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Effect of Leventhal’s self-regulatory intervention on the hypertensive patients’ illness perception and lifestyle: a randomized controlled trial

Effect of Leventhal’s self-regulatory intervention on the hypertensive patients’ illness... Background The perception of illness may lead to improving the hypertensive patients’ lifestyle, but no study was found in this regard. Therefore, this study was conducted to determine the effect of intervention based on Leventhal’s self-regulatory model on the illness perception and lifestyle of patients with hypertension. Methods In the present randomized controlled trial study, ninety eligible patients with primary hypertension were randomly assigned to one of the two groups of intervention and control. Patients in the intervention group received five sessions of Leventhal’s self-regulatory intervention, each of 60 min and weekly. However the control group received routine care. The outcomes were illness perception and lifestyle of the patients with hypertension. The Revised Illness Perception Questionnaire and the Lifestyle Questionnaire were administered to assess illness percep- tion and lifestyle before the treatment to establish a baseline and subsequently 12 weeks after the intervention. The collected data were analyzed using statistical IMB SPSS software, version 21. Qualitative data were analyzed using Chi- Square test or Fisher’s Exact test, and the Independent Sample t- test and Paired Sample t- test were used for analyz- ing quantitative data. Results Leventhal’s self-regulatory intervention improved subscales of illness perception (p < 0.05) except for emotional representations and consequences. The global mean scores of the hypertensive patients ̓ lifestyle in the intervention group significantly increased from 102.8 ± 2.3 at the baseline to 112.1 ± 3 post-intervention. Conclusions Interventions based on Leventhal’s self-regulatory model could improve the illness perception and lifestyle of patients with hypertension. Trial registration The present randomized controlled trial study was registered on the Iranian Registry of Clinical Trials Website (IRCT ); ID: IRCT20141222020401N6 on 8/5/2019. Keywords Self-regulatory model, Illness perception, Hypertension, Lifestyle *Correspondence: Nursing Department, Nursing School, Yasuj University of Medical Nazafarin Hosseini Sciences, Yasuj, Iran hosseinichenar@yahoo.com; hosseini.nazafarin@yums.ac.ir Social Determinants of Health Research Center, Yasuj University Student Research Committee, Yasuj University of Medical Sciences, of Medical Sciences, Yasuj, Iran Yasuj, Iran School of Nursing, Yasuj University of Medical Sciences, Yasuj, Iran Professor of Nursing, Yasuj University of Medical Sciences, Yasuj, Iran © The Author(s) 2023. 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The Creative Commons Public Domain Dedication waiver (http://creativecom- mons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Saranjam et al. BMC Cardiovascular Disorders (2023) 23:50 Page 2 of 10 medication interventions. However, suppose a person Introduction perceives hypertension acute. In that case, they may not Hypertension (HTN) is a significant risk factor for want to change their lifestyle and prioritize receiving the cardiovascular disease, which is a leading cause of medical interventions and adhering to treatment [13]. mortality [1]. In people 18  years and older, blood pres- The expectation is that, through cognitive and emo - sure less than 80.120  mmHg is normal blood pressure, tional responses, IP can increase patients’ motivation to systolic pressure 120–139  mmHg, or diastolic pres- improve their lifestyles [14]. For example, a study by Yan sure 80–89  mmHg is prehypertension stage. Moreover, et  al. indicated that improved illness perception could systolic pressure of 140–159 and diastolic pressure of affect the lifestyle of patients with myocardial infarction 90–99  mm Hg is classified as stage 1 hypertension. A [15]. Moreover, Rakhshan et  al. found that IP interven- systolic pressure ≥ 160 or a diastolic pressure ≥ 100  mm tions positively affect the lifestyle of patients with meta - Hg is classified as stage 2 hypertension [ 2]. HTN is an bolic syndrome [16]. In another study, training based on asymptomatic disease and hence, most patients are una- Leventhal’s self-regulatory model in patients with hyper- ware of the illness. As a result, they may have already tension improved adherence to treatment and reduced major health problems such as damage to their brain and patients’ blood pressure [17]. However, in the study by kidneys once they are diagnosed with HTN [3]. This dis - van Broekhovena et  al., more threatening IP was not ease is often called ‘silent killer’ since it has a high mor- associated with positive lifestyle changes in gynecological tality rate but no symptoms [4]. Even after diagnosis, cancer patients [14]. many patients do not adhere to the treatment and rec- The researchers have not found a study on the effect ommendations needed to control the disease. In addi- of IP intervention on the lifestyle of patients with HTN. tion to medication, maintaining a healthy lifestyle, which Therefore, this study was conducted to determine the involves being physically active, quitting smoking and effect of intervention based on Leventhal’s self-regulatory alcohol, managing stress [5], and following the Dietary model on the illness perception and lifestyle of patients Approaches to Stopping Hypertension (DASH), is of with hypertension. great importance in controlling HTN [6]. Illness misper- ception has negative effects on patients’ behaviors such as adherence to treatment, self-diagnosis, help-seeking Material and methods behavior and the disease outcomes [7]. Design and participants Perception of the disease is based on patients’ beliefs The present randomized parallel-controlled trial study and perceived knowledge of their condition and can was registered on the Iranian Registry of Clinical Tri- affect their mental health and how they deal with the als Website (IRCT), ID: IRCT20141222020401N6, on disease [8]. The illness perception frames living with ill - 8/5/2019. The present study was conducted on ninety ness mentally. In illness perception, the coherence of eligible hypertensive patients referring to Yasuj Shahid health information affects the cognitive representation Dastgheib Health Center, Iran, from May 2019 to Octo- and emotional response. For example, positive or nega- ber 2019. A total of 41 participants were calculated as tive beliefs about the disease can affect the ability to cope the sample size for each group considering α = 0.05, with the disease and perceive it as manageable or threat- z = 1.96, β = 0.2, 1-β = 0.8, z = 0.85, lifestyle stand- 1-α/2 1-β ening, affecting mental health and health behavior such ard deviations of S = 26.59 and S = 16.96, and lifestyle 1 2 as adherence to treatment [9]. Illness perception (IP) means of μ = 21.8 and μ = 41.2 [18], using the following 1 2 has been described as part of Leventhal’s self-regulatory formula: model [10]. The original model consists of five main sub - scales: identity, timeline (acute/chronic/cyclical), con- 2 2 2 × z + z × S + S sequences, cause, and control/cure (treatment control 1− 1−β 1 2 and personal control). Subsequently, the two subscales n = d = (μ − μ ) 1 2 of emotional representations and illness coherence were added to the model [11]. Leventhal’s self-regulatory According to the researcher’s guess and dropout pre- model is useful for gaining insights into how people with diction in interventional studies, 10% attrition rate was hypertension think of their illness and how this affects considered. Therefore, a total of 90 participants, each their adherence to,therapeutic regimens, and health group comprising 45 patients, participated in the present outcomes [12]. Patients select and evaluate self-care study. behaviors based on the manifestations of their illness. Patients with hypertension who had health records in For example, someone who perceives hypertension as a Shahid Dasghib Health Center were selected as research chronic disease and views it as a result of lifestyle factors participants. The telephone numbers of the patients is likely to change their lifestyle first and then seek proper were contacted, and the objectives of the research were S aranjam et al. BMC Cardiovascular Disorders (2023) 23:50 Page 3 of 10 explained to them. Those who wanted to participate in the disease is cyclical until its stability), personal control this research were invited to attend the health center (belief in more control), treatment control (belief in more and were assessed in terms of inclusion and exclusion treatment), emotional representations, illness coherence criteria. Then, written informed consent was signed by (higher level of illness perception), and perception of the eligible patients. The written informed consent included causes. The score of the identity subscale was obtained familiarizing with the research, goals, and interventions, by adding up the positive answers to symptoms. Further- stating the advantages and disadvantages of participating more, the subscales of 2 to 9 were based on a 5-point Lik- in the research and compensating for the disadvantages, ert scale (strongly disagree: 1, disagree: 2, neither agree maintaining the confidentiality, and the right to withdraw nor disagree: 3, agree: 4, and strongly agree: 5). A lower from the study. score in the subscales of identity, consequence, timeline They were selected through convenience sampling. cyclical and emotional representations indicates a higher However, they were randomly assigned to one of the perception. On the contrary, higher scores in the sub- two groups of intervention (n = 45) and control (n = 45), scales of timeline acute/chronic, personal control, treat- using the randomized block allocation method as fol- ment control, and illness coherence indicate a higher lows: Initially, by multiplying the number of study groups perception of the disease. by two (an intervention group and a control group), The validity and reliability of the IPQ-R had previously four people were assigned to each group. At that point, been confirmed. The Cronbach alpha’sfor each of the sub - twenty-four blocks were calculated using the factorial scales ranged from 0.79 for the timeline cyclical dimen- rule (24 = 1 × 2 × 3 × 4 = !4). The members of each block sion to 0.89 for the timeline acute/chronic dimension. were marked with the letters A, B, C, D. Subsequently, The average scale content validity (S-CVI ) for each of Ave letters A and B were assigned to the control group, and the dimensions was as follows: Consequences was 0.75, letters C and D were randomly assigned to the interven- Timeline acute/chronic was 0.75, Treatment control was tion group. A total of twenty-four blocks with possible 0.89, Personal control was 0.81, Emotional representa- layouts were identified. Allocation was done by randomly tions was 0.77, Illness coherence was 0.74, and Timeline selecting each block by an individual outside the research cyclical was 0.66. The S-CVI for the whole question- Ave team. naire was 0.79 [19, 20]. The validity and reliability of the Furthermore, the samples were selected based on the Persian version of the questionnaire had likewise been sequence of blocks and the time priority of the partici- established. The internal consistency of the scales was pants’ entry. Randomization continued until 45 patients over 0.78 [21]. were in the intervention group and 45 in the control Lifestyle was assessed by LSQ. The LSQ consists of 70 group. Blinding was not done in the present study. items divided into 10 subscales: physical health, exercise, Inclusion criteria consisted of a definitive diagnosis and fitness; weight control and nutrition; illness preven - of primary hypertension, stage 1 or 2 hypertension, age tion; psychological health; spiritual health; social health, range of 18–65 years, at least six months of hypertension, avoidance of drugs, opiates, and alcohol, prevention informed consent to participate in the study, and lifestyle of accidents and environmental health. The LSQ score score of ≤ 105. Patients’ unwillingness to participate in is based on a four-point Likert scale (never = 0, some- the study, not having other chronic diseases or severe times = 1, usually = 2, and always = 3). Global score of complications following hypertension and lack of inclu- the LSQ ranges from zero to 210. The validity of LSQ had sion criteria were considered exclusion criteria. been established through content validity by 10 experts, factor analysis (10 factor with a factor load of 0.31 to 0.88 Instrument and data gathering and an specific value of 1.04 to 6.23), and convergence The outcomes were Lifestyle and Illness Perception, the validity (r = 0.59–0.62). Cronbach’s alpha (r = 0.76–0.89) formerly measured by the Lifestyle Questionnaire (LSQ) and test–retest (r = 0.84–0.94) were used to determine and the latter by the Revised Illness Perception Ques- reliability of the questionnaire. Cronbach’s alpha for the tionnaire (IPQ-R) two times: the baseline (week 0) and whole questionnaire was 0.87 [22]. 12 weeks following the intervention (week 17). The IPQ-R was originally developed by Moss-Morris et  al. [19] to Interventions assess patients̓ illness perception. This questionnaire The intervention protocol designed based on Leventhal’s comprises 70 items which are divided into nine subscales: self-regulatory model and the literature review focusing identity (attributing unrealistic symptoms to the disease), on the subscales of illness perception and lifestyle [16, consequences (belief in negative consequences of the 23]. Due to a large number of patients in the interven- disease), timeline acute/chronic (patients’ perception of tion group, the patients were divided into three groups. the illness chronicity), timeline cyclical (believing that The intervention, on a weekly basis (5  weeks), five Saranjam et al. BMC Cardiovascular Disorders (2023) 23:50 Page 4 of 10 60-min sessions were held for the intervention group. pamphlet containing a summary of the educational con- The intervention was performed by one of the research - tent was handed over to the patients. ers (master’s student in Community Health Nursing), a However, the control group received routine education psychologist, and a nutritionist consistentin Shahid Dast- based on the hypertensive guideline, face-to-face in the gheib Health Center as following:. health centers. In the first session, the purpose was to increase the The data were collected before the intervention as the patients’ perception of illness identity and causes, espe- baseline (week 0) and 12  weeks after the intervention cially those related to lifestyle. For this purpose, the (week 17) [24, 25]. patients’ perception of the illness identity was discussed by asking several questions about the symptoms, the Data analysis cause (s) of the disease, and lifestyle factors believed The data were analyzed, using inferential statistics. The to have contributed to the disease. In this session, the nominal data were analyzed by Chi-Square test or Fish- patient’s perception of the illness identity and causes was er’s Exact test. For quantitative data with normal distri- determined, and the pathophysiology, causes, and symp- bution, independent sample t-test and paired t-test were toms of hypertension were discussed. used. P- value < 0.05 was considered a significant differ - In the second session, the purpose was to increase the ence for all data analyses. The data analyzer was blind to perception of the patients about the effect of hyperten - the allocation of the patients to the groups. sion on their life and the disease consequences, the dis- ease duration, personal control, and treatment control. Results The patients were evaluated by asking the following Ninety hypertensive patients initially consented to partic- open-ended questions: How long do you think it will take ipate in the present study. However, seven patients either to recover? Do you think your disease can be controlled withdrew or failed to complete the intervention (Fig.  1). and cured? What will be the consequences of this disease The mean value of the participant’s age was 53 ± 6.5 years for you? Moreover, misconceptions of the relevant issues (Range 37–65). All hypertensive patients were married were clarified through discussion between the patients and taking oral antihypertensive drugs at the time of and the researcher. The use of drugs and their side effects the study. Moreover, most of them were female (84.3%), were also discussed. housewives (79.5%), and had undergraduate education In the third session, the purpose was to improve the (79.5%). In terms of demographic variables and disease patients’ perception about the subscales including the ill- characteristics, including duration of hypertension, there ness coherence and the necessity of avoiding drugs, opi- was no significant difference between the participants in ates, and alcohol, emotional representations, as well as the intervention and control groups before the interven- psychological, spiritual, and social health. The patients tion (Table  1).Likewise, before the intervention, there and the researcher discussed illness coherence and the was no statistically significant difference between the necessity of avoidance of drugs, opiates, and alcohol. intervention and control groups in terms of subscales Following that, the psychologist talked about emotional of illness perception. However, after the intervention, representations and psychological, spiritual, and social the scores of subscales of illness perception improved health, using counseling techniques and providing the significantly (p < 0.05), compared with the hypertensive necessary training. patients in the control group except for illness conse- In the fourth session, the purpose was to increase the quences (p = 0.1) and emotional representation subscales patients’ perception about the subscales such as Weight (p = 0.07) (Table 2). control, nutrition, and physical health. To this, the par- In the intragroup comparison, the results showed a ticipants were asked about their perception of and adher- significant improvement in the subscales of illness per - ence to weight control and nutrition in hypertension and ception in the intervention group (p = 0.001) after the were advised about proper diet. Moreover, the researcher intervention, except for the emotional representation discussed the importance of maintaining physical health. subscale. However, in the control group, no significant In the fifth session, the purpose was to improve the difference was observed in any of the subscales after the patients’ perception of exercise and fitness, environmen - intervention compared to the time before the interven- tal health, and prevention of accidents and illness. There - tion (Table 2). fore, this session was devoted to the patient’s perception In addition, before the intervention, there was no of the importance and benefits of exercise and fitness, statistically significant difference between the inter - environmental health, and prevention of accidents and vention and control groups in terms of lifestyle and illness. Meanwhile, proper educational interventions its subscales. However, the results indicated that after were provided. At the end of each session, an educational the intervention, the hypertensive patients in the S aranjam et al. BMC Cardiovascular Disorders (2023) 23:50 Page 5 of 10 Fig. 1 CONSORT flowchart of the study Table 1 Comparing demographic characteristics between the two groups Characteristics Group Control Intervention P- value N = 42 N = 41 M ± SD Age 55.1 ± 6 52.5 ± 6.8 0.07 Gender; Male 9(21.4) 4(9.8) 0.1 N (%) Female 33(77.6) 37(90.2) Education; Under Diploma 32(76.2) 34(82.9) 0.3 N (%) Diploma 10(23.8) 7(17.1) Job; Home maker 30(71.4) 36(87.8) 0.4 N (%) Others 12(28.6) 5(12.2) Family history; N (%) Yes 31(73.8) 30(73.2) 0.5 No 11(26.2) 11(26.8) Personal history (month) M ± SD 88.5 ± 66.6 69.2 ± 44.4 0.1 M ± SD Mean ± Standard deviation, N (%) Frequency (percent) P- value are based on Independent sample t-test for Age variables and Chi- square test for others variables intervention group reported significantly (p < 0.05) The results showed that the intervention based on more improvement in their lifestyle and its subscales, Leventhal’s self-regulatory model caused a significant compared with the hypertensive patients in the control increase in lifestyle and its subscales in the intervention group, except for psychological health (p = 0.6) spiritual group (p < 0.05) after the intervention, as compared to the health (p = 0.5) and social health (p = 0.09) (Table 3). time before the intervention, except for psychological, Saranjam et al. BMC Cardiovascular Disorders (2023) 23:50 Page 6 of 10 Table 2 Between and within group comparison for illness perception Subscale Group time Intervention Control Between group comparison 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 Eec ff t size 0.4 0.002 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 Eec ff t size 0.5 0.002 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 Eec ff t size 0.1 0.001 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 Eec ff t size 0.2 0.07 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 Eec ff t size 0.4 0.03 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 Eec ff t size 0.5 0.03 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 Eec ff t size 0.5 0.01 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 Eec ff t size 0.08 0.01 p-value 0.05 0.7 Between group comparison based on t-test Within group comparison based on paired t-test spiritual, and social health. However, in the control group, illness perception in the subscales of the identity, time- in terms of the same variables, there was no significant line acute/chronic, personal control, treatment control, difference before and after the intervention (Table 3). illness coherence, and timeline cyclical. However, it had no significant effect on the consequences and emotional Discussion representations. To the best of our knowledge, no study has been carried As suggested by the present study’s findings, the ill - out to determine the effect of interventions based on Lev - ness perception-based intervention improved the illness enthal’s self-regulatory model on the illness perception coherence subscale in the study of Broadbent et al. (2009) and lifestyle of patients with hypertension. Therefore, the in the spouses of patients with myocardial infarction [26]. present study aimed to fill this lacuna. The results showed In contrast, Cossette et  al. indicated that cardiac reha- that intervention based on the present model improved bilitation nursing intervention in patients with the acute S aranjam et al. BMC Cardiovascular Disorders (2023) 23:50 Page 7 of 10 Table 3 Between and within group comparison for life style Subscale Group time Intervention Control Between group comparison 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 Eec ff t size 0.8 0.07 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 Eec ff t size 0.7 0.02 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 Eec ff t size 0.5 0.002 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 Eec ff t size 0.7 0.006 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 Eec ff t size 0.2 0.001 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 Eec ff t size 0.5 0.04 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 Eec ff t size 0.08 0.03 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 Eec ff t size 0.05 0.003 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 ± 1.71 (0.8–11.8) 0.09 Within group comparison Eec ff t size 0.02 0.03 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 Eec ff t size 0.5 0.07 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 Eec ff t size 0.5 0.01 p-value 0.001 0.4 Between group comparison based on t-test Within group compariason based on paired t-test Saranjam et al. BMC Cardiovascular Disorders (2023) 23:50 Page 8 of 10 coronary syndrome has no effect on the illness coherence coronary heart disease reduced obesity and increased subscales and timeline acute/chronic, treatment con- physical activity in patients [33]. As in the present study, trol, and timeline cyclical subscales [27]. The difference the intervention affected the weight management of par - between the results of these two studies indicates that ticipants by creating a better perception of the disease interventions based on improving the illness perception and a sense of threat. can be more effective in improving illness coherence and Blood pressure is affected by environmental fac - other subscales than other educational interventions. tors such as noise and air pollution. Therefore, patients In addition, participants in the present study bet- should be informed to avoid exposure to these factors ter perceived their illness identity after the interven- [34]. Familiarizing patients with risk factors and chang- tion, including the symptoms and the disease timeline, ing their high-risk behaviors are the main objectives of acute/chronic. This is in line with the study’s findings by the prevention subscale [35]. In the present study, all of Yan et  al. [15]. Among other things, they found that the the issues mentioned above were incorporated into the training program based on Leventhal’s model increases education of the patients, and, as a result, these subscales patients’ perception of the symptoms and disease dura- improved after the intervention. Moreover, the subscale tion after myocardial infarction [15]. In this study, of avoidance of drugs, opiates, and alcohol improved increasing patients’ perception of the chronic timeline of after the interventions. Similar to this study, Dehghani hypertension improved patients’ adherence to treatment et  al. indicated that lifestyle-based intervention in and several lifestyle subscales. patients with coronary heart disease helped them resist The present study’s findings confirmed the results the urge to smoke [33]. obtained by Lee et  al. in patients with injury [28] and In the present study, the psychological health subscale Weldam et  al. [29] in patients with chronic obstructive did not improve after the research intervention. Similarly, pulmonary disease. Similarly, Richardson et  al. found Rakhshan et  al. found that education based on percep- that the treatment control subscale was promoted after tion in patients with metabolic syndrome did not affect the self-regulatory model-based intervention in cancer stress management, although it improved all areas of patients in the intervention group. However, no signifi - lifestyle [16]. Contrary to the results of the present study, cant improvement was observed in the follow-up study the study by Shayesteh et al. showed that the educational with an interval of 6  months [30]. This may be attrib - intervention improved stress management in patients uted to the frustration and fatigue of cancer patients. It with hypertension [32]. Moreover, findings by Sararoudi is also necessary to note that in the present study, it was et al. showed that the interventions based on Leventhal’s not possible to conduct a follow-up study. Therefore, no self-regulatory model reduced anxiety and depression in meaningful comparison can be made in this regard. patients with myocardial infarction [36]. Patients’ psy- As in the study by Rakhshan et  al. [16], in the present chological health was expected to improve with increased study, no significant difference was observed in terms of illness perception. This difference may be due to the dif - the subscales of the consequences and emotional rep- ferent natures of diseases targeted in the above studies. resentations, even if it has already been reported that However, in this study, the intervention based on Lev- emotional representations can affect self-care and health enthal’s model did not improve psychological, social, and consequences [31]. It can be argued that to improve the spiritual health in patients with hypertension. According perception of consequences, and emotional representa- to these results, other spiritual and behavioral interven- tions should be improved in patients with hypertension. tions may be needed to improve psychological, social, This probably requires long-term training programs and and spiritual health. proper psychological interventions. The present study’s overall lifestyle score was improved, The results of the present study indicated that after probably due to increased perception. In their system- the intervention, the scores of total lifestyles and its sub- atic review study, French et  al. showed that patients scales, except for spiritual and social health, increased with acute myocardial infarction and a positive percep- in the intervention group, as compared with the control tion of identity, consequences, cure/control, and illness group. Likewise, in Yan et al.’s study, an educational pro- coherence feel the need for cardiac rehabilitation [37]. gram based on Leventhal’s model improved nutrition and Although the variable measured in the study above dif- physical activity in patients after myocardial infarction fers from the variable of consequences in the present [15]. Likewise, the study by Shayesteh et al. revealed that study (i.e., healthy lifestyle), it was shown in both stud- following lifestyle-based intervention, the overall score of ies that a higher illness perception is associated with the lifestyle and physical activity increased in patients with acceptance of health-related behaviors. hypertension [32]. The study by Dehghani et al. also indi - In contrast to the results of the present study, Rakhshan cated that lifestyle-based intervention in patients with et al. found that education based on Leventhal perception S aranjam et al. BMC Cardiovascular Disorders (2023) 23:50 Page 9 of 10 LSQ Lifestyle questionnaire improved the domains of lifestyle but did not affect the IPQ-R Revised illness perception questionnaire subscales of perception [16]. This raises the question of IP Illness perception how it can improve lifestyle without improving percep- Acknowledgements tion. The reason for this difference could be that educa - This research was extracted from the master’s thesis of a Community Health tion focuses on lifestyle, not illness perception. nursing student at the Yasuj University of Medical Sciences. We sincerely The results of this study can help healthcare providers thank all the hypertensive patients and personnel of Shahid Dastgheib Health Center in Yasuj, Iran. to improve the healthy lifestyle of patients with hyper- tension by identifying the possible role of subscales of Author contributions illness perception, including identity, acute/chronic time- FS: she was a contributor in writing the manuscript, design of the work, Inves- tigation, and data acquisition. AA: He was a major contributor in methodology, line, personal control, treatment control, disease coher- analyzing, and interpreting the patient data. AAf: He was a major contributor ence, and cyclical timeline. Also, the use of Leventhal’s in the design of interventions and Reviewing and Editing of the manuscript, self-regulatory model in the educational curriculum of NH: she was a major contributor in writing the manuscript, Supervision. All authors read and approved the final manuscript. medical science students can be considered. Moreover, It is suggested that healthcare providers should design and Funding implement the educational program based on the model This work was supported and funded by the Vice-chancellor of Research Deputy of Yasuj University of Medical Sciences. to improve the lifestyle of patients with hypertension. The present study helped to improve the illness per - Availability of data and materials ception, including subscales of identity, timeline acute/ The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. However, all data generated chronic, personal control, treatment control, illness or analyzed during this study are included in this published article. coherence, and timeline cyclical, as well as the lifestyle of patients with hypertension. Moreover, the presence of an Declarations external academic observer and the active participation of patients in the research were considered the strengths Ethics approval and consent to participate The present study was approved by the Research Ethics Committee (REC) of this study. of Yasuj University of Medical Sciences (YUMS) with ID code; IR.YUMS. There were some limitations in carrying out the study, REC.1397.147. Written informed consent was obtained from the participants. including the lack of a specific questionnaire for meas - The principles of voluntariness and confidentiality were emphasized. All methods were performed under the relevant guidelines and regulations by uring the illness perception and lifestyle of patients the Declaration of Helsinki 1994. with hypertension, the short duration of follow-up to determine possible long-lasting effects for maintaining Consent for publication Not applicable. a healthy lifestyle. However, the main limitation of the study was the lack of blinding of the study, mostly due Competing interests to the nature of the intervention. Although the external The Authors declare that there is no conflict of interest. academic supervisor supervised the research process, the findingsould be interpreted cautiously. Received: 9 July 2022 Accepted: 6 January 2023 Conclusion The results of the present study showed that, the inter - vention based on Leventhal’s self-regulatory model References brings about significant changes in the subscales of ill - 1. 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Effect of Leventhal’s self-regulatory intervention on the hypertensive patients’ illness perception and lifestyle: a randomized controlled trial

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10.1186/s12872-023-03049-6
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Abstract

Background The perception of illness may lead to improving the hypertensive patients’ lifestyle, but no study was found in this regard. Therefore, this study was conducted to determine the effect of intervention based on Leventhal’s self-regulatory model on the illness perception and lifestyle of patients with hypertension. Methods In the present randomized controlled trial study, ninety eligible patients with primary hypertension were randomly assigned to one of the two groups of intervention and control. Patients in the intervention group received five sessions of Leventhal’s self-regulatory intervention, each of 60 min and weekly. However the control group received routine care. The outcomes were illness perception and lifestyle of the patients with hypertension. The Revised Illness Perception Questionnaire and the Lifestyle Questionnaire were administered to assess illness percep- tion and lifestyle before the treatment to establish a baseline and subsequently 12 weeks after the intervention. The collected data were analyzed using statistical IMB SPSS software, version 21. Qualitative data were analyzed using Chi- Square test or Fisher’s Exact test, and the Independent Sample t- test and Paired Sample t- test were used for analyz- ing quantitative data. Results Leventhal’s self-regulatory intervention improved subscales of illness perception (p < 0.05) except for emotional representations and consequences. The global mean scores of the hypertensive patients ̓ lifestyle in the intervention group significantly increased from 102.8 ± 2.3 at the baseline to 112.1 ± 3 post-intervention. Conclusions Interventions based on Leventhal’s self-regulatory model could improve the illness perception and lifestyle of patients with hypertension. Trial registration The present randomized controlled trial study was registered on the Iranian Registry of Clinical Trials Website (IRCT ); ID: IRCT20141222020401N6 on 8/5/2019. Keywords Self-regulatory model, Illness perception, Hypertension, Lifestyle *Correspondence: Nursing Department, Nursing School, Yasuj University of Medical Nazafarin Hosseini Sciences, Yasuj, Iran hosseinichenar@yahoo.com; hosseini.nazafarin@yums.ac.ir Social Determinants of Health Research Center, Yasuj University Student Research Committee, Yasuj University of Medical Sciences, of Medical Sciences, Yasuj, Iran Yasuj, Iran School of Nursing, Yasuj University of Medical Sciences, Yasuj, Iran Professor of Nursing, Yasuj University of Medical Sciences, Yasuj, Iran © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecom- mons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Saranjam et al. BMC Cardiovascular Disorders (2023) 23:50 Page 2 of 10 medication interventions. However, suppose a person Introduction perceives hypertension acute. In that case, they may not Hypertension (HTN) is a significant risk factor for want to change their lifestyle and prioritize receiving the cardiovascular disease, which is a leading cause of medical interventions and adhering to treatment [13]. mortality [1]. In people 18  years and older, blood pres- The expectation is that, through cognitive and emo - sure less than 80.120  mmHg is normal blood pressure, tional responses, IP can increase patients’ motivation to systolic pressure 120–139  mmHg, or diastolic pres- improve their lifestyles [14]. For example, a study by Yan sure 80–89  mmHg is prehypertension stage. Moreover, et  al. indicated that improved illness perception could systolic pressure of 140–159 and diastolic pressure of affect the lifestyle of patients with myocardial infarction 90–99  mm Hg is classified as stage 1 hypertension. A [15]. Moreover, Rakhshan et  al. found that IP interven- systolic pressure ≥ 160 or a diastolic pressure ≥ 100  mm tions positively affect the lifestyle of patients with meta - Hg is classified as stage 2 hypertension [ 2]. HTN is an bolic syndrome [16]. In another study, training based on asymptomatic disease and hence, most patients are una- Leventhal’s self-regulatory model in patients with hyper- ware of the illness. As a result, they may have already tension improved adherence to treatment and reduced major health problems such as damage to their brain and patients’ blood pressure [17]. However, in the study by kidneys once they are diagnosed with HTN [3]. This dis - van Broekhovena et  al., more threatening IP was not ease is often called ‘silent killer’ since it has a high mor- associated with positive lifestyle changes in gynecological tality rate but no symptoms [4]. Even after diagnosis, cancer patients [14]. many patients do not adhere to the treatment and rec- The researchers have not found a study on the effect ommendations needed to control the disease. In addi- of IP intervention on the lifestyle of patients with HTN. tion to medication, maintaining a healthy lifestyle, which Therefore, this study was conducted to determine the involves being physically active, quitting smoking and effect of intervention based on Leventhal’s self-regulatory alcohol, managing stress [5], and following the Dietary model on the illness perception and lifestyle of patients Approaches to Stopping Hypertension (DASH), is of with hypertension. great importance in controlling HTN [6]. Illness misper- ception has negative effects on patients’ behaviors such as adherence to treatment, self-diagnosis, help-seeking Material and methods behavior and the disease outcomes [7]. Design and participants Perception of the disease is based on patients’ beliefs The present randomized parallel-controlled trial study and perceived knowledge of their condition and can was registered on the Iranian Registry of Clinical Tri- affect their mental health and how they deal with the als Website (IRCT), ID: IRCT20141222020401N6, on disease [8]. The illness perception frames living with ill - 8/5/2019. The present study was conducted on ninety ness mentally. In illness perception, the coherence of eligible hypertensive patients referring to Yasuj Shahid health information affects the cognitive representation Dastgheib Health Center, Iran, from May 2019 to Octo- and emotional response. For example, positive or nega- ber 2019. A total of 41 participants were calculated as tive beliefs about the disease can affect the ability to cope the sample size for each group considering α = 0.05, with the disease and perceive it as manageable or threat- z = 1.96, β = 0.2, 1-β = 0.8, z = 0.85, lifestyle stand- 1-α/2 1-β ening, affecting mental health and health behavior such ard deviations of S = 26.59 and S = 16.96, and lifestyle 1 2 as adherence to treatment [9]. Illness perception (IP) means of μ = 21.8 and μ = 41.2 [18], using the following 1 2 has been described as part of Leventhal’s self-regulatory formula: model [10]. The original model consists of five main sub - scales: identity, timeline (acute/chronic/cyclical), con- 2 2 2 × z + z × S + S sequences, cause, and control/cure (treatment control 1− 1−β 1 2 and personal control). Subsequently, the two subscales n = d = (μ − μ ) 1 2 of emotional representations and illness coherence were added to the model [11]. Leventhal’s self-regulatory According to the researcher’s guess and dropout pre- model is useful for gaining insights into how people with diction in interventional studies, 10% attrition rate was hypertension think of their illness and how this affects considered. Therefore, a total of 90 participants, each their adherence to,therapeutic regimens, and health group comprising 45 patients, participated in the present outcomes [12]. Patients select and evaluate self-care study. behaviors based on the manifestations of their illness. Patients with hypertension who had health records in For example, someone who perceives hypertension as a Shahid Dasghib Health Center were selected as research chronic disease and views it as a result of lifestyle factors participants. The telephone numbers of the patients is likely to change their lifestyle first and then seek proper were contacted, and the objectives of the research were S aranjam et al. BMC Cardiovascular Disorders (2023) 23:50 Page 3 of 10 explained to them. Those who wanted to participate in the disease is cyclical until its stability), personal control this research were invited to attend the health center (belief in more control), treatment control (belief in more and were assessed in terms of inclusion and exclusion treatment), emotional representations, illness coherence criteria. Then, written informed consent was signed by (higher level of illness perception), and perception of the eligible patients. The written informed consent included causes. The score of the identity subscale was obtained familiarizing with the research, goals, and interventions, by adding up the positive answers to symptoms. Further- stating the advantages and disadvantages of participating more, the subscales of 2 to 9 were based on a 5-point Lik- in the research and compensating for the disadvantages, ert scale (strongly disagree: 1, disagree: 2, neither agree maintaining the confidentiality, and the right to withdraw nor disagree: 3, agree: 4, and strongly agree: 5). A lower from the study. score in the subscales of identity, consequence, timeline They were selected through convenience sampling. cyclical and emotional representations indicates a higher However, they were randomly assigned to one of the perception. On the contrary, higher scores in the sub- two groups of intervention (n = 45) and control (n = 45), scales of timeline acute/chronic, personal control, treat- using the randomized block allocation method as fol- ment control, and illness coherence indicate a higher lows: Initially, by multiplying the number of study groups perception of the disease. by two (an intervention group and a control group), The validity and reliability of the IPQ-R had previously four people were assigned to each group. At that point, been confirmed. The Cronbach alpha’sfor each of the sub - twenty-four blocks were calculated using the factorial scales ranged from 0.79 for the timeline cyclical dimen- rule (24 = 1 × 2 × 3 × 4 = !4). The members of each block sion to 0.89 for the timeline acute/chronic dimension. were marked with the letters A, B, C, D. Subsequently, The average scale content validity (S-CVI ) for each of Ave letters A and B were assigned to the control group, and the dimensions was as follows: Consequences was 0.75, letters C and D were randomly assigned to the interven- Timeline acute/chronic was 0.75, Treatment control was tion group. A total of twenty-four blocks with possible 0.89, Personal control was 0.81, Emotional representa- layouts were identified. Allocation was done by randomly tions was 0.77, Illness coherence was 0.74, and Timeline selecting each block by an individual outside the research cyclical was 0.66. The S-CVI for the whole question- Ave team. naire was 0.79 [19, 20]. The validity and reliability of the Furthermore, the samples were selected based on the Persian version of the questionnaire had likewise been sequence of blocks and the time priority of the partici- established. The internal consistency of the scales was pants’ entry. Randomization continued until 45 patients over 0.78 [21]. were in the intervention group and 45 in the control Lifestyle was assessed by LSQ. The LSQ consists of 70 group. Blinding was not done in the present study. items divided into 10 subscales: physical health, exercise, Inclusion criteria consisted of a definitive diagnosis and fitness; weight control and nutrition; illness preven - of primary hypertension, stage 1 or 2 hypertension, age tion; psychological health; spiritual health; social health, range of 18–65 years, at least six months of hypertension, avoidance of drugs, opiates, and alcohol, prevention informed consent to participate in the study, and lifestyle of accidents and environmental health. The LSQ score score of ≤ 105. Patients’ unwillingness to participate in is based on a four-point Likert scale (never = 0, some- the study, not having other chronic diseases or severe times = 1, usually = 2, and always = 3). Global score of complications following hypertension and lack of inclu- the LSQ ranges from zero to 210. The validity of LSQ had sion criteria were considered exclusion criteria. been established through content validity by 10 experts, factor analysis (10 factor with a factor load of 0.31 to 0.88 Instrument and data gathering and an specific value of 1.04 to 6.23), and convergence The outcomes were Lifestyle and Illness Perception, the validity (r = 0.59–0.62). Cronbach’s alpha (r = 0.76–0.89) formerly measured by the Lifestyle Questionnaire (LSQ) and test–retest (r = 0.84–0.94) were used to determine and the latter by the Revised Illness Perception Ques- reliability of the questionnaire. Cronbach’s alpha for the tionnaire (IPQ-R) two times: the baseline (week 0) and whole questionnaire was 0.87 [22]. 12 weeks following the intervention (week 17). The IPQ-R was originally developed by Moss-Morris et  al. [19] to Interventions assess patients̓ illness perception. This questionnaire The intervention protocol designed based on Leventhal’s comprises 70 items which are divided into nine subscales: self-regulatory model and the literature review focusing identity (attributing unrealistic symptoms to the disease), on the subscales of illness perception and lifestyle [16, consequences (belief in negative consequences of the 23]. Due to a large number of patients in the interven- disease), timeline acute/chronic (patients’ perception of tion group, the patients were divided into three groups. the illness chronicity), timeline cyclical (believing that The intervention, on a weekly basis (5  weeks), five Saranjam et al. BMC Cardiovascular Disorders (2023) 23:50 Page 4 of 10 60-min sessions were held for the intervention group. pamphlet containing a summary of the educational con- The intervention was performed by one of the research - tent was handed over to the patients. ers (master’s student in Community Health Nursing), a However, the control group received routine education psychologist, and a nutritionist consistentin Shahid Dast- based on the hypertensive guideline, face-to-face in the gheib Health Center as following:. health centers. In the first session, the purpose was to increase the The data were collected before the intervention as the patients’ perception of illness identity and causes, espe- baseline (week 0) and 12  weeks after the intervention cially those related to lifestyle. For this purpose, the (week 17) [24, 25]. patients’ perception of the illness identity was discussed by asking several questions about the symptoms, the Data analysis cause (s) of the disease, and lifestyle factors believed The data were analyzed, using inferential statistics. The to have contributed to the disease. In this session, the nominal data were analyzed by Chi-Square test or Fish- patient’s perception of the illness identity and causes was er’s Exact test. For quantitative data with normal distri- determined, and the pathophysiology, causes, and symp- bution, independent sample t-test and paired t-test were toms of hypertension were discussed. used. P- value < 0.05 was considered a significant differ - In the second session, the purpose was to increase the ence for all data analyses. The data analyzer was blind to perception of the patients about the effect of hyperten - the allocation of the patients to the groups. sion on their life and the disease consequences, the dis- ease duration, personal control, and treatment control. Results The patients were evaluated by asking the following Ninety hypertensive patients initially consented to partic- open-ended questions: How long do you think it will take ipate in the present study. However, seven patients either to recover? Do you think your disease can be controlled withdrew or failed to complete the intervention (Fig.  1). and cured? What will be the consequences of this disease The mean value of the participant’s age was 53 ± 6.5 years for you? Moreover, misconceptions of the relevant issues (Range 37–65). All hypertensive patients were married were clarified through discussion between the patients and taking oral antihypertensive drugs at the time of and the researcher. The use of drugs and their side effects the study. Moreover, most of them were female (84.3%), were also discussed. housewives (79.5%), and had undergraduate education In the third session, the purpose was to improve the (79.5%). In terms of demographic variables and disease patients’ perception about the subscales including the ill- characteristics, including duration of hypertension, there ness coherence and the necessity of avoiding drugs, opi- was no significant difference between the participants in ates, and alcohol, emotional representations, as well as the intervention and control groups before the interven- psychological, spiritual, and social health. The patients tion (Table  1).Likewise, before the intervention, there and the researcher discussed illness coherence and the was no statistically significant difference between the necessity of avoidance of drugs, opiates, and alcohol. intervention and control groups in terms of subscales Following that, the psychologist talked about emotional of illness perception. However, after the intervention, representations and psychological, spiritual, and social the scores of subscales of illness perception improved health, using counseling techniques and providing the significantly (p < 0.05), compared with the hypertensive necessary training. patients in the control group except for illness conse- In the fourth session, the purpose was to increase the quences (p = 0.1) and emotional representation subscales patients’ perception about the subscales such as Weight (p = 0.07) (Table 2). control, nutrition, and physical health. To this, the par- In the intragroup comparison, the results showed a ticipants were asked about their perception of and adher- significant improvement in the subscales of illness per - ence to weight control and nutrition in hypertension and ception in the intervention group (p = 0.001) after the were advised about proper diet. Moreover, the researcher intervention, except for the emotional representation discussed the importance of maintaining physical health. subscale. However, in the control group, no significant In the fifth session, the purpose was to improve the difference was observed in any of the subscales after the patients’ perception of exercise and fitness, environmen - intervention compared to the time before the interven- tal health, and prevention of accidents and illness. There - tion (Table 2). fore, this session was devoted to the patient’s perception In addition, before the intervention, there was no of the importance and benefits of exercise and fitness, statistically significant difference between the inter - environmental health, and prevention of accidents and vention and control groups in terms of lifestyle and illness. Meanwhile, proper educational interventions its subscales. However, the results indicated that after were provided. At the end of each session, an educational the intervention, the hypertensive patients in the S aranjam et al. BMC Cardiovascular Disorders (2023) 23:50 Page 5 of 10 Fig. 1 CONSORT flowchart of the study Table 1 Comparing demographic characteristics between the two groups Characteristics Group Control Intervention P- value N = 42 N = 41 M ± SD Age 55.1 ± 6 52.5 ± 6.8 0.07 Gender; Male 9(21.4) 4(9.8) 0.1 N (%) Female 33(77.6) 37(90.2) Education; Under Diploma 32(76.2) 34(82.9) 0.3 N (%) Diploma 10(23.8) 7(17.1) Job; Home maker 30(71.4) 36(87.8) 0.4 N (%) Others 12(28.6) 5(12.2) Family history; N (%) Yes 31(73.8) 30(73.2) 0.5 No 11(26.2) 11(26.8) Personal history (month) M ± SD 88.5 ± 66.6 69.2 ± 44.4 0.1 M ± SD Mean ± Standard deviation, N (%) Frequency (percent) P- value are based on Independent sample t-test for Age variables and Chi- square test for others variables intervention group reported significantly (p < 0.05) The results showed that the intervention based on more improvement in their lifestyle and its subscales, Leventhal’s self-regulatory model caused a significant compared with the hypertensive patients in the control increase in lifestyle and its subscales in the intervention group, except for psychological health (p = 0.6) spiritual group (p < 0.05) after the intervention, as compared to the health (p = 0.5) and social health (p = 0.09) (Table 3). time before the intervention, except for psychological, Saranjam et al. BMC Cardiovascular Disorders (2023) 23:50 Page 6 of 10 Table 2 Between and within group comparison for illness perception Subscale Group time Intervention Control Between group comparison 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 Eec ff t size 0.4 0.002 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 Eec ff t size 0.5 0.002 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 Eec ff t size 0.1 0.001 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 Eec ff t size 0.2 0.07 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 Eec ff t size 0.4 0.03 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 Eec ff t size 0.5 0.03 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 Eec ff t size 0.5 0.01 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 Eec ff t size 0.08 0.01 p-value 0.05 0.7 Between group comparison based on t-test Within group comparison based on paired t-test spiritual, and social health. However, in the control group, illness perception in the subscales of the identity, time- in terms of the same variables, there was no significant line acute/chronic, personal control, treatment control, difference before and after the intervention (Table 3). illness coherence, and timeline cyclical. However, it had no significant effect on the consequences and emotional Discussion representations. To the best of our knowledge, no study has been carried As suggested by the present study’s findings, the ill - out to determine the effect of interventions based on Lev - ness perception-based intervention improved the illness enthal’s self-regulatory model on the illness perception coherence subscale in the study of Broadbent et al. (2009) and lifestyle of patients with hypertension. Therefore, the in the spouses of patients with myocardial infarction [26]. present study aimed to fill this lacuna. The results showed In contrast, Cossette et  al. indicated that cardiac reha- that intervention based on the present model improved bilitation nursing intervention in patients with the acute S aranjam et al. BMC Cardiovascular Disorders (2023) 23:50 Page 7 of 10 Table 3 Between and within group comparison for life style Subscale Group time Intervention Control Between group comparison 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 Eec ff t size 0.8 0.07 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 Eec ff t size 0.7 0.02 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 Eec ff t size 0.5 0.002 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 Eec ff t size 0.7 0.006 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 Eec ff t size 0.2 0.001 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 Eec ff t size 0.5 0.04 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 Eec ff t size 0.08 0.03 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 Eec ff t size 0.05 0.003 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 ± 1.71 (0.8–11.8) 0.09 Within group comparison Eec ff t size 0.02 0.03 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 Eec ff t size 0.5 0.07 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 Eec ff t size 0.5 0.01 p-value 0.001 0.4 Between group comparison based on t-test Within group compariason based on paired t-test Saranjam et al. BMC Cardiovascular Disorders (2023) 23:50 Page 8 of 10 coronary syndrome has no effect on the illness coherence coronary heart disease reduced obesity and increased subscales and timeline acute/chronic, treatment con- physical activity in patients [33]. As in the present study, trol, and timeline cyclical subscales [27]. The difference the intervention affected the weight management of par - between the results of these two studies indicates that ticipants by creating a better perception of the disease interventions based on improving the illness perception and a sense of threat. can be more effective in improving illness coherence and Blood pressure is affected by environmental fac - other subscales than other educational interventions. tors such as noise and air pollution. Therefore, patients In addition, participants in the present study bet- should be informed to avoid exposure to these factors ter perceived their illness identity after the interven- [34]. Familiarizing patients with risk factors and chang- tion, including the symptoms and the disease timeline, ing their high-risk behaviors are the main objectives of acute/chronic. This is in line with the study’s findings by the prevention subscale [35]. In the present study, all of Yan et  al. [15]. Among other things, they found that the the issues mentioned above were incorporated into the training program based on Leventhal’s model increases education of the patients, and, as a result, these subscales patients’ perception of the symptoms and disease dura- improved after the intervention. Moreover, the subscale tion after myocardial infarction [15]. In this study, of avoidance of drugs, opiates, and alcohol improved increasing patients’ perception of the chronic timeline of after the interventions. Similar to this study, Dehghani hypertension improved patients’ adherence to treatment et  al. indicated that lifestyle-based intervention in and several lifestyle subscales. patients with coronary heart disease helped them resist The present study’s findings confirmed the results the urge to smoke [33]. obtained by Lee et  al. in patients with injury [28] and In the present study, the psychological health subscale Weldam et  al. [29] in patients with chronic obstructive did not improve after the research intervention. Similarly, pulmonary disease. Similarly, Richardson et  al. found Rakhshan et  al. found that education based on percep- that the treatment control subscale was promoted after tion in patients with metabolic syndrome did not affect the self-regulatory model-based intervention in cancer stress management, although it improved all areas of patients in the intervention group. However, no signifi - lifestyle [16]. Contrary to the results of the present study, cant improvement was observed in the follow-up study the study by Shayesteh et al. showed that the educational with an interval of 6  months [30]. This may be attrib - intervention improved stress management in patients uted to the frustration and fatigue of cancer patients. It with hypertension [32]. Moreover, findings by Sararoudi is also necessary to note that in the present study, it was et al. showed that the interventions based on Leventhal’s not possible to conduct a follow-up study. Therefore, no self-regulatory model reduced anxiety and depression in meaningful comparison can be made in this regard. patients with myocardial infarction [36]. Patients’ psy- As in the study by Rakhshan et  al. [16], in the present chological health was expected to improve with increased study, no significant difference was observed in terms of illness perception. This difference may be due to the dif - the subscales of the consequences and emotional rep- ferent natures of diseases targeted in the above studies. resentations, even if it has already been reported that However, in this study, the intervention based on Lev- emotional representations can affect self-care and health enthal’s model did not improve psychological, social, and consequences [31]. It can be argued that to improve the spiritual health in patients with hypertension. According perception of consequences, and emotional representa- to these results, other spiritual and behavioral interven- tions should be improved in patients with hypertension. tions may be needed to improve psychological, social, This probably requires long-term training programs and and spiritual health. proper psychological interventions. The present study’s overall lifestyle score was improved, The results of the present study indicated that after probably due to increased perception. In their system- the intervention, the scores of total lifestyles and its sub- atic review study, French et  al. showed that patients scales, except for spiritual and social health, increased with acute myocardial infarction and a positive percep- in the intervention group, as compared with the control tion of identity, consequences, cure/control, and illness group. Likewise, in Yan et al.’s study, an educational pro- coherence feel the need for cardiac rehabilitation [37]. gram based on Leventhal’s model improved nutrition and Although the variable measured in the study above dif- physical activity in patients after myocardial infarction fers from the variable of consequences in the present [15]. Likewise, the study by Shayesteh et al. revealed that study (i.e., healthy lifestyle), it was shown in both stud- following lifestyle-based intervention, the overall score of ies that a higher illness perception is associated with the lifestyle and physical activity increased in patients with acceptance of health-related behaviors. hypertension [32]. The study by Dehghani et al. also indi - In contrast to the results of the present study, Rakhshan cated that lifestyle-based intervention in patients with et al. found that education based on Leventhal perception S aranjam et al. BMC Cardiovascular Disorders (2023) 23:50 Page 9 of 10 LSQ Lifestyle questionnaire improved the domains of lifestyle but did not affect the IPQ-R Revised illness perception questionnaire subscales of perception [16]. This raises the question of IP Illness perception how it can improve lifestyle without improving percep- Acknowledgements tion. The reason for this difference could be that educa - This research was extracted from the master’s thesis of a Community Health tion focuses on lifestyle, not illness perception. nursing student at the Yasuj University of Medical Sciences. We sincerely The results of this study can help healthcare providers thank all the hypertensive patients and personnel of Shahid Dastgheib Health Center in Yasuj, Iran. to improve the healthy lifestyle of patients with hyper- tension by identifying the possible role of subscales of Author contributions illness perception, including identity, acute/chronic time- FS: she was a contributor in writing the manuscript, design of the work, Inves- tigation, and data acquisition. AA: He was a major contributor in methodology, line, personal control, treatment control, disease coher- analyzing, and interpreting the patient data. AAf: He was a major contributor ence, and cyclical timeline. Also, the use of Leventhal’s in the design of interventions and Reviewing and Editing of the manuscript, self-regulatory model in the educational curriculum of NH: she was a major contributor in writing the manuscript, Supervision. All authors read and approved the final manuscript. medical science students can be considered. Moreover, It is suggested that healthcare providers should design and Funding implement the educational program based on the model This work was supported and funded by the Vice-chancellor of Research Deputy of Yasuj University of Medical Sciences. to improve the lifestyle of patients with hypertension. The present study helped to improve the illness per - Availability of data and materials ception, including subscales of identity, timeline acute/ The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. However, all data generated chronic, personal control, treatment control, illness or analyzed during this study are included in this published article. coherence, and timeline cyclical, as well as the lifestyle of patients with hypertension. Moreover, the presence of an Declarations external academic observer and the active participation of patients in the research were considered the strengths Ethics approval and consent to participate The present study was approved by the Research Ethics Committee (REC) of this study. of Yasuj University of Medical Sciences (YUMS) with ID code; IR.YUMS. There were some limitations in carrying out the study, REC.1397.147. Written informed consent was obtained from the participants. including the lack of a specific questionnaire for meas - The principles of voluntariness and confidentiality were emphasized. All methods were performed under the relevant guidelines and regulations by uring the illness perception and lifestyle of patients the Declaration of Helsinki 1994. with hypertension, the short duration of follow-up to determine possible long-lasting effects for maintaining Consent for publication Not applicable. a healthy lifestyle. However, the main limitation of the study was the lack of blinding of the study, mostly due Competing interests to the nature of the intervention. Although the external The Authors declare that there is no conflict of interest. academic supervisor supervised the research process, the findingsould be interpreted cautiously. Received: 9 July 2022 Accepted: 6 January 2023 Conclusion The results of the present study showed that, the inter - vention based on Leventhal’s self-regulatory model References brings about significant changes in the subscales of ill - 1. 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Journal

BMC Cardiovascular DisordersSpringer Journals

Published: Jan 26, 2023

Keywords: Self-regulatory model; Illness perception; Hypertension; Lifestyle

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