Asian Nursing Research 17 (2023) 158e166

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Asian Nursing Research

Research Article

Educational Program with Text Messaging for Community-Dwelling

a r t i c l e i n f o s u m m a r y

Article history: Purpose: Controlling blood pressure minimizes the risk of cardiovascular events among patients with
Received 15 December 2022 hypertension. Despite regular follow-ups, the hypertension management for patients aged
45 years is
Received in revised form limited as evidenced from a decreased control rate. This pilot study aimed to test a theory-guided
31 May 2023
educational program for community-dwelling patients with hypertension.
Accepted 1 June 2023
Methods: Sixty-nine patients with hypertension aged
45 years and having high blood pressure (>130/
80 mmHg) were recruited in this two-arm pilot randomized controlled trial. Participants in the inter-
Keywords:
vention group underwent a program guided by the Health Promotion Model, whereas those in the
blood pressure
health education
control group received usual care. Data were collected at baseline, week 8, and week 12 and used to
hypertension assess the blood pressure, pulse pressure, self-efficacy, and adherence to hypertension management.
mhealth Data were analyzed using a generalized estimating equation based on the intention-to-treat principle.
self-efficacy Process evaluation was conducted to assess the feasibility and acceptability of the educational program.
Results: The results obtained using the generalized estimating equation revealed that the educational
program led to reduction in the systolic blood pressure (b ¼ 7.12, p ¼ .086) and pulse pressure
(b ¼ 8.20, p ¼ .007) and to improve self-efficacy (b ¼ 2.61, p ¼ .269) at week 12. The program had a
small-to-moderate effect on the reduction of systolic blood pressure (effect size ¼ 0.45) and pulse
pressure (effect size ¼ 0.66) and self-efficacy (effect size ¼ 0.23). The participants were highly satisfied
with the educational program.
Conclusions: The educational program was found to be feasible and acceptable and may be incorporated
into current hypertension management practices at the community level.
Trial registration: ClinicalTrials.gov with identifier: NCT04565548.
© 2023 Korean Society of Nursing Science. Published by Elsevier BV. This is an open access article under
the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction worldwide in 2019 [3]. Thus, many national and international in-
stitutions, including the American Heart Association and the In-
Hypertension, defined as persistent elevated blood pressure ternational Society of Hypertension, have developed guidelines for
(BP), affects more than 1 billion people worldwide [1]. Uncontrolled hypertension management and continue to post regular updates
hypertension can lead to various adverse outcomes, including heart [4e7]. These guidelines recommend medication and lifestyle
diseases, stroke, and chronic kidney disease [2]. According to the modifications (i.e., healthy eating, regular exercise, maintaining
Global Burden of Diseases study, hypertension is the leading global optimal body weight, smoking cessation, and limited alcohol con-
risk factor accounting for 10.8 million attributable deaths sumption) to effectively control BP. However, the Non-
communicable Disease Risk Factor Collaboration reported that
only 50% of the treated patients with hypertension achieved a
controlled BP, that is, a systolic blood pressure (SBP) of <140 mmHg
Hon Lon Tam: https://orcid.org/0000-0003-0344-6262; Eliza Mi Ling Wong:
https://orcid.org/0000-0003-0698-9000; Kin Cheung: https://orcid.org/0000- and diastolic blood pressure (DBP) of <90 mmHg [8]. The Macau
0002-8419-4847 Health Bureau also reported that 49.9% of the treated patients with
* Correspondence to: Hon Lon Tam, The Nethersole School of Nursing, The Chi- hypertension achieved a controlled BP and that this rate was
nese University of Hong Kong, Hong Kong SAR, China. decreased in patients aged
45 years [9]. Moreover, the BP control
E-mail address: [email protected]

https://doi.org/10.1016/j.anr.2023.06.001
p1976-1317 e2093-7482/© 2023 Korean Society of Nursing Science. Published by Elsevier BV. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
 H.L. Tam et al. / Asian Nursing Research 17 (2023) 158e166 159

rate among treated Chinese patients with hypertension was only Setting and sample
37.5%, and the rate was decreased in patients aged
45 years.
Nonadherence to hypertension management (i.e., medication The study was conducted at four community centers (two in
and lifestyle modifications) is a major limiting factor for BP control Macau and two in Shenzhen) that offer various health-related ac-
[2,4]. A systematic review of 61 observational studies revealed a tivities to both members and nonmembers in communities. Macau
medication adherence rate of 55.3% among patients with hyper- and Shenzhen are located in the Greater Bay Area in southern
tension [10]. A couple of studies reported low adherence to lifestyle China; these two cities were selected because they share similar
modifications (23.6%e27.4%) [11,12]. Furthermore, a secondary cultural traditions and eating habits [25]. The staff of the centers
analysis of a national dataset revealed that the rate of adherence to called their members to come for screening, and posters of this
lifestyle modifications among patients with hypertension was as study were posted in visible public areas for those interested
low as 1.7% [13]. The national data showed that patients with hy- nonmembers.
pertension tended not to practice lifestyle modifications (odds ratio By estimating a medium effect (Eta squared ¼ 0.05), Hertzog
0.48e0.53) [14]. Of note, health education can effectively improve suggested a 2-arm pilot study should include 35 participants per
adherence to medication and lifestyle modifications and signifi- group to achieve a power of 80.0% at a 5.0% level of significance in a
cantly reduce SBP and DBP among patients with hypertension two-tailed repeated measure [26].
[15e17]. Furthermore, a meta-analysis showed that health educa-
tion could significantly enhance self-efficacy among patients with Inclusion and exclusion criteria
hypertension [18]. Supportive techniques, such as written materials
and text messaging, can enhance the effects of health education on The criteria for inclusion in this study were as follows: (1) age
hypertension management [19,20]. However, evidence on the
45 years; (2) a diagnosis of hypertension and use of at least one
theoretical framework of hypertension studies is insufficient, and anti-hypertensive drug; (3) ability to use a mobile phone to read
this has limited our understanding of the associated behavioral text messages; (4) SBP of 131e159 mmHg or DBP of
changes [16,21,22]. 81e99 mmHg (as a BP of <130/80 mmHg helps patients with
On the other hand, the analysis of 169,613 individuals aged hypertension to significantly lower their risk of cardiovascular
40e69 years found that pulse pressure was a significant predictor events [27,28]); and (5) a Mini-Cog score of
3 (cognitive
of new onset of hypertension-related adverse outcomes [23], but competence was required to understand the contents of the
very limited study assessed the pulse pressure among patients with educational program; this threshold indicates a lower likelihood
hypertension. of cognitive impairment [29]).
Taking together, the currently available hypertension manage-
ment for patients to achieve a controlled BP is insufficient. Randomization and allocation concealment
Although health education could be an effective intervention in
terms of hypertension management, evidence on theory-guided In each study venue, the eligible participants were randomly
interventions is limited. This pilot study aimed to test a theory- assigned. The permuted block randomization, with a block size
guided educational program for community-dwelling patients of four, was used. The allocation sequence was computer
with hypertension. generated using an online tool (http://www.randomization.com)
by an independent assistant who was not affiliated with the
Methods study. Small cards indicating the group allocation were placed in
sequentially numbered, opaque, sealed envelopes. The partici-
Aims pants opened the envelopes after the completion of baseline
data collection. The participants from different groups visiting
This study aimed to test the preliminary effects of a theory- the same community center were then called to join the group
guided educational program on hypertension management and health education on different date and time to minimize subject
compare the effects of this program with those of usual care among contamination.
patients with hypertension. The following outcomes were
compared: BP, pulse pressure, self-efficacy in hypertension man- Interventions material
agement, and adherence to hypertension management. Moreover,
process evaluation was conducted to examine the feasibility Intervention group
(recruitment rate and retention rate) and acceptability (participant The participants in the intervention group received an
satisfaction and usefulness of the program for hypertension man- educational program that was developed according to the
agement) of the program. framework of the Health Promotion Model [30]. The program
consisted of health education, a summary leaflet, and text
messaging to increase the participants' cognition with respect to
Study design hypertension managementerelated adherence behaviors. The
construct-matched interventions and methods are shown in
This two-arm, prospective, multicenter, pilot randomized supplementary material, Table S1. Some interactive elements,
controlled trial (RCT) was conducted in accordance with the such as practice for measuring BP and discussion on healthy
Consolidated Standards of Reporting Trials statement was followed cooking, were added to the health education component. Inte-
[24]. The study was registered with the ClinicalTrials.gov (identi- gration of hypertension management into daily life was
fier: NCT04565548) before the baseline data collection. Eligible emphasized. For example, a daily alarm was set in the health
participants were randomly assigned to either an intervention education to remind taking medication regularly. Natural herbs,
group or a control group in a 1:1 ratio and were followed up twice such as star anise and clove, were introduced to substitute the
(at weeks 8 and 12). use of salt. Some packed foods were provided to practice how to
160 H.L. Tam et al. / Asian Nursing Research 17 (2023) 158e166

read and understand the food label. Also, an indoor 6-min ex- point Likert scale [40]. The total score ranged from 28 to 112, and
ercise was practiced together that facilitated participants to do a higher score indicates a higher level of adherence behavior.
exercise at anywhere and anytime. The health education content TAQPH, which was originally written in Chinese, has good reli-
was adopted from the educational manual developed by the ability (internal consistency ¼ 0.86; test-retest reliability ¼ 0.82)
World Health Organization [31] and was validated by five ex- and construct validity (goodness of fit index ¼ 0.99; root mean
perts in the fields of community nursing, family medicine, squared error of approximation ¼ 0.038) and can explain 62.5% of
nutrition, and academics with a good content validity index variance in adherence to hypertension management among pa-
(0.85). The leaflet summarized the hypertension-related tients [40].
knowledge, and quick response (QR) codes were added to The process evaluation included assessment of the recruitment
enable the participants to practice some exercises at their con- rate, retention rate, and participants' satisfaction with the pro-
venience. The text message content was adopted from other gram. A numerical program satisfaction rating scale was adopted
hypertension studies and international organizations, with from Ashe et al [41] and van Berckel et al [42]. This was an 11-
modifications made at the local level [32e34]. Practical aspects point scale and was scored from 0 to 10, with 0 indicating not
were focused. For example, a message of adding one fist-sized satisfied and 10 indicating highly satisfied. The 11-point scale was
fruit and four taels (unit of measurement used in China) of also used to rate the usefulness of the program components
vegetable in each lunch, and dinner was delivered. Making (health education, leaflet, and text messaging) for hypertension
healthy choice when eating outside was also included in the management.
pool of text messages. Demographic data (e.g., age, gender, and education level), family
One face-to-face group health education was conducted in history, and medical consultations were collected at baseline.
groups of 4e8 after baseline data collection and group allocation.
This session was administered by the first author, a registered Ethical consideration
nurse, who did not participate in data collection. The session lasted
for 45 min, and a leaflet was given to the participants at the end. This study was approved by the Human Subjects Ethics Sub-
Weekly one-way text messages were sent to the participants' mo- committee of the Hong Kong Polytechnic University before the
bile phones for 12 weeks. Each message covered a behavior tax- baseline data collection (Approval no. HSEARS20200821002-02).
onomy, and each participant received the standardized content.
Data collection
Control group
The differences and similarities of interventions between Trained RAs explained the study details to the potential partic-
intervention and control groups were summarized in supplemen- ipants and assessed their eligibility. Next, written informed consent
tary material, Table S2. In brief, the participants in the control group was obtained from the participants, and RAs collected the partici-
received a face-to-face group health education session, adminis- pants' baseline data before the start of the intervention. The in-
tered by an independent community nurse. The content was terventions were provided according to the randomization
directly adopted from the government (usual care) in the form of assignment and protocol. The same set of study outcomes was
lecture with no interactive element. After routine health education, obtained at the follow-ups after the health education session. In
a leaflet from the government was given to the participants. Text summary, data collection was completed at three time points by
messages related to general health practices, such as washing of the RAs who were blinded to the group allocation: baseline (T0), week
hands after coughing or sneezing, were delivered to the partici- 8 (T1), and week 12 (T2).
pants every week for 12 weeks.
Data analysis
Study outcomes
SPSS for Windows (version 26; IBM) was used for data analysis.
The study outcomes included BP (primary outcome), pulse Baseline characteristics were examined using the Chi-square test or
pressure, self-efficacy in hypertension management, adherence to Fisher's exact test for categorical variables. The Shapiro-Wilk test
hypertension management, and process evaluation. and Levene's test were used to examine the normality and homo-
BP, including SBP and DBP, was measured using a validated geneity of the continuous data. An independent t-test was used if
upper-arm BP monitor manufactured by Rossmax (model AU941) the assumptions were not violated; otherwise, ManneWhitney U
[35]. A standardized BP measurement procedure was adopted from test was used. The generalized estimating equation (GEE) based on
the Chinese Guidelines for Prevention and Treatment of Hyper- the intention-to-treat principle was used to estimate the effects of
tension [7]. In brief, the research assistant (RA) placed an appro- the educational program on SBP, DBP, pulse pressure, self-efficacy,
priately sized cuff on the participant's upper arm at the heart level. and adherence to hypertension management between two groups
Two BP readings (1-min apart) were obtained from the same arm. at T0, T1, and T2. Two-tailed tests were used for all data analyses,
SBP and DBP were recorded as the means of two BP readings. and significance was set at P < .05. The last observation carried
Pulse pressure, which is the difference between SBP and DBP, forward was used to handle the missing data. Effect size was used
was the secondary outcome in this study. to evaluate the clinical importance of all continuous variables and
Self-efficacy was measured on a 10-point Likert scale, namely, was determined as follows: small ¼ 0.2; moderate ¼ 0.5; and
Self-Efficacy for Managing Chronic Disease (SEMCD). The SEMCD large ¼ 0.8 [43].
comprises six items with a higher score indicating a higher level of
self-efficacy [36]. The Chinese version of SEMCD showed good in- Results
ternal consistency (0.88e0.98) [37,38] and was feasible for assess-
ing Chinese patients with hypertension [37] and Chinese older The study was conducted between February and December
adults [39]. 2021. Figure 1 presents a diagram of the flow of participants
The Treatment Adherence Questionnaire for Patients with Hy- through the trial. A total of 150 individuals were screened for
pertension (TAQPH) was used to measure adherence to hyperten- eligibility; 18 individuals denied participation before screening, and
sion management. TAQPH comprises 28 items measured on a 4- 51 individuals did not meet the eligibility criteria. Eighty-one
H.L. Tam et al. / Asian Nursing Research 17 (2023) 158e166 161

Figure 1. Flow of Participants through the Trial.

Table 1 Participant Characteristics and Outcome Variables at Baseline. Macau and Shenzhen. No significant difference was noted in the
demographic data of the individuals who completed the study and
Variables Intervention Control Chi-square p
those who dropped out of the study. The recruitment rate was
(n ¼ 35), n (%) (n ¼ 34), n (%) (df)/Mann-Whitney
/t-test 85.2% (69/81).
Age (yr),a mean 66.82 (10.5) 67.97 (9.5) 602.0 .937
(SD) Participant characteristics and baseline outcomes
Gender 2.02 (1) .155
Men 7 (20.0) 12 (35.3)
Women 28 (80.0) 22 (64.7)
The characteristics of the participants in the intervention and
Marital status 0.29 (1) .590 control groups are listed in Table 1. The mean participant age was
Married 27 (77.1) 28 (82.4) 67.39 ± 9.98 years. The majority of the participants were women
Others 8 (22.9) 6 (17.6) (72.5%) and married (79.7%). Most of the participants were unem-
Work status 0.004 (1) .947
ployed or retired (76.8%). Most of the participants (81.2%) had
Working 8 (22.9) 8 (23.5)
Unemployed 27 (77.1) 26 (76.5) completed primary school or higher. Appropriately 56.5% of the
or retried participants had a family history of hypertension. Nearly 52.2% of
Education level 0.06 (3) .995 the participants had hypertension for more than 10 years. No sta-
No formal 7 (20.0) 6 (17.7) tistically significant difference in any of these parameters was
education
Primary 8 (22.8) 8 (23.5)
noted between the two groups.
school For all outcome variables at baseline (T0), no statistical signifi-
Junior 10 (28.6) 10 (29.4) cance was noted between both groups (Table 1). The mean SBP of
secondary the participants in both groups was similar. Although the mean DBP
Senior 10 (28.6) 10 (29.4)
was higher in the control group than in the intervention group, the
secondary
and above difference was not statistically significant. The mean pulse pressure
Family history 0.46 (2) .792 in the intervention and control groups was 67.88 mmHg and
of 63.20 mmHg, respectively. The mean SEMCD and TAQPH scores
hypertension were similar in both groups.
Yes 21 (60.0) 18 (52.9)
No 7 (20.0) 9 (26.5)
Unclear 7 (20.0) 7 (20.6) Effect of the educational program on the study outcomes
Diagnosed with 2.08 (3) .554
hypertension
<4 yr 7 (20.0) 12 (35.3) The means and standard deviations of the outcomes and effect
5e9 yr 8 (22.9) 6 (17.6) sizes were summarized in Table 2. Compared with that in the
10e14 yr 7 (20.0) 5 (14.7) control group, the educational program in the intervention group

15 yr 13 (37.1) 11 (32.4)
produced a small effect size to improve self-efficacy (effect
Kind of 3.00 (1.86) 3.05 (1.80) 612.0 .839
medications size ¼ 0.230), a small-to-moderate effect size to reduce SBP (effect
used every size ¼ 0.450), a moderate effect size to reduce pulse pressure
day,a mean (effect size ¼ 0.667), and a very small effect size on the remaining
(SD) outcomes.
Change of .477
Figure 2 shows the changes of all outcomes across T0, T1, and
prescription
over the last T2. The SBP and pulse pressure in the intervention group
3 monthsb reduced the most at T1 but returned at T2, like a V-shape
Yes 3 (8.6) 5 (14.7) (Figure 2A and C). The DBP in the intervention group was
No 32 (91.4) 29 (85.3)
decreased gradually (Figure 2B), whereas an increasing trend
Outcome
variables,
was noted in the change of self-efficacy at T1 and T2 (Figure 2D).
mean (SD) The overall treatment adherence in the intervention group was
Systolic 146.64 (9.99) 145.38 (9.20) 549.50 .588 merely unchanged (Figure 2E).
blood
pressurea
Diastolic 78.75 (9.07) 82.17 (10.73) 1.43 .157
blood
Table 2 Results of Study Outcomes at Follow-ups.
pressure
Pulse 67.88 (12.12) 63.20 (10.68) 1.69 .093
Variables, mean (SD) Intervention (n ¼ 35) Control (n ¼ 34) Effect size
pressure
SEMCD 43.65 (8.16) 43.32 (9.25) 0.15 .874 Systolic blood pressure
(range 6e60) Week 8 132.65 (11.29) 135.78 (15.63) 0.20
TAQPH 92.94 (10.28) 91.94 (10.25) 566.50 .736 Week 12 136.00 (14.25) 140.31 (18.70) 0.45
(range 28 Diastolic blood pressure
e112)a Week 8 76.75 (9.01) 76.83 (11.72) 0.59
Week 12 76.03 (9.63) 77.44 (9.56) 0.08
Note. SD ¼ standard deviation; SEMCD ¼ self-efficacy for managing chronic disease;
Pulse pressure
TAQPH ¼ treatment adherence questionnaire for patients with hypertension. Itali-
Week 8 55.67 (11.83) 58.94 (13.98) 0.79
cized values were the results of t test analysis.
a Week 12 60.00 (14.48) 62.87 (15.45) 0.66
Mann-Whitney U test.
b SEMCD
Fisher's exact test.
Week 8 43.86 (7.89) 44.14 (11.19) 0.07
Week 12 45.65 (7.45) 43.66 (7.88) 0.23
TAQPH
individuals met the eligibility criteria, but 12 of those denied Week 8 92.82 (9.61) 92.32 (9.43) 0.07
participation after screening. Finally, 69 individuals were included Week 12 92.96 (8.74) 91.14 (11.51) 0.04
and randomly assigned to either the intervention group (n ¼ 35) or Note. SD ¼ standard deviation; SEMCD ¼ self-efficacy for managing chronic disease;
the control group (n ¼ 34). Both groups included participants from TAQPH ¼ treatment adherence questionnaire for patients with hypertension.
 H.L. Tam et al. / Asian Nursing Research 17 (2023) 158e166 163

Figure 2. The Changes of Outcome Variables at Week 8 (T1) and Week 12 (T2): (A) systolic blood pressure, (B) diastolic blood pressure, (C) pulse pressure, (D) self-efficacy, and (E)
treatment adherence.

The GEE results of the outcomes across T0, T1, and T2 between b ¼ 8.175, p ¼ .006; T2: b ¼ 8.203, p ¼ .007). The GEE results of
the two groups are presented in Table 3. At T1, the reduction of DBP the remaining outcomes were not statistically significant.
in the control group was significantly greater than that in the
intervention group (b ¼ 4.826, p ¼ .017); however, at T2, the Process evaluation
reduction of DBP in both the groups was not statistically significant.
The GEE results revealed that the reduction in pulse pressure was The feasibility of the program was evaluated based on the
greater in the intervention group than in the control group at both recruitment rate (85.2%, 69/81) and the overall retention rate at T2
T1 and T2 and that the differences were statistically significant (T1: (81.2%, 56/69; Figure 1). Program acceptability was shown in
164 H.L. Tam et al. / Asian Nursing Research 17 (2023) 158e166

Table 3 Results of the Generalized Estimating Equation Analysis. experience and learn from peers. A systematic review found that
the peer support interventions could have a small effect to reduce
Variables Beta 95% Confidence interval p
SBP but not DBP [45]. Furthermore, the QR codes on the leaflet and
Upper Lower the practical information of text messages could reinforce the
Systolic blood pressure practice to integrate hypertension management into daily life.
Group 1.26 3.20 5.72 .580 Although the reduction in SBP was not statistically significant,
T1 10.19 15.62 4.76 <.001* the reduction noted upon group health education was similar to
T2 3.57 9.10 1.95 .205
Group*T1 3.41 10.68 3.86 .358
that noted through individual health education. In the RCTs con-
Group*T2 7.13 15.26 1.00 .086 ducted by Wan et al [46] and Jahan et al [47], individual health
Diastolic blood pressure education with text messaging was administered to the partici-
Group 3.42 8.05 1.21 .148 pants in the intervention group; the net SBP reduction in the
T1 5.70 8.85 2.55 <.001*
intervention group at week 12 was 9.86 mmHg and 9.00 mmHg,
T2 3.01 6.06 0.03 .052
Group*T1 4.82 0.87 8.78 .017* respectively. As evident from the net SBP reduction at week 12 in
Group*T2 0.34 3.86 4.54 .872 the present study (146.64  136.00 ¼ 10.64 mmHg), group health
Pulse pressure education with interactive elements in this study resulted in a
Group 4.68 0.63 9.99 .084 better SBP reduction than individual health education. Further-
T1 4.69 8.54 0.84 .017*
T2 0.17 3.89 4.34 .934
more, group health education was cost-effective because one
Group*T1 8.17 13.96 2.38 .006* interventionist could attend to multiple participants per session.
Group*T2 8.20 14.20 2.20 .007* The nonsignificant SBP reduction results might be attributable to
SEMCD the small sample size of the present study. The nonsignificant DBP
Group 0.33 3.72 4.39 .872
reduction results might be attributable to the low baseline DBP
T1 0.31 2.99 3.61 .856
T2 0.15 3.49 3.18 .928 value among the participants in the intervention group had been in
Group*T1 0.55 4.15 5.25 .818 the optimal level of DBP [27,28].
Group*T2 2.61 2.02 7.24 .269 Pulse pressure also was evaluated in recent hypertension
TAQPH studies. Nolan et al [48] developed a web-based educational pro-
Group 1.00 3.77 5.77 .681
T1 0.08 3.61 3.43 .961
gram comprising videos, online reading material, and monitoring
T2 1.01 5.89 3.87 .685 forms; they reported that the program could significantly decrease
Group*T1 0.29 4.42 4.99 .904 pulse pressure at 16 weeks. Similarly, Chen et al [49] developed and
Group*T2 0.77 4.90 6.45 .789 implemented a web-based educational program comprising videos
Note. SEMCD ¼ self-efficacy for managing chronic disease; TAQPH ¼ treatment and monitoring forms and noted a significant decrease in pulse
adherence questionnaire for patients with hypertension. pressure at 12 weeks. However, compared with the present study,
*p < .05. the aforementioned studies required the participants to have a
greater level of digital competence. The present study was
comparatively simple as the participants were only required to
attend one group health education session and read a message
supplementary material, Table S3. The overall satisfaction with the
every week. Despite this, the educational program in this study
program was 8.79 of 10. Regarding the content of the program for
significantly reduced the pulse pressure of patients with hyper-
hypertension management, the participants agreed that the con-
tension to an optimal range [50].
tent of the health education, leaflet, and text message was useful
In this study, the participants' self-efficacy showed a positive
and sufficient. No adverse event was reported.
improvement after the educational program, although the change
was not statistically significant. Although Chen et al [49] noted a
Discussion significant improvement in the participants' self-efficacy at
12 weeks using SEMCD, it can be argued that the baseline self-
This study aimed to test the preliminary effects of a theory- efficacy of their participants (33.66 ± 9.11) was lower than that of
guided educational program on hypertension management. No the participants in this study (43.65 ± 8.16). Moreover, the old age
significant differences were noted in the baseline characteristics of the participants in this study might be responsible for the
and outcomes between the intervention and control groups. The nonsignificant changes in the self-efficacy because behavioral
educational program had a small-to-moderate effect on the changes were found to have a small effect on improving self-
reduction of the participants' SBP and pulse pressure and the efficacy among older adults [51]. Finally, the TAQPH score in this
improvement of self-efficacy at T2. Compared with the baseline, the study was high. A ceiling effect was suggested, which might limit
SBP, DBP, and pulse pressure were decreased at T2 after the the effect of the educational program on overall treatment adher-
educational program; the self-efficacy was increased, and the ence and cause a nonsignificant result in GEE analysis [52].
treatment adherence was merely unchanged. The results of the GEE
analysis indicated that the reduction of pulse pressure in the Limitations
intervention group was statistically significant at T1 and T2. The
recruitment and retention rates were good, indicating that the This study has some limitations. The results should be inter-
educational program was feasible. The good satisfaction and con- preted cautiously because of the small sample size. It remains un-
tent scores indicated the program was highly appreciated. clear whether the program would be effective for uninterested,
The reduction of SBP and pulse pressure and improvement of excluded, or younger people with hypertension. The participants
self-efficacy in this study could be related to the design of the may have recognized their group allocations based on the text
educational program. The demonstrations and practices in the message content. Moreover, participants from different groups
health education allowed the participants to have a mastery visiting the same community center may have communicated with
experience, which could enhance their self-efficacy [44]. The dis- each other. However, such communication was limited because the
cussion could help them overcome difficulties in their daily hy- centers had reduced their activities during the COVID-19 pandemic,
pertension management, whereas they could share their and the health education sessions and follow-ups for the
 H.L. Tam et al. / Asian Nursing Research 17 (2023) 158e166 165

intervention and control groups were scheduled on different dates Conflict of interest
to minimize subject contamination. Furthermore, both SEMCD and
TAQPH were administrated by trained RAs and self-reported by the No conflict of interest.
participants; hence, the high scores could be related to the social
desirability bias [52]. Acknowledgments

Implications Sincere thanks to Dr. Leung DYP for the support on statistical
analysis. Dr. Wang Q, Ms. Liu F, and Ms. Li H for the support in
The results of this pilot RCT, that is, the effect sizes and process Shenzhen. Warmest thanks to Mr. Cheang CM, Mr. Leung IH, Mr. Lee
evaluation, provide valuable information for further research. The WC, and Mr. Tam KL for the support in Macau. Special thanks to the
construct-matched interventions may be applicable to other hy- patients who participate in our project.
pertension studies guided by the Health Promotion Model. A
reinforcement educational intervention, such as health education Appendix A. Supplementary data
session or phone call, at week 8 is recommended and should be
included in future studies. A website link could be included in the Supplementary data to this article can be found online at
text messages to enable the patients to watch videos related to https://doi.org/10.1016/j.anr.2023.06.001.
hypertension management [53]. Furthermore, the follow-up
duration should be increased to assess the sustainable effects of
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