NURS SCI J THAIL Vol. 37 No.

1 January - March 2019

Factors Associated with

Self-Management Ability among
Older Adults with Hypertension in
Asia: A Systematic Review of
Qualitative Studies
Junjira Seesawang, RN, PhD1, Pulawit Thongtang, RN, PhD2

Abstract
Purpose: To identify and summarize factors associated with self-management
ability among older adults with hypertension in Asia from a systematic review.
Design: A qualitative systematic review was performed. A search for qualitative
studies published in English from 2008 to 2018 was conducted using CINAHL,
PsycInfo, PubMed, Medline, and Google Scholar databases. Ten qualitative studies
were included in this review. Conventional content analysis was used to analyze and
synthesize findings from qualitative studies.
Main findings: Findings covered the factors found to influence self-management
among older adults with hypertension in Asia including: 1) patient-level factors including
personal beliefs, attitudes, individual experiences of symptoms, perceptions of physical
health, sense of responsibility, sense of control, family responsibility and financial
concern, 2) organizational-level factors including time management and
communication, and 3) community-level factors including community resources and
social support.
Conclusion and recommendations: The findings suggest that self-management
ability among older adults with hypertension in Asia are associated with a diverse range
of patient-, organizational-, and community-level factors. To assess a person suffering
from hypertension the associated factors should be included so that more appropriate
strategies and nursing interventions would be developed and adjusted to enhance
hypertension self-management behaviors. A conceptual model used for improving
hypertension self-management practices should be developed and tested in future
research. How factors influencing self-management ability vary between subgroups of
patients such as gender and ethnicity should also be explored using qualitative
research.

Keywords: hypertension, qualitative research, self-management

Nursing Science Journal of Thailand.
2019;37(1):86-107
Corresponding Author: Lecturer Junjira Seesawang, Prachomklao College of Nursing, Phetchaburi Province, 76000
Thailand; e-mail: jseesawang@yahoo.com
1
Prachomklao College of Nursing, Phetchaburi, Thailand
2
Boromarajonani College of Nursing, Chiang Mai, Thailand

Received: 4 January 2019 / Revised: 26 January 2019 / Accepted: 28 January 2019

86 Nursing Science Journal of Thailand

NURS SCI J THAIL Vol. 37 No. 1 January - March 2019

ปั จจัยทีเ่ กีย
่ วข ้องกับความสามารถในการ
จัดการตนเองของ ผู ้สูงอายุโรคความดัน
โลหิตสูงในเอเชย ี : การทบทวนวิจัยเชงิ
คุณภาพ อย่างเป็ นระบบ
ี ว่าง, PhD1 ปุลวิชช ์ ทองแตง, PhD2
จันทร์จริ า สส

บทคัดย่อ
วัตถุประสงค์: เพื่อศึกษาและสรุปปัจจัยที่เกี่ยวข้องกับความสามารถในการจัดการตนเองของผู้สูงอายุโรค
ความดัน โลหิตสูงในเอเชีย จากการทบทวนวรรณกรรมอย่างเป็นระบบ
รูปแบบการศึกษา: เป็นการทบทวนวรรณกรรมอย่างเป็นระบบเชิงคุณภาพ โดยการสืบค้นหลักฐานเชิง
ประจักษ์ ทีเ่ ป็นงานวิจัยเชิงคุณภาพซึ่งตีพิมพ์เป็นภาษาอังกฤษตั้งแต่ปีค.ศ. 2008 ถึง 2018 จากฐานข้อมูล
CINAHL, PsycInfo, PubMed, Medline, and Google Scholar ข้อมูลจากงานวิจัยเชิงคุณภาพจำ นวน 10
เรื่อง ถูกนำ มาวิเคราะห์และ อธิบายโดยใช้การวิเคราะห์เนื้อหาแบบดั้งเดิม
ผลการศึกษา: จากการวิเคราะห์เนื้อหาพบปัจจัยทีม่ ผี ลต่อการจัดการตนเองของผูส้ ูงอายุโรคความดันโลหิตสูง
ในเอเชีย คือ 1) ปัจจัยระดับบุคคล ประกอบด้วย ความเชื่อส่วนบุคคล ทัศนคติประสบการณ์ส่วนตัวเกี่ยวกับ
อาการ การรับรูเ้ กี่ยวกับสุขภาพกาย สำ นึกความรับผิดชอบ ความรู้สึกและความสามารถในการจัดการตนเอง
ความรับผิดชอบ ต่อครอบครัว และปัญหาทางการเงิน 2) ปัจจัยระดับองค์กร ประกอบด้วย การบริหารจัดการ
เวลา และการสื่อสาร และ 3) ปัจจัยระดับสังคม ประกอบด้วย ทรัพยากรชุมชน และแรงสนับสนุนทางสังคม
สรุปและข้อเสนอแนะ: การทบทวนวรรณกรรมนีพ้ บว่า ปัจจัยทีม่ ีความเกี่ยวข้องกับความสามารถในการ
จัดการ ตนเองของผูส้ ูงอายุทเี่ ป็นโรคความดันโลหิตสูงในเอเชีย มีความหลากหลาย ทั้งในระดับบุคคลองค์กรและ
สังคม บุคลากร สุขภาพจึงควรมีการประเมินปัจจัยทีเ่ กี่ยวข้องกับการจัดการตนเองในผู้ป่วยโรคความดันโลหิตสูง
เพื่อพัฒนากลวิธี ทีเ่ หมาะสมและปรับเปลี่ยนรูปแบบการพยาบาล เพื่อส่งเสริมพฤติกรรมการจัดการตนเองเกี่ยวกับ
โรคความดันโลหิตสูง ในประชากรกลุ่มนีก้ ารวิจัยในอนาคตควรพัฒนาและทดสอบแบบจำลองความคิดที่สามารถใช้
ในการส่งเสริมพฤติกรรม การจัดการตนเองเกี่ยวกับโรคความดันโลหิตสูง และการวิจัยเชิงคุณภาพควรค้นหาว่า
ปัจจัยที่มผี ลต่อความสามารถ ในการจัดการตนเองมีความแตกต่างกันอย่างไรในกลุ่มผูป้ ่วยที่ต่างกัน เช่น เพศและ
เชื้อชาติ

คำสำ คัญ: ความดันโลหิตสูง วิจัยเชิงคุณภาพ การจัดการตนเอง

Nursing Science Journal of Thailand.

2019;37(1):86-107
Corresponding Author: อาจารย์จันทร์จิรา สีสว่าง, วิทยาลัยพยาบาลพระจอมเกล้า จังหวัดเพชรบุรี 76000, e-mail:
jseesawang@yahoo.com 1 วิทยาลัยพยาบาลพระจอมเกล้า จังหวัดเพชรบุรี
2
วิทยาลัยพยาบาลบรมราชชนนี เชียงใหม่
วันที่รับบทความ: 4 ม.ค. 2562 / วันที่แก้ไขบทความเสร็จ: 26 ม.ค. 2562 / วันที่ตอบรับบทความ: 28 ม.ค. 2562

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NURS SCI J THAIL Vol. 37 No. 1 January - March 2019
been identified as a critical component in

Introduction hypertension management5. Successful

Hypertension common management requires patients to engage

is very
among older adults in many Asian in a range of activities including: (1)
countries1. For example, the prevalence medication adherence, (2) self-blood
of hypertension among older adults is pressure monitoring, and (3) lifestyle
66.18% in China2, 54.5% in Malaysia3, modifications involving dietary changes,
and 58% in Taiwan4. The prevalence of exercise, restriction of alcohol intake,
5
hypertension uncontrolled and quitting smoking . Preventing the
and
hypertension contributes to the present serious complications of hypertension
pandemic of morbidity and disability, requires patients to incorporate these
mortality, high economic costs, and loss lifestyle changes into their daily routines
6
of quality of life for patients and along with a high level of adherence .
families1. The success of hypertension Previous studies documented that h
care depends on the patient’s ability to y p e r t e n s i o n s e l f - m a n a g e m
perform hypertension self-management e n t i s suboptimal among Asian older
7-8
which involves a complex and adults with hypertension . High levels
multifactorial process5. of poor adherence to hypertension

Hypertension self-management has self-management such as dietary

change and blood pressure self in the daily lives of Asian older adults. In
monitoring have been reported in this addition, no prior systematic reviews or
population. Moreover, they did not syntheses of qualitative studies have
adhere to medication regimen, for been conducted.
example, they purposely had skipped To address these gaps in
taking medications or forgot to take their knowledge, it is important to capture and
medications7. The reasons for synthesize findings from qualitative
medication non-adherence are not well research on factors associating with
known, suggesting a critical need to self-management among Asian older
identify factors influencing hypertension adults to gain understanding and to
self management behaviors and to provide directions for future research.
develop interventions that will effectively Consequently, this paper reports a
target such factors. Quantitative studies systematic review of qualitative
10
have previously reported facilitators and research focusing on the factors
barriers to hypertension associating with self-management
self-management6,9. However, there is a among Asian older adults. This
lack of knowledge about how these systematic review of qualitative research
factors influence self-management will assist in targeting and tailoring
process based on Asian older adults’ self-management interventions for older
experience or perspective, and lacked adults with hypertension in Asia.
knowledge on how these factors operate

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Objective Design
This systematic review was A qualitative systematic review was
undertaken to synthesize qualitative
research evidence on the factors Table 1: Inclusion and exclusion
associated with self-management ability
among older adults with hypertension in criteria Criteria
Asia. This review was to answer the conducted using Butler’s
following question: ‘what factors are methodology10.This method was
associated with self-management among developed specifically to guide
older adults with hypertension in Asia researchers conducting qualitative
and how?’ systematic reviews that aim to present a
comprehensive understanding of
individual experiences and perceptions. perspectives, attitude or feelings as a
Eligibility Criteria primary aim
Inclusion criteria searching The review focused on older adult
for
included: (a) period of publication population with hypertension both urban
(2008-2018), (b) language (English), (c) and rural areas in Asian countries. Any
type of journal (academic), (d) research studies which included older adults with
subject (human), and (e) age (60 years hypertension outside Asian countries
or older). were excluded, because of the difference
in the context.

Any studies which did not focus on factors

Justification
Study participants are men and women
with hypertension aged ≥60 years who
live in a rural and urban setting of Asian
countries
Study objectives that relates to the factors did not relate to self-manage
associating with hypertension
self-management
Examines older adult experiences,
associating with hypertension
self-management were excluded.
Older adult experiences, perspectives,
attitude or feelings surrounding
hypertension self-management must be a
primary aim of each study. Studies that
hypertension or healthcare providers’
perspective were excluded, owing to the
expansive number of reviews on each
topic.

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Table 1: Inclusion and exclusion Justification

criteria Criteria
Original qualitative data Search Strategy literature search
between June and August, 2018.
The review focused on the experiences,
attitude, feelings or perspectives of older studies. Reference lists from each study
adults, which was most appropriately
answered through qualitative research.
Qualitative data from a mixed methods
study was included. Any study which
utilized survey data or statistical reporting screened titles and abstracts for the
of results and grey literature (e.g.,
dissertation studies, books, published
abstracts, conference proceedings, etc.)
were excluded.
author and second author independently
The electronic databases CINAHL,
PsycInfo, PubMed, Medline, and Google
Scholar were searched using Medical
Subject Headings (MeSH) key words
including: “hypertension”, “high blood
pressure”, “self-management”,
“self-care”, “qualitative research”. The
was undertaken
Search Outcome
The Preferred Reporting Items for
Systematic Reviews and Meta-Analyses
(PRISMA) guidelines11 was used to
report the selection and exclusion of
studies. A flow diagram describing the
selection of studies is shown in Figure 1.
The initial search identified 1,510
were hand-searched for additional
relevant studies, resulting in an
additional two studies. Then, 419
duplicates were removed. The first
remaining 1,091 studies. After
screening, 1,051 studies were excluded
due to not meeting criteria as they were
conducted outside Asian countries and
quantitative studies. Forty studies met
inclusion criteria and were reviewed in
full. Next, during the preliminary review
of full-text of each study, 30 studies
were excluded due to not meeting
inclusion criteria for the following
reasons: a) being a quantitative study (n
= 8); b) conducting interviews with Asian
immigrant population outside Asian
countries (n = 3); c) lacking focus on
self-management (n = 7); and d) being
grey literature (n = 12). The final set of
10 studies, including two generated from
hand searching, varied in terms of
design, population, aims, and findings as
they focused on different things (Table
2).
90 Nursing Science Journal of Thailand
NURS SCI J THAIL Vol. 37 No. 1 January - March 2019
Records after = 1,051)
duplicates removed (n
n = 1,091)
o

it

c
Full-text articles excluded,
fii

with reasons (n = 30)

t

dI
Records screened
Records identified
(n = 1,091)
through database
searching
de

(n = 1,510)
Additional records
d

Full-text articles
u

lc

identified through assessed

n

other sources (n = 2) (n = 40)

Studies included in
qualitative synthesis
(n = 10)
g

1. Quantitative study: 8
i

2. Interviews Asian
e

c immigrant population
S

outside Asian countries: 3

3. Lacks focus on self
for eligibility
management: 7
4. Grey literature: 12
y

Records excluded (n
i

Figure 1: Flow diagram of included studies through review process

After obtaining all of the studies
Study Selection resulting from searching the electronic
databases, duplicates were removed. conducted preliminary screens of each
The authors independently screened the article, and determined which studies
title and abstract of each study. The met the above inclusion criteria. Then,
authors also discussed whether to the authors read the full-text of each
include each study, and came to an study in detail.
agreement about any differences. The Data Extraction
full-text of studies that appeared to meet The authors read each study and
the inclusion extracted: a) authors; b) year of
criteria were obtained for
further publication;
screening. The authors independently

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Table 2: Overview of studies

c) country; d) study design; e) study to the review. The authors entered this
purpose; f) participants; g) setting; h) information into a table to allow for
data collection and analysis techniques; comparison across articles (Table 2).
i) findings relevant
Findings relevant to
County Study design Data collection / Data
Purpose factors influencing
analysis
Author, Participants / Setting self-management

Thailand Explore the behavior

Udompittayason, in Northern Content analysis
perception on 11 Thai-Melayu Data collection: Patients stopped
Boonyasopun
Ethnographic hypertension older adults In-depth taking
and
Songwathana12 study interview, medication and
Rural village in observation not change their
Southern and focus group lifestyle due to
Thailand
Data analysis: the absence of
Thematic symptom.
analysis They only took
medication
when they had
clinical symptom
such as
headache.

Explore barriers Patients believed

and facilitators 10 older adults that the cause of
Suthipan and
associated with Data collection: hypertension is
Intarakamhang13 Qualitative focus
group study healthy lifestyle Urban area Focus group the imbalance of
Data analysis:
Leard (blood) lifestyle adopting healthy of safe or motivated
and Lom (wind), Patients modification due lifestyle affordable places patients in
leading them not described that a to perceived behavior. to exercise. hypertension
to change their lack of motivationpoor physical management
behavior. regarding health as the There was a lack Family members such as taking
barriers for medications.

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County Study design

Purpose Findings relevant to
Table 2: Overview of Data collection / Data
studies factors influencing
analysis
Participants / Setting self-management
Author,
approach conventional
Thongtang and among elderly
using in-depth hypertension Rural areas content analysis
Seesawang7
interviews and

Thailand focus group Content analysis

Explore factors
affecting health
Zhang, Shan behavior and
and Jiang16 health needs in
Woodham, et the elderly
China
Conventional
al.14 Thailand
content A qualitative 40 older adults
analysis descriptive
approach design Rural area
Explore self care
among Thai
Investigate the
older Data collection:
meaning of life
Directed adults with In-depth
and health
content hypertension interview and
experience of
analysis focus group
Chinese elderly
approach Data analysis:
Kitreerawutiwo, 30 Thai older
and Gain better content analysis
adults
understanding 11 older adults f
Mekrungrongwo f = 20, m = 10
of perspective on = 6, m = 5
living with
ng15 Thailand Urban area in
hypertension Urban areas
Western
and how they Data collection:

manage in-depth Data collection:

30 older adults f
medication interview In-depth
= 17, m = 13
Qualitative Data analysis: interview
at home
 and exercise. Patients used
Data analysis:
Thematic Patients with no their time to Patients

analysis sign and take care small expressed that

Patients Patients symptoms Patients children and did they must care

received support perceived that believed that received support not have time to for themselves

from family to taking there was no from family and take care and they have

manage their medications reason to group in themselves, the power and

hypertension, would cause continue taking motivating them such as forgot responsibility to

such as taking other serious medication. to change to take take care of

medication, health eating behavior medication. themselves such

eating habit, problems. and do exercise. as exercising.

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County Study design

Purpose Findings relevant to
Table 2: Overview of
Data collection / Data
studies factors influencing
analysis
Participants / Setting self-management
Author,
learning to
Long and Li17
manage their
disease and
China
complications.

Patients in rural
area with
Explore patients, 10 older adults f insufficient
their families, = 5, m = 5 Data collection: income
and healthcare semi-structured impacted on
providers’ Urban areas interview ability to acquire
Data collection: food and
Conventional experiences Data analysis:
semi-structured
content about conventional medication.
interview
analysis hypertension content analysis
Data analysis:
treatment Patients Patients had a
Nayeri, approach
Explore health an abductive concentrated on negative attitude
adherence
Dehghan and 24 Chinese approach
seeking fulfilling their toward the
Iranmanesh18 elders and
behaviors responsibility as disease,
through which 24 caregivers f = member s of treatment,
Iran 12, m = 12
elders manage their doctor, and
A qualitative
diagnoses, households. medication, for
narrative
treatment, and Urban and rural Thus, they were example, they
design
health care. areas not interested in believed that
their body had medication. that their body is they ate and how relatives or
ability to recover a loan from God to care of this It was difficult to friend offer them
itself and did not They believed and they paid loan. resist when their unhealthy food.
want to use attention to what

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positive impact of following appointment.
supportive family
Table 2: Overview of Data collection / Data
studies atmosphere on adhering Patients complained that
analysis
to treatment regimen health offices were often
Author,
including eating safe crowded and there was
County Study design Findings relevant to
little time to consult
Purpose foods, exercising,
factors influencing physician.
recalling
self-management
medication usage, and
Participants / Setting
Patients experienced a
Urban areas Data analysis: able to control
content
Khezri, et al. 19
directed content their disease by
analysis
analysis complying with
approach
Iran Explore how medication

older Korean Data collection: regimen and

adults perceive 13 older adults focus group exercising.

and cope with Data analysis:

A qualitative
their chronic Urban areas content analysis
narrative design
illness Patients Patients
Kang, et al.20 Explore the
9 older adults experienced not
challenges in Data collection: perceived that
being heard or
South Korea self-managemen semi-structured even they were
interviews old; they were considered by
t empowerment
doctors.
Directed

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 = 0, partial = 1, yes = 2).
The author added all the scores for
Quality Appraisal
all items to obtain a total score, dividing
The authors critically appraised of
this by the total possible score to obtain
each study using the QualSyst Tool for
the summary score (Table 3). For each
Qualitative Studies21. The ten items
study, a maximum total score of 20 and
include (1) sufficient description of
a maximum summary score of 1 was
question/objective,((2) evident and
possible. Studies that failed to meet the
appropriate study design, (3) context for
minimum summary score of .5519 were
the study clearly described, (4)
not included. The cut-point of .55 is the
connection to a theoretical framework or
minimum recommended threshold for
wider body of knowledge, (5) sampling
inclusion for qualitative studies21. All
strategy described, relevant and
studies met this minimum level. Overall
justified, (6) data collection methods
score ranged from 0.70 to 1.00. Our
systematic and clearly described, (7)
review is therefore grounded on findings
data analysis systematic and clearly
of an overall ‘good’ methodological
described, (8) verification procedure(s)
quality. Common weaknesses within the
used to establish credibility, (9)
10 included studies were mainly around
conclusions supported by the results,
the lack of a clear description of
and (10) evidence of researcher
analysis; and limited contextual
reflexivity. These 10 questions were
information about participants.
scored depending on the degree to
which the specific criteria were met (no

Table 3: Quality assessment for qualitative studies with QualSyst Tool

Qualitative Studies
Studies 1 2 3 4 5 6 7 8 9 10 Total Score Summary
Quality Assessment Criteria for score
Udompittayason, Boonyasopun 2 2 2 1 2 2 2 2 2 2 19 19/20 = 0.95 and Songwathana12

Suthipan and Intarakamhang13 2 2 1 2 2 2 2 0 2 1 16 16/20 = 0.80 Thongtang and Seesawang7 2 2

2 2 2 2 1 2 2 1 18 18/20 = 0.90 Woodham, et al.14 2 2 2 2 2 1 1 2 2 1 17 17/20 = 0.85
Kitreerawutiwo and Mekrungrongwong15 2 2 1 1 2 2 1 1 1 1 14 14/20 = 0.70 Zhang, Shan and
Jiang16 2 2 2 2 2 2 2 2 2 1 19 19/20 = 0.95 Long and Li17 2 2 2 2 2 2 2 0 2 1 17 17/20 = 0.85 Nayeri,
Dehghan and Iranmanesh18 2 1 2 2 2 2 2 2 2 2 19 19/20 = 0.95 Khezri, et al.19 2 2 1 2 2 1 2 1 2 1 16
16/20 = 0.80 Kang, et al.20 2 2 1 2 2 2 1 0 2 0 14 14/20 = 0.70

Note: The QualSyst tool for qualitative studies: 1. Question / objective sufficiently described?; 2. Study
design evident and appropriate?; 3. Context for the study clear?; 4. Connection to a theoretical
framework / wider body of knowledge?; 5. Sampling strategy described, relevant and justified?; 6.
Data collection methods clearly described and systematic?; 7. Data analysis clearly described and
systematic?; 8. Use of verification procedure(s) to establish credibility?; 9. Conclusions supported by
the results?; 10. Reflexivity of the account? (2 = Yes, 1= Partial, No = 0)

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 content, for example, what is obvious in
the data and category names were
Data Synthesis
factual. For instance, category
Data synthesis was performed using
“patient-level influence” demonstrated
conventional content analysis22. The
factors at individual level that influenced
authors initially read and immersed
hypertension self-management.
themselves in the data from manuscripts
This synthesis revealed a range of
to obtain a sense of the whole and
factors affecting hypertension
recorded first impressions. Next, we
self-management that were grouped into
developed codes reflective of categories
three board categories: patient-level
and concepts reported in the ten
influences, organizational-level
studies. Categories were inductively
influences and community-level
developed by grouping codes based on
influences on hypertension
similarities and differences, and
self-management as identified in the ten
organizing codes into meaningful
studies (Table 4).
clusters22. Categories were an
expression of manifest

Table 4: Categories of factors affecting self-management and associated codes

• Time constraints of family
Categories
work affect time to
Patient-level influences and
Financial concerns self-manage
hypertension Codes
self-management • Perception of cause of
Sub-categories
hypertension • Self-manage
Personal beliefs
is inconvenient • Cultural
belief/value/practice (e.g.,
food and traditional
medicine) • Spiritual belief
in God
• Negative attitude towards
healthcare provider
Attitudes
• Negative attitude towards
Western medicine (e.g.,
Individual experiences of
adverse effect) •
symptoms
Appearance of symptoms
Perceptions of physical
• Absence of symptoms
health Sense of
• Perceptions of poor
responsibility Sense of
physical health • The
control
responsibility of the healthy
• Self-perceived control of
Family responsibility
own health • Insufficient income to
• Focusing on family work
self-manage (e.g., buying healthy food)

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Table 4: Categories of factors affecting self-management and associated codes

Sub-categories consultation • Longer
Categories
Time management waiting time
Organizational-level
• Lack of active discussion
influences and
• Perceive doctors do not
hypertension listen to patients
Communication
self-management
• Exercise environment
Community resources • Lack of public place for
exercise • Perceived
Community-level
Social support support (family, peer) •
influences and
Participation in peer
hypertension support
Codes
self-management
• Lack of time for
ethnography (n = 1). In terms of
location, 5 were from Thailand, 2 were
Findings
from China, 2 were from Iran, and one
Overview of Studies
was from South Korea. Three studies
This review included 7 studies
were conducted in rural areas, 6 studies
involving Asian older patients with
in urban areas and only one study was
hypertension and only 3 studies
conducted both in urban and rural areas
involving Asian older patients with
of Asian countries. The sample sizes
hypertension who had one or two
varied from 9 to 44 and included both
comorbidities (e.g., diabetes and heart
male and female patients in each study.
disease). These 3 studies presented
Detailed Results
results that were specific to
The results of this review include a
hypertension self-management among
synthesis of the factors that were found
Asian older adults. The study
to influence self-management among
participants ranged in age 60-95 years.
Asian older adults with hypertension. In
Both men and women were included in
each of the included studies, Asian older
all selected studies.
adults were interviewed using
Methodologies used in reviewed
open-ended questions such as “how you
studies included; narrative approach (n
manage your hypertension” “What is
= 2), conventional content analysis (n =
your view of the factors that support you
3), directed content analysis (n = 4), and
 to manage your hypertension” “What do
you think the obstacles might be when
managing hypertension.” Study results
focused on perceptions of hypertension,
knowledge about hypertension and its
treatments, reasons for poor treatment
adherence, self-management
approaches, and the factors influencing
Asian older adult’s self-management. In
this review, several included studies
contributed to each of sub-categories
(e.g., personal belief and social support),
while only one study contributed to
sense of responsibility and time.
The three main categories
synthesized from the literature are
shown in Table 5 below.

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NURS SCI J THAIL Vol. 37 No. 1 January - March 2019
y
9

y
0

2 d

0 u

t
1

8 p
d
1

u
8
t

S p

t
e

i S

4
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1

g
4

t y

a
d

c
u

-
t

b S

7
s

d
y

n
d
a
u

t
s

S
e
d

u 3

t 1

S 2

7 y

1
d

7
u

t
y

S
d

u 2

1
t

1
S

y
6

1
d

6
u

t
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S
d

u
d
t

n
S

s
5

s
u
pppp pp

pp

pp

ppp

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hypertension self-management.

Patient-level influences and Patient level influences were associated

with the individual life style and beliefs Attitudes.Older adults with
that affected their ability to self hypertension who demonstrated their
manage. Sub-themes included “personal attitudes and views toward illness,
beliefs”, “attitudes”, ‘individual symptom treatment, healthcare providers, and
experiences”, “motivation”, “sense of medications did not want to engage with
responsibility”, “sense of control”, “family self-management behavior. For example,
responsibilities”, and“financial concerns”. they believed that western medications
Personal beliefs. had more problems than benefits and
18

Cultural and spiritual beliefs influenced that taking medications would cause
14
hypertension self management. In one other serious health problems . Thus,
study, upon receiving a hypertension they decided not to take medications to
diagnosis, older adults expressed a decrease their high blood pressure.
belief that the imbalance between Leard Understanding of
(blood) and Lom (wind) caused symptoms. Older adults with
hypertension, and was related to hypertension reported that they stopped
inappropriate behavior such as eating taking medication and decided not to
habits and hot body change their lifestyle behaviors because
and cold
temperature and environment12. This they had no symptoms. They only took
belief led them to use traditional medications when experiencing clinical
medicine while not changing their symptom such as headache and
behavior as by dizziness12. Similarly, older adults with
recommended
healthcare providers. Another study18 no symptoms believed that there was no
found that some older adults with reason to continue taking medication, or
hypertension viewed diet as an integral changing their lifestyle, or adopting
part of social gatherings, finding that it preventive behaviors such as exercise14.
was difficult to maintain their dietary Perceptions of
restrictions during social gatherings physical health. One study
when others were eating and drinking found that perceptions of poor physical
food not recommended for people with heath interfered with motivation to make
hypertension. Spiritual beliefs about changes related to hypertension
illness were also found to influence self management13. Hypertensive older
management behavior. For example, adults with perception of poor physical
Iranian older adults believed that the health were less likely than others to
outcome of hypertension was in the engage in physical activities.
“God’s hands” and their body was a loan Perceptions of poor physical health made
from god18. Thus, the idea of self- them wanted to stay at home and watch
management, of personal control, was television and did not want to engage in
not an option to them. exercises.
 Sense of hypertension and other chronic
responsibility. Findings conditions such as diabetes
suggested that older adults with

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was the explanation some older adults
gave for failing to take medica tions15,17.
and heart disease who believed they had
a responsibility to take care Financial. One study
of
themselves were more likely than others reported financial concerns influencing
to view self management as important to that ability to self manage. Insufficient
achieving a good quality of life16. In income limited their ability to purchase
addition to feeling responsible for healthy food, medications, and
themselves, they believed that taking transportation to healthcare provider
17
care of themselves would prevent them appointments .
from adding burden to their country. Organizational-level influences
and hypertension self-management.
Sense of control.
Only two studies addressed
Hypertensive older adults with a sense
organizational-level issues that
of control over their illness were more
influenced individual ability to self
likely to trust their ability to engage
19-20
self-management behavior than those manage .
with poor sense of control over their Time management.
illness19. They were also more likely to One study found that many older adults
have stronger confidence in their ability with hypertension described having

to manage their hypertension insufficient time to consult with providers

independently. about their concerns due to short visits18.
Thus, they experienced rarely having a
Family
chance to discuss or learn about realistic
responsibility. Some older
self-management strategies that they can
adults with hypertension and other
implement at home. Sometimes, they
chronic conditions such as heart
experienced long waiting time which
disease and diabetes re p or t e d fo c u
made them were frustrated at the
s i ng on t h e i r f am i ly responsibility,
healthcare office.
such as earning an income or caring for
small children. These older adults Communication. One
expressed a lack of interest in managing study found that older adults with

their disease as it would redirect their hypertension reported feeling they

focus and interfere with their ability to received inadequate attention from
20
engage in these other activities. This healthcare providers . They perceived
that doctors did not listen to patients. and exercising.
Sometimes, they experienced not being Community-level influences and
considered when talking about having hypertension self-management.
trouble with self management. Moreover, Community level influences included two
their doctors did not
actively discuss sub-categories: a) community resources
hypertension management strategies and b) social support facilitating or
such as following an appropriate diet or inhibiting self-management efforts.
regular exercise but only mentioned not
eating salty food, taking medications,

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with self-management7,13,18. In addition
Community to family support, peer provided
resources. One study reported emotional support and suggestions
inadequate community resources about reducing salt or taking
affecting self-management among older medications which increased their
adults with hypertension such as lacking confidence to engage in
15
access to places for participating in self-management activities .
physical activities. Some abandoned the
idea of exercising due to lack of safe or Discussion
affordable places to exercise13. The purpose of this systematic
Social support. Some review was to synthesize evidence on
older adults with hypertension reported the issues that influenced the ability of
that receiving support from others Asian older adults to self-manage
encouraged them to self-manage and hypertension. Older adults were found
assisted them in making and maintaining to face several issues that affected their
lifestyle changes, especially support from ability to engage effectively in managing
families. Older adults often shared their their own health care. Findings showed
hypertension management strategies that patient-level (e.g., cultural belief,
with family members who could provide negative
assistance with daily self-management attitude regarding medication, and lack
tasks such as reminding to taking of motivation), organizational-level
medications, preparing appropriate food, influences (e.g., lack of attention and
and attending appointments. Families time from healthcare provider)), and
also provided emotional support that community-level influences (e.g.,
could motivate older adults to engage support from others) can sway ability to
self-manage among Asian older adults influencing factors. For example,
with hypertension. communication with healthcare
The three main categories that providers and consistent,
characterized the literature on issues understandable and specific education to
influencing ability to self-manage among facilitate self-management was found to
o l d e r a d u l t s w e r e p a t i e n t - l e affect self-management behaviors 24.
v e lorganizational-level, and Another systematic review found that
,
community-level. These findings are only personal factors, including health
congruent with factors influencing beliefs, perceived susceptibility,
self-management in patients with perceived barriers, and self efficacy were
chronic obstructive pulmonary disease23 associated with diabetes self
and in adult patients with diabetes24 that management behaviors25. An integrative
have been reported by others. review of factors influencing
Comparing to self-management in self-management of chronic obstructive
different illnesses, systematic review on pulmonary disease showed other factors
experience of self-management among that influenced patient self-management
diabetic patients found different including physical status and

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symptoms would resolve on their own
postponed appointments with their
presence of symptoms (e.g., dyspnea
healthcare providers.
and functional impairment) and
Social support also played important
existential determinants (e.g., meaning
role in hypertension self-management.
of life and religiosity) as most influential
In this review, social support from family
on self-management23.
and peers has been reported to improve
Personal beliefs are an important
hypertension self-management behavior
issue influence on individual’s ability to
that was consistent with other illnesses
self-manage their hypertension. In a
such as diabetes and chronic
qualitative study of self-manage in
obstructive pulmonary disease23-24.
diabetes26, documented that patients
Social support can promote patients to
who believed in their ability to control
engage in healthy diet, physical
diabetes, had a positive outlook about
activities, and decision to contact
their quality of life, and were willing to
6,9,27
healthcare providers . Pertaining to
make changes in their lifestyle were
support from healthcare providers, this
more likely to change eating habit and
review presented that older adults with
exercise. Moreover, researchers27 found
hypertension were often experienced
that patients who believed their
insufficient consultation time from their on factors influencing ability to
healthcare providers. self-manage, this review took a broad
Even though the review includes perspective among Asian older adults.
studies from different countries, there Nevertheless, this systematic review
are still many unanswered questions does not provide a complete profile of
about self-management what may help or impede
in hypertension that are important to self-management in hypertension.
explore if effective interventions are to Another limitation, our sample included
be developed. In this review, the older adults with other chronic disease
participants of included studies were such as diabetes and heart disease.
mixed between older men and women. Studies did not identify factors both
Our search did not yield any studies that common among and specific to
focused on differences between self-management of different chronic
populations. Better distinctions in the illness that may differ across the illness
experiences of these subgroups were trajectory. Moreover, only published
not generally visible. Thus, it should be studies and only English-language
taken into account when interpreting the articles were included that may affect
obtained results. There is a possibility the results of the review.
that the generalizability of our findings
may be limited as no data were found Conclusion and Recommendations
around how perceptions and factors Hypertension is a chronic condition that
influencing ability to self-manage may requires self-management behaviors
vary between and within different social which
groups.
To provide a foundation for research

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living with hypertension. Synthesizing
involves a shift from being controlled by qualitative evidence suggests that
hypertension to an ability to limit the healthcare providers working with older
impact of the condition. This review has adults who have hypertension have to
found some evidences that a diverse consider those factors that influence
range of patient-level influences, ability to self-manage. In order to
organizational-level influences, and facilitate further development of theory
community-level influences are for Asian older adults with hypertension,
associated with the individual’s ability to future studies should attempt replication
self-manage among Asian older adults among those with different backgrounds.
 Implications for practice and policy Hypertension self-management
Healthcare providers should provide should be considered a national focus in
more attention to individual by giving Asian countries, strengthening services
more chances for individual to discuss to assist older adults in managing their
their concerns and discussion needs to hypertension. Health policy to support
be sensitive to the social, cultural or national programs for improving
financial distinctions. Length of hypertension self-management and
appointment with healthcare provider is better hypertension control based on
an important aspect for supporting an local culture, financial characteristics,
individual to effectively self-manage and healthcare systems, and available
facilitate the needs of older adults with resources in Asian countries is needed.
hypertension and their confidence in Implications for further study
managing their condition. To promote the Future research in the area of self
individual incorporate hypertension self management should focus on developing
management into their daily life, exercise and testing a conceptual model based
and dietary recommendations should on the results of this review that can be
align with used to enhance hypertension
the individual’s social circumstances and self-management behaviors. Finally, to
cultural beliefs. In addition, convening contribute to long-term reduction in
support groups that peers led to hypertension-related mortality,
facilitate the sharing of ideas should be researchers should focus on how best to
provided to promote learning tailor interventions to improve
self-management strategies through self-management and should examine
other experiences. Innovative programs ways to extend and maintain
and initiatives that address these hypertension self-management practices
barriers warrant attention. among Asian older adults.

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factors among older people with

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