertensive drugs at the time of the study. Moreover, most of them were housewives and had undergraduate education. In terms of demographic variables and disease characteristics including duration of hypertension, there was no significant difference between the participants in the intervention and control groups before the intervention (Table 1).

Table 1. Comparing demographic characteristics between the two groups

M±SD: Mean± Standard Deviation; N (%): Frequency (percent)

P- value^a are based on Independent sample t-test for Age variables and Chi- square test for others variables

Likewise, before the intervention, there was no statistically significant difference between the intervention and control groups in terms of subscales of illness perception. However, after the intervention, which was consistent with Leventhal’s self-regulatory, the scores of subscales of illness perception improved significantly (p < 0.05), compared with the hypertensive patients in the control group except for illness consequences (p = 0.1) and emotional representation subscales (p = 0.07) (Table 2).

Table 2

Between and within group comparison for illness perception
Subscale	Group Time		Intervention	Control	Between group Comparison
Subscale	Group Time		Mean ± SD (95% CI)	Mean ± SD (95% CI)	p-value
Identity	Before		3.5 ± 1.6 (3.1–4.1)	3.9 ± 1.8 (3.4–4.5)	0.3
	Post		2.8 ± 1.5 (2.3–3.2)	3.9 ± 1.9 (3.3–4.5)	0.006
	Within group Comparison	Effect size	0.4	0.002
	Within group Comparison	p-value	0.001	0.7
Timeline (acute/chronic)	Before		19.1 ± 4.3(17.7–22.4)	19.9 ± 3.3(18.9–20.9)	0.3
	Post		21.7 ± 3.4(20.5–22.7)	19.8 ± 2.9 (19-20.7)	0.009
	Within group Comparison	Effect size	0.5	0.002
	Within group Comparison	p-value	0.001	0.8
Consequences	Before		19.4 ± 5.6(17.7–21.2)	18.1 ± 6.2(16.1–19.9)	0.3
	Post		18.5 ± 4.9(16.8–20.2)	18.1 ± 5.5(16.3–19.8)	0.7
	Within group Comparison	Effect size	0.1	0.001
	Within group Comparison	p-value	0.001	0.9
Personal Control	Before		21.2 ± 4.2(19.8–22.6)	20.5 ± 3.3(19.5–21.5)	0.3
	Post		22.7 ± 3.1(21.7–23.7)	20.9 ± 3.5(19.9–22)	0.01
	Within group Comparison	Effect size	0.2	0.07
	Within group Comparison	p-value	0.001	0.08
Treatment Control	Before		20.2 ± 2 (19.5–20.8)	19.9 ± 1.8(19.4–20.5)	0.4
	Post		21.5 ± 2 (20.9–22.1)	20.1 ± 2 (19.5–20.8)	0.003
	Within group Comparison	Effect size	0.4	0.03
	Within group Comparison	p-value	0.001	0.3
Illness Coherence	Before		15.6 ± 3.1(14.7–16.6)	15.8 ± 3.6(14.7–16.9)	0.7
	Post		17.9 ± 2.8 (17.1–18.9)	16.1 ± 3.6(15.1–17.2)	0.01
	Within group Comparison	Effect size	0.5	0.03
	Within group Comparison	p-value	0.001	0.3
Timeline Cyclical	Before		13.8 ± 2.7 (13-14.7)	13.19 ± 3.1(12.2–14.1)	0.2
	Post		11.5 ± 2.3 (10.8–12.2)	13 ± 2.7 (12.1–13.8)	0.01
	Within group Comparison	Effect size	0.5	0.01
	Within group Comparison	p-value	0.001	0.5
Emotional Representations	Before		22.9 ± 5.5 (21.3–24.5)	20.7 ± 6.2 (19-22.7)	0.1
	Post		22 ± 4.5 (20.6–23.2)	20.9 ± 5.5(19.3–22.6)	0.3
	Within group Comparison	Effect size	0.08	0.01
	Within group Comparison	p-value	0.05	0.7
Between group Comparison based on t-test
Within group Comparison based on paired t-test

In the intragroup comparison, the results showed that there was a significant improvement in the subscales of illness perception in the intervention group (p = 0.001) after the intervention, except for the emotional representation subscale. However, in the control group, no significant difference was observed in any of the subscales after the intervention, as compared to the time before the intervention (Table 2).

In addition, prior to the intervention, there was no statistically significant difference between the intervention and control groups in terms of lifestyle and its subscales. However, the results indicated that after the intervention, the hypertensive patients in the intervention group reported significantly (p < 0.05) more improvement in their lifestyle and its subscales, compared with the hypertensive patients in the control group, except for psychological health (p = 0.6) spiritual health (p = 0.5) and social health (p = 0.09) (Table 3).

Table 3

Between and within group comparison for Life Style
Subscale	Group Time		Intervention	Control	Between group Comparison
Subscale	Group Time		Mean ± SD (95% CI)	Mean ± SD (95% CI)	p-value
Global Life Style	Before		102.8 ± 2.3(102 − 03.5)	112.1 ± 3(111.1–13.1)	0.6
	Post		112.1 ± 3(111.1-113.1)	103.5 ± 2.1(102.9-104.2)	0.001
	Within group Comparison	Effect size	0.8	0.07
	Within group Comparison	p-value	0.001	0.09
Physical health	Before		9.1 ± 2.4 (8.4–9.8)	9.2 ± 2.2 (8.4–9.8)	0.7
	Post		10.6 ± 1.8 (10.1–11.2)	9.1 ± 2.2 (8.4–9.7)	0.001
	Within group Comparison	Effect size	0.7	0.02
	Within group Comparison	p-value	0.001	0.4
Exercise and fitness	Before		7.5 ± 3.8 (6.3–8.7)	7 ± 3.2 (6-7.9)	0.5
	Post		8.9 ± 3.2 (8 -9.9)	6.9 ± 2.5 (6.1–7.7)	0.002
	Within group Comparison	Effect size	0.5	0.002
	Within group Comparison	p-value	0.001	0.8
Weight control and nutrition	Before		9.1 ± 2.5 (8.4–9.8)	9 ± 2.4 (8.3–9.7)	0.8
	Post		10.8 ± 2.4 (10.1–11.6)	9.1 ± 2.2 (8.5–9.8)	0.002
	Within group Comparison	Effect size	0.7	0.006
	Within group Comparison	p-value	0.001	0.6
Environmental health	Before		11.3 ± 2.4 (10.5–12)	10.6 ± 1.9(10-11.3)	0.2
	Post		11.9 ± 2.2(11.2–12.7)	10.7 ± 1.7(10.1–11.2)	0.005
	Within group Comparison	Effect size	0.2	0.001
	Within group Comparison	p-value	0.001	0.7
Illness prevention	Before		10.8 ± 1.3 (10.5–11.3)	11.1 ± 1.3 (10.7–11.6)	0.3
	Post		12.5 ± 1.6(11.9–13)	11.3 ± 1.5(10.9–11.8)	0.002
	Within group Comparison	Effect size	0.5	0.04
	Within group Comparison	p-value	0.001	0.1
Psychological health	Before		8.5 ± 2.3 (7.9–9.3)	9.3 ± 2.1(8.7–9.9)	0.1
	Post		8.9 ± 2.1 (8.3–9.5)	9.1 ± 2 (8.5–9.7)	0.6
	Within group Comparison	Effect size	0.08	0.03
	Within group Comparison	p-value	0.06	0.2
Spiritual health	Before		10.7 ± 2.1(10.1–11.4)	10.6 ± 2.5(9.8–11.4)	0.7
	Post		10.6 ± 2.3(10.2–11.6)	10.6 ± 2.5(9.9–11.4)	0.5
	Within group Comparison	Effect size	0.05	0.003
	Within group Comparison	p-value	0.1	0.7
Social health	Before		10.5 ± 1.8(9.9–11.1)	11.1 ± 1.9(10.5–11.2)	0.1
	Post		10.6 ± 1.7(10.1–11.2)	11.3 ± 1.710.8–11.8)	0.09
	Within group Comparison	Effect size	0.02	0.03
	Within group Comparison	p-value	0.3	0.2
Avoidance of drugs, opiates and alcohol	Before		13.1 ± 1.6(12.6–13.7)	13.5 ± 1.6(12.9–13.9)	0.3
	Post		13.9 ± 1.6(13.5–14.4)	13.7 ± 1.9(13.1–14.3)	0.01
	Within group Comparison	Effect size	0.5	0.07
	Within group Comparison	p-value	0.001	0.08
Prevention of accidents	Before		12 ± 2.6 (11.2–12.8)	11.3 ± 2.1(10.7–12)	0.2
	Post		12.9 ± 2.3(12.3–13.7)	11.5 ± 1.7(11-12.1)	0.002
	Within group Comparison	Effect size	0.5	0.01
	Within group Comparison	p-value	0.001	0.4
Between group Comparison based on t-test
Within group Comparison based on paired t-test

The results showed that the intervention based on Leventhal’s self-regulatory model causes a significant increase in lifestyle and its subscales in the intervention group (p < 0.05) after the intervention, as compared to the time before the intervention, except for psychological, spiritual and social health. However, in the control group, in terms of the same variables, no significant difference was observed before and after the intervention (Table 3).

Discussion

To the best of our knowledge, to date no study has been carried out to determine the effect of interventions based on Leventhal’s self-regulatory model on illness perception and lifestyle of patients with hypertension. Therefore, the present study aimed to fill this lacuna. The results showed that intervention based on the present model resulted in the improvement of illness perception in the subscales of the identity, timeline acute/chronic, personal control, treatment control, illness coherence, and timeline cyclical. However, it had no significant effect on the consequences and emotional representations.

As suggested by the findings of the present study, the illness perception-based intervention improved the illness coherence subscale in the study of Broadbent et al. (2009) in the spouses of patients with myocardial infarction, (21). In contrast, Cossette et al. indicated that cardiac rehabilitation nursing intervention in patients with acute coronary syndrome has no effect on the illness coherence subscales and timeline acute/chronic, treatment control, and timeline cyclical subscales (22). The difference between the results of these two studies indicates that interventions based on improving the illness perception can be more effective in improving illness coherence and other subscales, as compared with other educational interventions.

In addition, participants in the present study had a better perception of their illness identity after the intervention, including the symptoms and the disease timeline acute/chronic. This is in line with the findings of the study by Yan et al. (2014). Among other things, they found that the training program based on Leventhal’s model increases patients’ perception of the symptoms and duration of disease after myocardial infarction (13). In this study, increasing patients’ perception of the chronic timeline of hypertension improved patients’ adherence to treatment and a number of lifestyle subscales.

The findings of the present study confirmed the results obtained by Lee et al. in patients with injury (23) and Weldam et al. in patients with chronic obstructive pulmonary disease (24). In a similar vein, Richardson et al. found that the treatment control subscale was promoted after the self-regulatory model-based intervention in cancer patients in the intervention group. However, in the follow-up study with an interval of 6 months, no significant improvement was observed (25). This may be attributed to the frustration and fatigue of cancer patients. It is also necessary to note that in the present study, it was not possible to conduct a follow-up study. Therefore, no meaningful comparison can be made in this regard.

As in the study by Rakhshan et al. (14), in the present study, no significant difference was observed in terms of the subscales of the consequences and emotional representations, even if it has already been reported that emotional representations can affect self-care and health consequences (26). It can be argued that for the purpose of improving the perception of consequences, emotional representations should be improved in patients with hypertension. This probably requires long-term training programs and proper psychological interventions.

The results of the present study indicated that after the intervention, the scores of total lifestyles and its subscales, with the exception of spiritual and social health, increased in the intervention group, as compared with the control group. Likewise, in Yan et al.’s study, educational program based on Leventhal’s model improved nutrition and physical activity in patients after myocardial infarction (13). Likewise, the study by Shayesteh et al. revealed that following lifestyle-based intervention, the overall score of lifestyle and physical activity increased in patients with hypertension (27). The study by Dehghani et al. also indicated that lifestyle-based intervention in patients with coronary heart disease reduced obesity and increased physical activity in patients (28). As in the present study, the intervention affected the weight management of participants by creating a better perception of the disease and a sense of threat.

Blood pressure is affected by environmental factors such as noise and air pollution. Therefore, patients should be informed to avoid exposure to these factors (29). Familiarizing patients with risk factors and changing their high-risk behaviors are the main objectives of the prevention subscale (30). In the present study, all of the above-mentioned issues were incorporated into the education of the patients, and, as a result, these subscales improved after the intervention. As suggested by Leventhal’s self-regulatory model, the subscale of avoidance of drugs, opiates and alcohol improved after the interventions. Similar to this study, the study by Dehghani et al. showed that lifestyle-based intervention in patients with coronary heart disease helped them at times to resist the urge to smoke (28).

In the present study, the psychological health subscale did not improve after the research intervention. Similarly, Rakhshan et al. found that education based on perception in patients with metabolic syndrome had no effect on stress management, although it improved all areas of lifestyle (14) Contrary to the results of the present study, the study by Shayesteh et al. showed that the educational intervention improved stress management in patients with hypertension (27). Moreover, the results of the study by Sararoudi et al. showed that the interventions based on Leventhal’s self-regulatory model reduced the level of anxiety and depression in patients with myocardial infarction (31). Patients’ psychological health was expected to improve with increased illness perception. This difference may be due to the different nature of disease targeted in the above studies. However, in this study, the intervention based on Leventhal’s model did not improve the dimensions of psychological, social and spiritual health in patients with hypertension. According to these results, other spiritual and behavioral interventions may be needed to improve psychological, social and spiritual health.

The overall lifestyle score was improved in the present study, which is probably due to increased perception. In their systematic review study, French et al. showed that patients with acute myocardial infarction and positive perception of identity, consequences, cure/control and illness coherence, feel the need for cardiac rehabilitation (32). Although the variable measured in the study above differs from the variable of consequences in the present study (i.e., healthy lifestyle), it was shown in both studies that a higher illness perception is associated with the acceptance of health-related behaviors.

In contrast to the results of the present study, Rakhshan et al. found that education based on Leventhal perception improved the domains of lifestyle, but did not affect the subscales of perception (14). This raises the question of how it can improve lifestyle without improving perception. The reason for this difference could be that the focus of education is lifestyle, not illness perception. Given that there were limitations in carrying out the study, the findings should be interpreted with caution.

Even if including a control group and random allocation of the participants are considered as the strengths of this study, nevertheless, there were some limitations. One limitation was the lack of a specific questionnaire for measuring illness perception and lifestyle of patients with hypertension. In addition, for practical reasons, duration of intervention was kept short, and there was no opportunity for a follow-up study to determine possible long-lasting effects.

References

Neupane D, McLachlan CS, Mishra SR, Olsen MH, Perry HB, Karki A, et al. Effectiveness of a lifestyle intervention led by female community health volunteers versus usual care in blood pressure reduction (COBIN): an open-label, cluster-randomised trial. The Lancet Global Health. 2018;6(1):e66-e73.
Asresahegn H, Tadesse F, Beyene E. Prevalence and associated factors of hypertension among adults in Ethiopia: a community based cross-sectional study. BMC research notes. 2017;10(1):629. DOI: 10.1186/s13104-017-2966-1.
Zhang Y, Fan X, Li S, Wang Y, Shi S, Lu H, et al. Prevalence and risk factors of hypertension among Hui population in China: A systematic review and meta-analysis based on 30,565 study participants. Medicine. 2021;100(18):e25192. DOI: 10.1097/MD.0000000000025192 .
Pires GE, Peuker AC, Castro EK. Brief intervention for stress management and change in illness perception among hypertensive and normotensive workers: pilot study and protocol. Psicologia: Reflexão e Crítica. 2017;30(1):26. DOI: 10.1186/s41155-017-0080-x.
Kim H, Andrade FC. Diagnostic status of hypertension on the adherence to the Dietary Approaches to Stop Hypertension (DASH) diet. Preventive Medicine Reports. 2016;4:525–31. DOI: 10.1016/j.pmedr.2016.09.009.
Astin F, Jones K. Changes in patients’ illness representations before and after elective percutaneous transluminal coronary angioplasty. Heart & Lung. 2006;35(5):293–300. DOI: 10.1016/j.hrtlng.2005.09.006.
Yaraghchi A, Rezaei O, Mandegar MH, Bagherian R. The relationship between Illness perception and quality of life in Iranian patients with coronary artery bypass graft. Procedia-Social and Behavioral Sciences. 2012;46:3329–34. DOI: 10.1016/j.sbspro.2012.06.061.
Hoving JL, van der Meer M, Volkova AY, Frings-Dresen MHW. Illness perceptions and work participation: a systematic review. International Archives of Occupational and Environmental Health. 2010;83(6):595–605. DOI: 10.1007/s00420-010-0506-6.
Morgan K, Villiers-Tuthill A, Barker M, McGee H. The contribution of illness perception to psychological distress in heart failure patients. BMC Psychology. 2014;2(1):50. DOI: 10.1186/s40359-014-0050-3.
Chen SL, Tsai JC, Lee WL. The impact of illness perception on adherence to therapeutic regimens of patients with hypertension in Taiwan. Journal of Clinical Nursing. 2009;18(15):2234–44. DOI: 10.1111/j.1365-2702.2008.02706.x
Duwe EA, Koerner KM, Madison AM, Falk NA, Insel KC, Morrow DG. Defining older adults’ perceived causes of hypertension in the Brief Illness Perception Questionnaire. Health Education Journal. 2014;73(6):731–45. DOI:10.1177/0017896913516096.
van Broekhoven ME, de Rooij BH, Pijnenborg JM, Vos MC, Boll D, Kruitwagen RF, et al. Illness perceptions and changes in lifestyle following a gynecological cancer diagnosis: A longitudinal analysis. Gynecologic Oncology. 2017;145(2):310–8. DOI: 10.1016/j.ygyno.2017.02.037.
Yan J, You L-m, Liu B-l, Jin S-y, Zhou J-j, Lin C-x, et al. The effect of a telephone follow-up intervention on illness perception and lifestyle after myocardial infarction in China: A randomized controlled trial. International Journal of Nursing Studies. 2014;51(6):844–55. DOI: 10.1016/j.ijnurstu.2013.10.011.
Rakhshan M, Rahimi M, Zarshenas L. The Effect of an Education Program Based on Illness Perception on the Lifestyle of Patients with Metabolic Syndrome: A Randomized Controlled Clinical Trial. International Journal of Community Based Nursing & Midwifery.2019;7(4):279–87. DOI:10.30476/IJCBNM.2019.81658.0.
Rajabloo M, Mohammadpour A, Sajjadi M. The effect of education based on Leventhal's model on adherence to treatment and control of blood pressure in patients with hypertension. Nursing Practice Today. 2021;8(4):333–44. DOI: 10.18502/npt.v8i4.6709.
Issazadegan A, Shiekhy S, Hafeznia M. The effectiveness of cognitive–behavioral therapy on style and quality of life in patients with hypertension. Studies in Medical Sciences. 2013;24(8):598–92. [In Persian]
Moss-Morris R, Weinman J, Petrie K, Horne R, Cameron L, Buick D. The revised illness perception questionnaire (IPQ-R). Psychology and health. 2002;17(1):1–16. DOI: 10.1080/08870440290001494.
Masoudnia E, Orayzi F, Rabbani R, Zamani A, Ahmadi S. Impact of Social Class on Rheumatoid Arthritis Patient's Perception of Illness Symptoms & Pain. Clinical Psychology and Personality. 2005;3(2):37–46. [In Persian]
Lali M, Abedi A, Kajbaf MB. Construction and validation of the lifestyle questionnaire (LSQ). Psychological Research. 2012;15(1):64–80. [In Persian]
Petrie KJ, Cameron LD, Ellis CJ, Buick D, Weinman J. Changing illness perceptions after myocardial infarction: an early intervention randomized controlled trial. Psychosomatic medicine. 2002;64(4):580–6.
Broadbent E, Ellis CJ, Thomas J, Gamble G, Petrie KJ. Can an illness perception intervention reduce illness anxiety in spouses of myocardial infarction patients? A randomized controlled trial. Journal of psychosomatic research. 2009;67(1):11–5. DOI: 10.1016/j.jpsychores.2008.11.006.
Cossette S, Frasure-Smith N, Dupuis J, Juneau M, Guertin M-C. Randomized controlled trial of tailored nursing interventions to improve cardiac rehabilitation enrollment. Nursing research. 2012;61(2):111–20. DOI: 10.1097/NNR.0b013e318240dc6b.
Lee BO, Chien CS, Hung CC, Chou PL. Effects of an in-hospital nursing intervention on changing illness perceptions in patients with injury. Journal of advanced nursing. 2015;71(11):2540–50. DOI: 10.1111/jan.12716.
Weldam SWM, Schuurmans MJ, Zanen P, Heijmans MJWM, Sachs APE, Lammers J-WJ. The effectiveness of a nurse-led illness perception intervention in COPD patients: a cluster randomised trial in primary care. ERJ Open Research. 2017;3(4):00115–2016. DOI:10.1183/23120541.00115-2016.
Richardson AE, Tennant G, Morton RP, Broadbent E. A self-regulatory intervention for patients with head and neck cancer: Pilot randomized trial. Annals of Behavioral Medicine. 2017;51(5):629–41. DOI: 10.1007/s12160-017-9885-1.
Duwe EA, Holloway BM, Chin J, Morrow DG. Illness experience and illness representation among older adults with hypertension. Health Education Journal. 2018;77(4):412–29. DOI: 10.1177/0017896917751553.
Shayesteh H, Mirzaei A, Sayehmiri K, Qorbani M, Mansourian M. Effect of Education Intervention on Lifestyle of Patients with Hypertension among the Rural Population of Lorestan Province. Journal of lifestyle medicine. 2016;6(2):58–63. DOI: 10.15280/jlm.2016.6.2.58.
Dehghani A, Kumar Bhasin S, Dwivedi S, Kumar Malhotra R. Influence of Comprehensive Life Style Intervention in Patients of CHD. Glob J Health Sci. 2015;7(7 Spec No):6–16. DOI:10.5539/gjhs.v7n7p6.
Brook RD, Weder AB, Rajagopalan S. “Environmental hypertensionology” the effects of environmental factors on blood pressure in clinical practice and research. The Journal of Clinical Hypertension. 2011;13(11):836–42. DOI: 10.1111/j.1751-7176.2011.00543.x.
Syme SL. The prevention of disease and promotion of health: the need for a new approach. European Journal of Public Health. 2007;17(4)329–30. DOI: 10.1093/eurpub/ckm081.
Sararoudi RB, Motmaen M, Maracy MR, Pishghadam E, Kheirabadi GR. Efficacy of illness perception focused intervention on quality of life, anxiety, and depression in patients with myocardial infarction. J Res Med Sci. 2016;21:125. DOI: 10.4103/1735-1995.196607.
French DP, Cooper A, Weinman J. Illness perceptions predict attendance at cardiac rehabilitation following acute myocardial infarction: a systematic review with meta-analysis. Journal of psychosomatic research. 2006;61(6):757–67. DOI: 10.1016/j.jpsychores.2006.07.029.

The effect of Leventhal’s Self-Regulatory Intervention on the hypertensive patients’ Illness Perception and Lifestyle: A randomized controlled trial

Abstract

Introduction