The Association between Blood Pressure Control and Multiple Self-Management Behaviors in Elderly Patients with Hypertension: A Study Based on Latent Class Analysis

doi:10.21203/rs.3.rs-3746748/v1

Background

Hypertension in elderly people has become one of the major challenges in China due to the acceleration of population aging. There are few studies on the self-management behavior of elderly people with hypertension. Elderly people with hypertension are a unique group, and self-management behavior is heterogeneous among different groups of individuals. The present study explored the latent class of self-management behaviors in elderly patients with hypertension and its association with blood pressure control.

Methods

Elderly individuals with hypertension who participated in a community health examination in the lakeside community of Bengbu City were selected as research subjects, and a physical examination and questionnaire survey were carried out. Latent class analysis was used to explore the self-management class of elderly patients with hypertension; the characteristics of self-management class were analyzed by a logistic regression model; and the relationship between self-management class and blood pressure control level was analyzed by multiple linear regression.

Results

A total of 3211 elderly patients with hypertension in the community were enrolled, and their self-management behaviors could be divided into four classes: comprehensive positive management (23.70%), positive exercise management (16.29%), comprehensive negative management (25.20%) and negative exercise management (34.81%). Logistic regression results showed that older age, male sex, widowhood, lower education levels, rural residence, and ADL limitations had greater associations with comprehensive negative management (P < 0.05). The results of multiple linear regression analysis showed that compared with comprehensive negative management, patients with positive exercise management and comprehensive positive management had better blood pressure control (positive exercise management: β = 0.059, t = 2.345, P = 0. 019; comprehensive positive management: β = 0.073, t = 2.603, P = 0. 009), suggesting that exercise plays an important role in blood pressure control in elderly hypertensive patients.

Conclusion

There is significant heterogeneity in the self-management behavior of elderly patients with hypertension, and community workers should respond as follows: identify the self-management characteristics and risk factors for various classes of patients as early as possible; formulate different treatment plans for different classes of elderly patients with hypertension; and provide corresponding intervention strategies to help them improve their awareness of self-management behavior, change their bad habits, and improve their quality of life.

latent class analysis

hypertension

self-management behavior

elderly individuals

According to the National Bureau of Statistics, by the end of 2022, there were approximately 280 million elderly people aged 60 years and older in China, accounting for 19.8% of the total population, indicating that China has an aging society ^[1]. The greatest challenge posed by the aging population is the severe and complex health problems of elderly individuals. Hypertension has now become one of the most common chronic diseases among elderly individuals, and according to the Report on the Status of Nutrition and Chronic Diseases in China (2020), the prevalence of hypertension in people aged 60 years and older in China has increased to 59.2% ^[2]. Hypertension easily induces cardiovascular and cerebrovascular diseases such as stroke and coronary heart disease during disease progression. According to the "China Cardiovascular Health and Disease Report" ^[3], the annual incidence of stroke in China is 200/100,000, the annual mortality rate is (80–120)/100,000, and 40% of surviving stroke patients have severe disability. As the most important complication of hypertension in China, stroke has become the disease with the highest disability and mortality rate in China, bringing a heavy burden to families and society.

At present, the control rate of hypertension in elderly individuals in China is only 13.4 ~ 14.8% ^[4], which is still at a low level. The Guidelines for the Management of Hypertension in the Elderly in China (2023) point out that positive and effective blood pressure control in elderly patients with hypertension can confer obvious clinical benefits, and most elderly patients with hypertension in China need to add drug therapy on the basis of lifestyle intervention to ensure that blood pressure control is achieved ^[4–7]. Lifestyle intervention is the basic antihypertensive measure in elderly patients with hypertension, and its role in the prevention and treatment of hypertension in elderly individuals should be considered in combination with the potential role of drug therapy. At any time, an optimal lifestyle can be regarded as a reasonable and effective treatment for hypertension in elderly individuals ^[8–10] and should be continuously integrated throughout the treatment of hypertension; common lifestyle interventions include healthy diet, smoking cessation and alcohol limitation, moderate exercise, maintenance of ideal body weight, and regular blood pressure monitoring. Controlling blood pressure and other risk factors through appropriate medication use and good self-management behaviors can benefit more elderly patients with hypertension by minimizing the risk of damage to target organs such as heart, brain and kidney, minimizing the rate of death and disability, and improving the quality of life.

Most previous studies have explored the self-management behavior of hypertensive adults toward blood pressure control, whereas few studies have studied the self-management behavior of elderly hypertensive people. In fact, the elderly hypertensive population is a unique group; the treatment and intervention strategies for hypertension are significantly different from those of middle-aged and young hypertensive populations, and self-management behaviors are heterogeneous among different groups of individuals. Latent class analysis is currently the most popular method for dividing a population into different groups, and it uses probabilistic models to explore classifications and determine the class to which individuals belong ^[11]. Therefore, this study used latent class analysis to classify the characteristics of five self-management behaviors of elderly hypertensive patients, namely, medication adherence, exercise, smoking, alcohol consumption and blood pressure monitoring, to divide the hypertensive population into different classes of self-management behaviors and analyze the characteristics of each class and their control of blood pressure, thus providing a reference for formulating targeted self-management intervention programs and improving the self-management of elderly hypertensive patients.

Study population

The convenience sampling method was used to select local elderly individuals who participated in the community health examination in the lakeside community of Bengbu City from September 2022 to September 2023 as the research objects. The inclusion criteria were as follows: (1) age ≥ 60 years old, (2) confirmed essential hypertension according to the Chinese Guidelines for the Management of Hypertension in the Elderly (2023) ^[5], and (3) informed consent and voluntary participation in this study. The exclusion criteria were as follows: (1) people diagnosed with severe mental illness and (2) people with severe cognitive impairment.

Sample size estimates: Referring to the Medical Research Methods edited by Chen et al. ^[12], the calculation formula for baseline sample content sampling is as follows: N=[Z2*p*(1-p)]/d². Z represents the confidence interval, the Z value usually chooses 95% of the confidence interval that is 1.96, d represents the allowable error, and the allowable error is 0.02 considering the research purpose and sample distribution in this study. The sample size was calculated according to the prevalence of hypertension in people aged 60 years and older in China as shown in the guidelines ^[2], i.e., p = 0.592. The total sample size was calculated as N= [1.962*0.592*(1-0.592)]/0.022 ≈ 2320, and considering the 20% loss to follow-up rate, the sample size was at least 2784 cases, and the final sample size was 3211 cases.

Research tools

By querying various books and electronic information databases related to hypertension and self-management behavior intervention in elderly individuals at home and abroad, as well as inquiring about the research situation in various databases such as books, journals, master's and doctoral theses, newspapers and periodicals, the relevant variables were comprehensively sorted out, and the general data questionnaire was compiled. The General Information Questionnaire includes sociodemographic and clinically relevant data. Sociodemographic variables include age, sex, marital status, education, place of residence, self-rated health, economic status, etc., and clinical data mainly include activities of daily living (ADLs), body mass index (BMI) and waist circumference.

Based on the Chinese Guidelines for the Prevention and Treatment of Hypertension ^[9–10] and the summary of the best evidence on self-management behaviors of hypertensive patients ^[8], in this study, five self-management behaviors of elderly patients with hypertension were measured, including smoking, drinking, exercise, medication adherence and blood pressure monitoring, and each self-management behavior was scored on a 0–2 scale.

Smoking status was determined by asking, "Have you smoked? Are you still smoking or have you quit?", with a score of 0 indicating smoker status, a score of 1 indicating quitting status, and a score of 2 indicating never status. Alcohol consumption status was determined by asking, "Do you drink?" and “What are the types, frequencies and amounts of alcohol you drink?" The types of alcohol were divided into beer, wine and other colored liquors, and liquor. Alcohol consumption frequency was divided into three levels based on the times of drink per week: < 3 times per week, 3 to 5 times per week, and > 5 times per week ^[13]. The amount of alcohol consumed should not exceed 2 standard drinks per day for men and 1 standard drink per day for women, and 1 standard drink = 50 ml of liquor, 100 ml of wine, and 300 ml of beer ^[10]. A score of 0 represents excessive drinking, a score of 1 represents moderate drinking, and a score of 2 represents never drinking.

Moderate aerobic exercise in elderly patients with hypertension can effectively lower blood pressure. According to guidelines ^[10], it is recommended that older adults should perform no less than 30 minutes of moderate aerobic exercise per day, no less than 5 days a week. In this study, the question about exercise was as follows: "How much time do you spend each week doing moderate-intensity exercise, such as carrying light objects, walking, jogging, tai chi, or swimming, etc.". A score of 0 indicated never exercising, a score of 1 indicated insufficient intensity or frequency, and a score of 2 indicated sufficient intensity and frequency.

The medication adherence scale developed by Morisky et al. ^[14] was used to assess medication adherence. The Chinese version of the scale has been applied in the Chinese hypertensive population, and Ding et al. ^[15] applied the translated Chinese version to the Chinese hypertensive population and studied its reliability and validity. The results showed that the total Cronbach's alpha coefficient of the scale was 0.823. The scale has a total of 8 items ^[16], with a total score of 8 points; < 6 points is poor medication adherence, which is recorded as 0 points; a total score of 6–8 is medium medication adherence, which is recorded as 1 point; and a total score of 8 is good medication adherence, which is scored as 2 points.

According to the Clinical Practice Guidelines for Hypertension (2022) ^[17], home blood pressure monitoring is recommended at least five days a week for patients with hypertension who are newly diagnosed or have poor blood pressure control and 1 to 2 days a week for those with good blood pressure control. The question about blood pressure monitoring in this study was as follows: "Have you monitored your blood pressure in the community or at home in the last week?" A score of 0 indicated no monitoring, a score of 1 indicated irregular monitoring, and a score of 2 indicated regular monitoring.

Blood pressure was measured by an Omron HEM-7200 blood pressure monitor while the patient remained quiet and relaxed during the measurement. The palm of the hand was facing up when sitting, the upper arm was at the same height as the heart, the blood pressure of the same arm was measured 3 times in a row with an intertest interval of 2 minutes each time, and the average value of the 3 measurements was taken as the final blood pressure value.

Covariates

The sociodemographic and clinical data that may be associated with hypertension in elderly individuals were selected. Sociodemographic variables include age, sex, marital status, education, place of residence, smoking, alcohol consumption, self-rated health, economic status, etc. Clinical data mainly include ADLs, BMI and waist circumference. The ADLs consisted of 6 activities: dressing, bathing, eating, getting into or out of bed, going to the toilet, and controlling ones bowels and bowel movements. According to the severity, they are classified as “no difficulty”, “some difficulty but can be completed”, “difficulty and need help to complete”, and “no completion at all”, and difficult in any one of the tasks is considered indicative of having limited ADLs ^[18]. The Chinese standard was used to determine the BMI of elderly individuals, and the BMI was divided into four types, namely, underweight (BMI < 18.5 kg/m2), normal weight (18.5 kg/m2 ≤ BMI < 24.0 kg/m2), overweight (BMI ≥ 24.0 kg/m2) and obesity (BMI ≥ 28 kg/m2). The weight status of waist circumference was based on sex ^[19]: male: normal weight (WC < 85 cm), overweight/obese (WC ≥ 85 cm), female: normal weight (WC < 80 cm), and overweight/obese (WC ≥ 80 cm).

Statistical methods

Normally distributed measures are expressed as the mean ± standard deviation (x ± s), nonnormally distributed measures are expressed as the median (M) and interquartile range (IQR), and counts are described as the frequency and percentage. SPSS software version 26.0 was used for multiple linear regression analysis, and the control of blood pressure by different types of self-management behaviors was compared after controlling for variables such as age, sex, education level, place of residence, economic income, self-rated health, ADLs, BMI, and waist circumference. Mplus 8.3 was used for latent class analysis, and the latent class and classifications of five self-management behavior traits of elderly hypertensive patients were comprehensively judged according to the model suitability index.

Basic information

A total of 3211 elderly people with hypertension in the community were selected, and their descriptive statistics were as follows: the average age was 69.24 (SD = 8.4) years; 54.4% were female; 58.6% had a primary school education or less; the majority of the married population was married; 57.1% were rural households; 37.9% of elderly individuals self-rated their health as poor; the proportion of central obesity was relatively large, accounting for 51.64%; the proportion of abdominal obesity accounted for 71.66%; and the number of ADL restrictions was 1434. General information on elderly individuals with hypertension is shown in Table 1.

Common method bias test

The Harman univariate test was used to analyze the factors of five hypertension self-management behaviors; there were 3 common factors with eigenvalues greater than 1, and the cumulative explanation rate was 72.42%. The variation rate of the first common factor was 28.39%, which was lower than the cutoff value of 40% ^[20], suggesting that there was no serious common method bias in the data of this study.

Latent class analysis of self-management behavior

Five indicators, including smoking, alcohol consumption, exercise, medication adherence and blood pressure monitoring, were used as explicit variables, and the number of latent classes of self-management behaviors of hypertensive patients was increased sequentially for model fitting estimation for latent class analysis. AIC, BIC, aBIC, entropy index, LMR, and BLRT were used as model fitness indicators. The smaller the three statistical values of AIC, BIC, and aBIC are, the better the fit of the model. The value of the entropy index ranges from 0 to 1, and values closer to 1 indicate that the latent classification is more accurate. The LMR and BLRT are mainly used to compare the differences between n class models and n-1 class models, and significant values indicate that n class models are better than n-1 class models ^{[11, 21]}. The results of this study showed that although the entropy index of the 2-class model was higher than that of the 3-, 4- and 5-class models, the AIC, BIC and aBIC were the highest compared with those of the 3-, 4- and 5 class models, and the fitting indexes of the 5-class model were better than those of the 4-class model. In principle, the 5-class model should be retained, but in the 5-class model, there was a class with only 6.1% of patients. In addition, there were 2 latent classes that were very similar, and the distinction was not obvious. Considering the simplicity of the model, the final choice was to retain the 4-class model, as shown in Table 2.

Nomenclature and characteristics of self-management behaviors

A total of 3211 elderly patients with hypertension were included in this study, which can be divided into four classes, as shown in Figure 1. The first class was named "comprehensive negative management", and the performance of five self-management behaviors of elderly hypertensive patients in this class was poor, with a total of 809 people, accounting for 25.20%. The second class was named "positive exercise management", and elderly patients with hypertension in this class had better medication adherence, drinking behavior control and exercise management, especially exercise management, with a total of 523 people, accounting for 16.29%. The third class was named "comprehensive positive management", and the performance of five self-management behaviors of elderly hypertensive patients in this class was good, with a total of 761 patients, accounting for 23.70%. The fourth class was named "negative exercise management", and there were 1118 elderly hypertensive patients with good medication adherence, blood pressure monitoring and behavior control but poor exercise levels, accounting for 34.81%.

Univariate analysis of demographic and clinical characteristics among the four classes of self-management of elderly patients with hypertension showed that there were significant differences in age, sex, place of residence, education level, marital status, self-rated health, ADLs, BMI, and waist circumference among the different classes (P<0.05). There was no significant difference in economic status among the four classes, as shown in Table 1. The four self-management classes determined by latent class analysis were used as the dependent variables, the meaningful variables of univariate analysis were used as the independent variables, and the multivariate logistic regression analysis was performed with "Comprehensive negative management" as the reference class, as shown in Table 3. The results showed that the overall level of self-management behavior was worse in older hypertensive patients who were older, male, widowed, less educated, rural, obese, and ADL-limited (P<0.05).

Table 1 Relationship between hypertensive self-management behavior and sociodemographic and clinical characteristics in the elderly population

Variables	Total（%）	Class 1	Class2	Class 3	Class 4	c²	P
Age (years)						147.389	0.000
60-69	1832(57.05)	402(49.69)	365(69.79)	514(67.54)	551(49.28)
70-79	1069(33.29)	327(40.42)	130(24.86)	214(28.12)	398(35.60)
≥80	310(9.65)	80(9.89)	28(5.35)	33(4.34)	169(15.12)
Sex						1591.577	0.000
Male	1464(45.59)	703(86.90)	459(87.76)	126(16.56)	176(15.74)
Female	1747(54.41)	106(13.10)	64(12.24)	635(83.44)	942(84.26)
Place of residence						11.281	0.010
Rural	1833(57.09)	448(55.38)	312(59.66)	466(61.24)	607(54.29)
Urban	1378(42.91)	361(44.62)	211(40.34)	295(38.76)	511(45.71)
Marital status
Married	2393(74.53)	561(69.34)	442(84.51)	637(83.71)	753(67.35)	108.563	0.000
Widowed	769(23.95)	232(28.68)	72(13.77)	115(15.11)	350(31.31)
Other	49(1.52)	16(1.98)	9(1.72)	9(1.18)	15(1.34)
Education						427.764	0.000
<6 years	1703(53.04)	540(66.75)	226(43.21)	184(24.18)	753(67.35)
≥6 years	1508(46.96)	269(33.25)	297(56.79)	577(75.82)	365(32.65)
Income						2.336	0.506
Low-middle income	1857(57.83)	467(57.73)	317(60.61)	440(57.82)	633(56.62)
High income	1354(42.17)	342(42.27)	206(39.39)	321(42.18)	485(43.38)
Self-rated health
Poor	1217(37.90)	343(42.40)	126(24.09)	253(33.25)	495(44.28)	84.089	0.000
Fair	1406(43.79)	348(43.02)	264(50.48)	349(45.86)	445(39.80)
Good	588(18.31)	118(14.58)	133(25.43)	159(20.89)	178(15.92)
BMI(kg/m²)
<18.5	161(5.01)	52(6.43)	35(6.69)	32(4.20)	42(3.76)	47.277	0.000
18.5-23.9	1392(43.35)	399(49.32)	250(47.80)	305(40.08)	438(39.18)
≥24	1658(51.64)	358(44.25)	238(45.51)	424(55.72)	638(57.06)
WC						123.506	0.000
Normal	910(28.34)	307(37.95)	208(39.77)	178(23.39)	217(19.41)
Abnormal	2301(71.66)	502(62.05)	315(60.23)	583(76.61)	901(80.59)
ADLs						459.681	0.000
Normal	1777(55.34)	312(38.57)	414(79.16)	592(77.79)	459(41.06)
ADL-limited	1434(44.66)	497(61.43)	109(20.84)	169(22.21)	659(58.94)

Table 2 Fitting information table of latent class for self-management behaviors of hypertension in the elderly population

Model	AIC	BIC	aBIC	Entropy	LMR	BLRT	Class Probability
C1	37602.370	37663.113	37631.339	—	—	—	1
C2	32494.052	32591.241	32540.402	0.953	<0.001	<0.001	0.384/0.616
C3	31884.827	32018.462	31948.559	0.926	0.0027	<0.001	0.123/0.295/0.582
C4	29711.670	29881.752	29792.784	0.934	<0.001	<0.001	0.252/0.163/0.237/0.348
C5	27224.792	27431.320	27323.287	0.959	<0.001	<0.001	0.175/0.172/0.348/0.061/0.244

Table 3 Predictors of self-management in elderly patients with hypertension

Variables	Class 1			Class 2			Class 4
Variables	OR	95% CI	P	OR	95% CI	P	OR	95% CI	P
Age (years)
60-69	Ref			Ref			Ref
70-79	1.392	1.054-1.838	0.020	0.750	0.550-1.023	0.070	1.369	1.095-1.712	0.006
≥80	1.781	1.054-3.009	0.031	0.819	0.446-1.505	0.520	2.695	1.748-4.155	0.000
Sex
Famale	Ref			Ref			Ref
Male	41.530	29.839-57.800	0.000	40.197	28.051-57.602	0.000	0.939	0.704-1.252	0.667
Place of residence
Urban	Ref			Ref			Ref
Rural	0.752	0.578-0.980	0.035	0.832	0.626-1.107	0.208	0.803	0.651-0.991	0.052
Marital status
Married	Ref			Ref			Ref
Widowed	1.470	1.066-2.026	0.019	1.089	0.753-1.575	0.651	1.136	0.897-1.439	0.289
Other	0.699	0.264-1.852	0.471	0.563	0.196-1.623	0.288	0.976	0.398-2.393	0.957
Education
≥6 years	Ref			Ref			Ref
<6 years	1.503	1.133-1.994	0.005	1.144	0.846-1.547	0.382	1.074	0.853-1.353	0.541
Self-rated health
Good	Ref			Ref			Ref
Fair	0.967	0.682-1.372	0.852	0.981	0.679-1.418	0.920	0.763	0.578-1.007	0.056
Poor	1.171	0.817-1.677	0.390	0.846	0.573-1.249	0.401	0.845	0.636-1.122	0.244
BMI(kg/m²)
18.5-23.9	Ref			Ref			Ref
<18.5	1.954	1.066-3.580	0.061	1.881	0.990-3.576	0.054	0.965	0.564-1.653	0.898
≥24	0.629	0.465-0.850	0.003	0.697	0.501-0.969	0.052	0.916	0.728-1.152	0.452
WC
Normal	Ref			Ref			Ref
Abnormal	1.372	0.975-1.931	0.070	1.109	0.769-1.599	0.579	1.330	0.999-1.771	0.051
ADLs
Normal	Ref			Ref			Ref
ADL-limited	4.817	3.680-6.304	0.000	0.781	0.570-1.069	0.123	4.981	4.028-6.159	0.000

Self-management behavior and blood pressure control

Multiple linear regression was used to explore the correlation between different types of self-management behaviors and blood pressure control, and the results showed that after controlling for covariates such as age, sex, place of residence, education level, marital status, self-rated health, BMI, waist circumference, and ADLs in elderly hypertensive patients, the blood pressure control of positive exercise management and comprehensive positive management was better than that of comprehensive negative management (comprehensive positive management: β=0.073, P=0.009; positive exercise management: β=0.059, P=0.019). In addition, to explore whether there was a difference between patients with positive exercise management and comprehensive positive management, a multiple linear regression was performed with comprehensive positive management, and the results showed that there was no significant difference in blood pressure between the two groups. The correlation regression analysis between the 4 classes of self-management and blood pressure control is shown in Table 4.

Table 4 Regression analysis of the association between latent class analysis of self-management and blood pressure control

Class	β	S.E.	t	P	95% CI
Class 1	Ref-
Class 2	0.059	0.025	2.345	0.019	0.675-1.481
Class 3	0.073	0.028	2.603	0.009	0.726-1.378
Class 4	0.028	0.023	1.214	0.225	0.644-1.553

In this study, 3211 elderly patients with hypertension were divided into four classes of five self-management behaviors by latent class analysis: positive exercise management, negative exercise management, comprehensive negative management, and comprehensive positive management.

“Positive exercise management” accounted for the smallest proportion of patients (16.29%). Elderly hypertensive patients in this class were attentive to exercise and had better blood pressure control, but the control of smoking and drinking behavior and blood pressure monitoring were poor. The regression analysis results showed that most of these patients were young (66.47 ± 7.49 years) and male, which was consistent with the results of a previous study ^[22]. Younger elderly patients may have just retired, have better self-care ability in daily life, and have enough time and energy for outdoor exercise, especially young male patients, They are more inclined to relieve stress or make friends through exercise, and at the same time, they often use smoking and drinking to establish or enhance their social support network, which also indirectly leads to poor behavior control, such as smoking and drinking behavior. Men, who have different lifestyles than women, are generally less concerned with disease, measure their blood pressure or take antihypertensive drugs only when they are unwell and have less awareness of health care services ^[23]. For these elderly people with hypertension, we encourage them to maintain their enthusiasm and continuity of exercise. Especially for young men, the focus of health education should emphasize the harm of smoking and drinking, advise them to quit smoking and limit alcohol consumption, and advocate medication adherence to prevent the occurrence of other complications. This study showed that only 2.24% of elderly individuals were widowed in this class, the role of family support should be fully utilized ^[24], and family members should be encouraged to simultaneously participate in the disease management of patients to improve their blood pressure monitoring behavior and self-care awareness. Community services can facilitate regular physical examination activities and provide free blood pressure monitoring for elderly hypertensive patients in the community to improve the disease perception of such people.

“Negative exercise management” accounted for the largest proportion of participants (34.81%). Elderly hypertensive patients in this class have poor exercise habits and poor blood pressure control, but they have better behavioral control, such as smoking and drinking behaviors and medication adherence, and pay more attention to blood pressure monitoring. The regression analysis results showed that these patients were mainly middle-aged and elderly (average age 70.66 ± 8.37 years) and had limited ADLs due to diseases or other physical reasons (the ADL limitation rate was 20.52%), which led to poor exercise compliance in these elderly hypertensive people. However, due to the prolongation of the course of the disease, the self-care awareness or perception of the disease of this elderly group has deepened, and with the health education of community health workers in their daily life, they will consciously change their bad habits, such as smoking and drinking. For such elderly people with hypertension, medication is an effective way to control blood pressure, and we should encourage them to take medication regularly to improve medication adherence. In addition, we should effectively evaluate the exercise ability of elderly people with hypertension and formulate personalized exercise prescriptions for them according to their conditions and personal preferences ^[25], such as joint exercises, Baduanjin and other traditional Chinese medicine exercise therapies, to improve their cardiopulmonary function and physical strength. Community workers should have a deep understanding of why elderly people do not exercise. For example, some people have musculoskeletal pain or a fear of falling and thus are afraid to exercise; therefore, we should develop a clear exercise plan, teach them exercise methods and skills, strengthen supervision during exercise, and enhance their confidence and enthusiasm for exercise ^[26]. At the same time, community workers should also successfully construct an infrastructure, create a comfortable and safe exercise environment for elderly individuals, and prevent the occurrence of adverse events such as falls.

The proportion of "comprehensive negative management" (25.20%) is second only to "negative exercise management". The five self-management behaviors of these elderly people were poor, and blood pressure control was ranked the lowest among the classes. The regression analysis results showed that older age, low education level, rural residence, widowhood, obesity and limited ADLs were independent risk factors for patients in the "comprehensive negative management" class. Older adults with limited ADLs have poor exercise compliance, and older people living in rural areas and with low education have fewer ways to obtain and use health information, this may lead to certain misunderstandings about exercise, resulting in the belief that doing housework or farm work counts as exercise, although it often does not meet the exercise frequency, time, and volume requirements for controlling blood pressure ^[27]. The blood pressure monitoring and medication adherence of this group of people is also very poor, There is less awareness of the benefits of monitoring blood pressure, therefore, blood pressure is only monitored when seeking medical treatment or physical examination. The knowledge related to preventive health care and drug use is low, therefore, patients are easily influenced by traditional concepts such as “medicine is three parts poison” and usually only start taking medication when blood pressure is abnormal. Widowed elderly individuals lack family support and often feel lonely. Studies ^[28–29] have shown that a lack of family support is an important risk factor for the development of hypertension, which unconsciously reduces an individual’s ability to self-regulate and results in increased unhealthy lifestyle behaviors, such as alcohol abuse and reduced physical activity, thus increasing the risk of cardiovascular disease ^[30]. Obesity is a detrimental factor for blood pressure control in older adults, possibly due to changes in hormonal, inflammatory, and endothelial cell levels, which can lead to increased blood pressure, increased incidence of cardiovascular and cerebrovascular diseases, and reduced effectiveness of blood pressure control efforts ^{[19, 31–32]}. This group of elderly people is the object of attention, and a comprehensive treatment plan should be formulated for them based on their actual situation to stimulate their subjective initiative and self-efficacy for effective blood pressure control. For example, rehabilitation guidance for community-dwelling elderly patients with hypertension can be carried out through the intervention of family physician teams and a continuum of care to improve their awareness of hypertension and their cooperation with treatment activities ^[10], and the following concepts can be incorporated: maximally simplified medication regimens to improve medication adherence in elderly individuals ^[33] and increase their confidence in treatment; regular community health education and health lectures; positive promotion of healthy diet, exercise, and weight reduction; formulation of corresponding intervention plans when necessary to be implemented in strict accordance with the plan; and facilitation of positive community practice activities to provide targeted social support to widowed elderly hypertensive patients to reduce loneliness caused by the lack of social relationships.

Regression analysis showed that exercise has a better effect on blood pressure control than other self-management behaviors and that exercise can increase the antihypertensive effect of antihypertensive drugs, which is consistent with most studies ^[34–39]. Pescatello LS et al. ^[34] have shown that exercise is more effective in controlling blood pressure than medication and that combined exercise can enhance the antihypertensive effect of medication. Alves AJ et al. ^[35] showed that exercise alone lowered blood pressure more than medication alone. Shao X Q et al. ^[36] discussed the clinical value of standardized exercise in elderly patients with hypertension and showed that after standardized exercise intervention, the systolic and diastolic blood pressure of the subjects were significantly reduced, and the dietary and medication management behaviors were significantly improved. Pescatell et al. ^[37] found that aerobic exercise training can reduce blood pressure by 1 to 5 mmHg in hypertensive patients, and the most effective exercise interventions consisted of at least 12 weeks of moderate- to high-intensity aerobic exercise for 40 minutes three to four times a week. Wang et al. ^[38] conducted a prospective study on 80 hypertensive patients, showing that compared with the control group, individualized aerobic exercise can significantly and effectively reduce the blood pressure level of hypertensive patients and can reduce the levels of angiotensin II and endothelin-1 in the serum, which has a significant effect on the control of hypertension. With increasing age, the muscle strength of elderly individuals decreases, the muscle fibers become thinner and the number decreases, resulting in the limitation of their movement speed and strength ^[40]. Evidence suggests that exercise in elderly individuals can enhance muscle adaptability, thicken muscle fibers, promote blood circulation, improve joint elasticity and flexibility, and delay the aging process of skeletal muscle ^[41–42]. Insulin resistance is a risk factor for aging diseases, and exercise can improve skeletal muscle function, promote increased IGF-1 levels, increase nitric oxide bioavailability, and reduce peripheral vascular resistance, which in turn lowers blood pressure in older patients with hypertension ^[43–44]. At the same time, regular exercise can reduce depression and anxiety in elderly patients with hypertension, improving their sense of well-being and improving their mental health ^[45]. Community workers should strengthen the promotion of hypertension-related knowledge in elderly individuals, use a variety of methods and media to widely disseminate the knowledge of exercise for elderly individuals and their caregivers, and raise the awareness of the positive effects of exercise for elderly individuals ^[46]. Before exercising, a comprehensive health screening should be carried out; exercise function and potential risks should be assessed; a scientific and implementable personalized exercise prescription should be formulated according to personal abilities and goals and combined with one’s preferences; and the prescription should clarify the exercise mode, exercise intensity, exercise amount and duration. The Guidelines for the Management of Hypertension in the Chinese Elderly recommend that elderly patients with hypertension should focus on moderate-intensity aerobic exercise combined with resistance exercise, balance training, breathing training, etc., ≥ 30 minutes a day, ≥ 5 days a week ^[4]. Musculoskeletal pain and fear of falling are important reasons why most elderly people are reluctant to exercise, so it is necessary to teach elderly individuals the correct exercise skills and methods during exercise, do a good job in exercise monitoring, provide a sufficient sense of security for elderly individuals during exercise, and prevent the occurrence of adverse events.

Hypertension is a chronic disease that requires lifelong management, and improving the self-management ability of elderly patients with hypertension is an important means to control blood pressure. The establishment of a supportive environment has a positive impact on patient health and is an important condition for the sustainability of self-management behavior change ^[47]. At present, there is still an imbalance in the construction of urban and rural infrastructure, the level of medical services, and the pension policy in China ^[48], which to a certain extent restricts the improvement of the self-management behavior of elderly individuals in rural areas, especially those with low education levels and poor economic status. Therefore, the government should improve the construction of rural infrastructure, improve the level of medical and health service systems for elderly individuals, and incorporate the prevention and treatment of hypertension into local medical and health service policies ^[10]. The coverage of high-quality health services for elderly individuals should be expanded in terms of content, region, and infrastructure. In addition, the following concepts should be implemented, organization and implementation of health literacy promotion projects for elderly individuals with hypertension, strengthened health education in a targeted manner; wide dissemination of popular science knowledge regarding exercise, disease prevention, rational use of medicines, weight control, mental health, life education, and health care, improvement of health literacy in elderly individuals with hypertension; standardization of personal health behaviors and treatment compliance; implementation of regular health check-ups; emphasis on the health status of elderly individuals in the lower social classes, and provision of high-quality medical care.

The advantages of this study are, first, that the subjects of this study were community-dwelling elderly people with hypertension. Community-dwelling older adults were not affected by various external factors, the bias was less than that of hospital-recruited elderly inpatients, and the results of the study were more representative. Second, the 5 self-management behaviors associated with this study were measured on a scale to reduce bias from subjective reporting. Third, this study conducted a latent class analysis of the self-management behaviors of community-dwelling elderly patients with hypertension and concluded that exercise has a better effect on blood pressure control than medication use, which provides insights for the development of interventions for elderly patients with hypertension in the future. There are also some shortcomings in this study. First, this is a cross-sectional study, and the causal relationship between self-management behavior and blood pressure values needs to be further explored. Second, this study investigated the self-management behaviors of hypertension in elderly individuals based on five behaviors, smoking, alcohol consumption, exercise, blood pressure monitoring, and medication adherence, but there may be other important behaviors, such as salt reduction, stress reduction, and maintaining psychological balance, that were not included.

In this study, the latent classes of self-management behaviors of community-dwelling elderly patients with hypertension were analyzed, and the relationship between self-management behavior and blood pressure control was further explored. It was revealed that there were four different latent classes, namely, comprehensive positive management, positive exercise management, comprehensive negative management and negative exercise management, indicating that there is heterogeneity in the self-management behavior of elderly hypertensive patients; therefore, we should formulate or adopt different treatment plans or intervention strategies according to different classes of elderly hypertensive populations, improve the construction of community infrastructure, and improve the exercise compliance of the elderly population. At the same time, community workers should strengthen the health education of elderly people with hypertension, positively promote their self-management behavior, and improve their quality of life. In the future, this study will conduct a longitudinal study to explore the causal relationship between self-management behavior and blood pressure and expand the sample size to conduct more in-depth studies analyzing differences between regions.

Acknowledgments

We would like to express our gratitude to both the study participants and the community workers from the Lakeside Community.

Authors’ contributions

ML contributed to the conception and design of the study. ML and TZ organized the database. ML, WG, TZ and YC performed the statistical analysis. ML wrote the first draft of the manuscript. ML, LZ, MZ, WG, YC and SZ revised this draft and provided important suggestions. All authors contributed to the manuscript revision and read and approved the submitted version.

Funding

This study was supported by the 2021 Anhui University Humanities and Social Science Research Key Project “Research on Theoretical Model Construction and Intervention Research of Community Elderly Exercise Behavior Health Promotion” (No. SK2021A0443, 2018), the Anhui University Humanities and Social Sciences Research Key Project “Research on Evaluation Index System of Long-term Care Grading Standards for the Elderly” (No. SK2018A0178, 2023), and the Bengbu Medical College Graduate Research and Innovation Program Funding Project "Research on Healthy Life Expectancy and Social Stratification Analysis of Elderly People in China Based on Intrinsic Ability Health Standards" (Project No.: Byycx23016).

Availability of data and materials

The datasets generated and analyses performed during the current study are not publicly available due to the consent requirements for participants, but hypertensive self-management behavior descriptive data are available from the corresponding author upon reasonable request.

Ethics approval and consent to participate

The research protocol was approved by the ethics committee of Bengbu Medical College (Grant No. 2018045) and aligned with the principles of the Declaration of Helsinki. All participants signed informed consent forms prior to their participation. All methods were performed in accordance with relevant guidelines and regulations.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

National Bureau of Statistics of the People's Republic of China. National data-2022 annual data [EB-OL]. [2022]. National Bureau of Statistics of the People's Republic of China, http://www.stats.gov.cn/easyquery.htm?cn=C01.
Dietary guidelines for adults with hypertension. (2023 edition) [J]. Clinical and Education in General Practice,2023,21(06).
Interpretation of the key points of the Chinese Cardiovascular Health. and Disease Report 2022[J]. Chin J Cardiol 2023,28(04):297–312.
Hypertension Branch of Chinese Geriatrics Society; Beijing Association for the Prevention and Treatment of Hypertension; National Clinical Research Center for Geriatric Diseases. (General Hospital of the People's Liberation Army of Chinese. Chin J Hypertens 2023,31(06):508–38.10.16439/j.issn.1673-7245.2023.06.003.
Adnan I, Ali K, Naji A et al. Patient activation, adherence to hypertension treatment plans and blood pressure control in Saudi Arabia: a cross-sectional study. [J].BMJ open,2023,13(1).
Blood Pressure Lowering Treatment Trialists' Collaboration. Pharmacological blood pressure lowering for primary and secondary prevention of cardiovascular disease across different levels of blood pressure: an individual participant-level data meta-analysis[J]. Lancet 2021,397(10285):1625–36.
Valenzuela PL, Carrera-Bastos P, Gálvez BG, et al. Lifestyle interventions for the prevention and treatment of hypertension. Nat Rev Cardiol. 2021;18(4):251–75. 10.1038/s41569-020-00437-9.
Li CH, Fu R, Liang LP. Summary of the best evidence for lifestyle management in elderly patients with hypertension[J].Modern Clinical Nursing,2022,21(06).
Sun S, Yi S. 2023 Guidelines for the Prevention and Treatment of Hypertension in China Update Clinical Practice[J].ECG and Circulation,2023,42(03).
Guidelines for the prevention and treatment of hypertension in China. (2018 revised edition) [J]. Chinese Journal of Cardiology,2019,24(01):24–56.
Zeng LP, Zeng DP, Qu JN et al. Heterogeneity of work-family balance among primary and secondary school teachers: Based on potential profile analysis[J]. Chin J Clin Psychol 2021,29(01):161–4.10.16128/j.cnki.1005-3611.2021.01.032.
Chen SY, Liu XQ. Medical research methods[M]. Beijing: People's Medical Publishing House,2015:116–7.
Wu XD. Study on the correlation between drinking behavior and left atrial appendage thrombosis in elderly patients with paroxysmal atrial fibrillation[D].Nanchang University,2023.10.27232/d.cnki.gnchu.2023.001327.
Moon SJ, Lee WY, Hwang JS, Hong YP, Morisky DE. Accuracy of a screening tool for medication adherence: A systematic review and meta-analysis of the Morisky Medication Adherence Scale-8 [published correction appears in PLoS One. 2018;13(4):e0196138]. PLoS One. 2017;12(11):e0187139. Published 2017 Nov 2. 10.1371/journal.pone.0187139.
Ding PJ, Shi HQ, Li B. Reliability and validity evaluation of Chinese version of MMAS-8 scale in hypertensive patients[J]. Electron J Clin Med Literature,2017,4(39).
Qin Y, Qin MF, Tang XJ et al. Study on the current situation and influencing factors of medication adherence of elderly patients with hypertension at home in the community[J]. Contemporary Nurses(Mid-Term),2023,30(01).
Wang XY, Wang PQ, Xiong XJ, Evaluation of the Chinese Clinical Practice Guidelines for Hypertension. Edition) and the Exploration of Traditional Chinese Medicine to Reduce Blood Pressure[J]. China J Traditional Chin Med 2023. 2022;48(17):4819–24. 10.19540/j.cnki.cjcmm.20230603.501.
Wu X, Chen T. Analysis of unmet intergenerational care needs of the disabled elderly and its influencing factors[J]. Mod Prev Med 2022,49(19):3529–34.10.20043/j.cnki.MPM.202204367.
Jie W, Geng Y, Cheng JX et al. Correlation between different body mass index and waist circumference and blood pressure control in elderly patients with hypertension[J]. Chin J Prev Med 2023,24(04):368–74.10.16506/j.1009-6639.2023.04.015.
Podsakoff PM, MacKenzie SB, Lee JY et al. Common method biases in behavioral research: a critical review of the literature and recommended remedies. J Appl Psychol 2003,88(5): 879–903.
Shen Y, Wang T, Gao M, et al. Association of glucose control and stages of change for multiple self-management behaviors in patients with diabetes: A latent profile analysis. Patient Educ Couns. 2020;103(1):214–9. 10.1016/j.pec.2019.08.020.
Mariasole BD, Rachael S, R J M et al. Sex differences in the response to resistance exercise training in older people.[J].Physiological reports,2016,4(12):e12834–4.
Song YL, Lin J, Wu YP et al. Prevalence status of cardiovascular and cerebrovascular disease risk factors and influencing factors of hypertension awareness, treatment and control rates among residents in Handan City[J]. Chin J Stroke 2022,17(12):1360–5.
Chen CX, Song Q, Zhang M et al. Effect of family and social support on health self-management behavior of elderly diabetic adults at home[J]. Mod Prev Med 2017,44(01):116–20.
Lee PG, Jackson EA, Richardson CR. Exercise Prescriptions in Older Adults. Am Fam Physician. 2017;95(7):425–32.
Eric L, Phoebe U, Waldemar S et al. Cognitive behavioural therapy (CBT) with and without exercise to reduce fear of falling in older people living in the community. [J].The Cochrane database of systematic reviews,2023,11CD014666-CD014666.
Yang H. Opportunities, problems and strategies for rural sports development in rural revitalization[J]. J Chengdu Univ Phys Educ 2022,48(05):8–14.10.15942/j.jcsu.2022.05.002.
Cené CW, Beckie TM, Sims M, et al. Effects of Objective and Perceived Social Isolation on Cardiovascular and Brain Health: A Scientific Statement From the American Heart Association. J Am Heart Assoc. 2022;11(16):e026493. 10.1161/JAHA.122.026493.
Zhu YC, Zhou D, Feng YQ. Research progress on the relationship between loneliness and the occurrence and development of hypertension in the elderly[J/OL].Chinese Journal of Hypertension,1–5[2023-11-28].
Martín JC, Ortega-Sánchez D, Miguel IN et al. Music as a factor associated with emotional self-regulation: A study on its relationship to age during COVID-19 lockdown in Spain. Heliyon.2021;7(2):e06274.Published 2021 Feb 22. 10.1016/j.heliyon.2021.e06274.
Litwin M, Kułaga Z. Obesity, metabolic syndrome, and primary hypertension. Pediatr Nephrol. 2021;36(4):825–37. 10.1007/s00467-020-04579-3.
Seravalle G, Grassi G. Obesity and hypertension. Pharmacol Res. 2017;122:1–7. 10.1016/j.phrs.2017.05.013.
Li YS, Zhang ZX, Liu SS et al. Research progress on drug safety intervention for the elderly at home in the community[J]. Chin J Gerontol 2017,37(15):3898–900.
Pescatello LS, Wu Y, Gao S, Livingston J, Sheppard BB, Chen MH. Do the combined blood pressure effects of exercise and antihypertensive medications add up to the sum of their parts? A systematic meta-review. BMJ Open Sport Exerc Med. 2021;7(1):e000895. 10.1136/bmjsem-2020-000895. Published 2021 Jan 20.
Alves AJ, Wu Y, Lopes S, Ribeiro F, Pescatello LS. Exercise to Treat Hypertension: Late Breaking News on Exercise Prescriptions That FITT. Curr Sports Med Rep. 2022;21(8):280–8. 10.1249/JSR.0000000000000983. Published 2022 Aug 1.
Shao XQ. Clinical value of standardized exercise intervention in elderly patients with hypertension[J].Application of Modern Medicine in China,2022,16(09):181–3.10.14164/j.cnki.cn11-5581/r.2022.09.062.
Pescatello LS, MacDonald HV, Ash GI et al. Assessing the Existing Professional Exercise Recommendations for Hypertension: A Review and Recommendations for Future Research Priorities. Mayo Clin Proc. 2015;90(6):801 – 12. doi: 10.1016/j.mayocp.2015.04.008. PMID: 26046413.
Wang YP, Zou DY, He XJ et al. Effect of diversified health education combined with personalized aerobic exercise on health behavior and psychological stress state of hypertensive patients[J]. Chin J Health Care Med 2021,23(02):183–5.
Noone C, Dwyer CP, Murphy J, Newell J, Molloy GJ. Comparative effectiveness of physical activity interventions and anti-hypertensive pharmacological interventions in reducing blood pressure in people with hypertension: protocol for a systematic review and network meta-analysis. Syst Rev. 2018;7(1):128. Published 2018 Aug 21. 10.1186/s13643-018-0791-9.
Tapanya W, Maharan S, Sangkarit N et al. Using a Standing Heel-Rise Test as a Predictor of Ankle Muscle Strength in the Elderly[J]. Sports, 2023,11(8).
Liang YH, Ma LG. Intervention effect of long-term exercise on sarcopenia symptoms in the elderly[J]. Chin J Gerontol 2021,41(16):3460–2.
Huang K, Cheng ZQ. Research progress of exercise therapy in the treatment of hypertension[J]. J Cardiovasc Rehabilitation Med 2004(01):87–8.
Ciolac EG, Bocchi EA, Bortolotto LA, et al. Effects of high-intensity aerobic interval training vs. moderate exercise on hemodynamic, metabolic and neuro-humoral abnormalities of young normotensive women at high familial risk for hypertension. Hypertens Res. 2010;33(8):836–43. Epub 2010 May 7. PMID: 20448634.
Shen ZT, Zhang J, Zhang C. Effect of moderate-intensity aerobic exercise on ambulatory blood pressure and endothelin and nitric oxide levels in patients with essential hypertension[J]. China J Chronic Disease Prev Control 2019,27(01):46–8.10.16386/j.cjpccd.issn.1004-6194.2019.01.012.
Wang MX, Li SX, Song T. Research progress on the comorbid mechanism of depression and cardiovascular disease[J]. Chin J Gen Pract 2021,24(11):1426–30.
Wang H, Qin F, Li MW et al. A qualitative study on the promotion and hindrance factors of exercise behavior in the frail elderly in nursing institutions[J]. China Nurs Manage 2022,22(08):1204–9.).
Lynn H, Jeannine U, ,Taryn Y. Decision makers perceptions and experiences of developing population-level interventions targeting risk factors for hypertension and diabetes in South Africa: a qualitative study.[J].BMC health services research,2023,23(1):146–6.
Xuan D, Fang J. How the rural infrastructure construction drives rural economic development through rural living environment governance—case study of 285 cities in China[J].Frontiers in Environmental Science,2023,11.

No competing interests reported.

The Association between Blood Pressure Control and Multiple Self-Management Behaviors in Elderly Patients with Hypertension: A Study Based on Latent Class Analysis

Status:

Version 1

Abstract

Background

Methods

Results

Conclusion

Figures

Background

Methods

Study population

Research tools

Covariates

Statistical methods

Results

Basic information

Common method bias test

Latent class analysis of self-management behavior

Discussion

Conclusion

Declarations

References

Additional Declarations

Status:

Version 1