FACTORS RELATED TO HEALTH PROMOTING BEHAVIORS AMONG

HYPERTENSIVE PATIENTS IN BHUTAN

HEM KUMAR NEPAL

A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS

FOR THE MASTER DEGREE OF NURSING SCIENCE

(INTERNATIONAL PROGRAM)

FACULTY OF NURSING

BURAPHA UNIVERSITY

JULY 2015

COPYRIGHT OF BURAPHA UNIVERSITY

ACKNOWLEDGEMENT

I would like to express my sincere gratitude and deep appreciation to my

major advisor Assistant Professor Dr.Wanlapa Kunsongkeit and co-advisor

Dr. Khemaradee Masingboon for their continued guidance, support, encouragement,

and their time and effort during the entire period of this study. Without their help,

I would not have accomplished my goal.

I would like to send my great appreciation and heartfelt thanks to Thailand

International Development Cooperation Agency (TICA) and the Royal Government

of Bhutan for awarding me this scholarship to study Master of Nursing Science in

Burapha University. I would like to express my gratitude to the Dean, Faculty of

Nursing, Burapha University, and the Chairperson of Master of Nursing Science

(International Program) for giving me an opportunity to study Master of Nursing

Science Program in Burapha University. I am also thankful to all my lectures and

staff of Faculty of Nursing for rendering all possible support and assistance during my

study in Burapha University. I would like to express my gratitude to the experts, who

were involved in validating the research instrument, without their time and effort

I would not have completed my study.

I would like to express my gratitude to the Medical Director, Nursing

Superintendent, and nurses working in the Outpatient Department, Jigme Dorji

Wangchuck National Referral Hospital for rendering all possible help during my data

collection. Similarly, I would like to thank all the participants who participated in this

study. Gratitude remains in my heart for my parents, relatives and friends who have

always supported, encouraged and believed in me. Appreciation is especially

extended to my wife and two daughters for their patience and understanding for

the times I could not be with them. I am deeply sorry for the time we were apart.

Finally, I would like to extend my appreciations to all those who were

involved in accomplishing this project.

Hem Kumar Nepal

iv

56910102: MAJOR: NURSING SCIENCE, M. N. S.

KEY WORDS: PERCEIVED SELF-EFFICACY/ PERCEIVED

BENEFITS/ PERCEIVED BARRIERS/ PERCEIVED SOCIAL

SUPPORT/ HEALTH PROMOTING BEHAVIORS

HEM KUMAR NEPAL: FACTORS RELATED TO HEALTH

PROMOTING BEHAVIORS AMONG HYPERTENSIVE PATIENTS IN BHUTAN.

ADVISORY COMMITTEE: WANLAPA KUNSONGKEIT, Ph.D., KHEMARADEE

MASINGBOON, D.S.N. 96 P. 2015.

This descriptive correlational study aimed to describe health promoting

behaviors and to examine relationships among perceived self-efficacy, perceived

benefits, perceived barriers, perceived social support, and health promoting behaviors

in Bhutanese patients with hypertension. Conceptual framework of this study was

based on had Pender’s health promotion model. Simple random sampling technique

was used to recruit 123 primary hypertension patients visiting Jigme Dorji

Wangchuck National Referral Hospital, Thimphu, Bhutan. Data were collected by

self-report questionnaires. Which included demographic questionnaires, Health

Promoting Behaviors Questionnaires, Self-Rated Abilities for Health Practice Scale,

Benefits Assessment Scale, Barriers to Health Promoting Activities Scale, and Personal

Resource Questionnaire. Data were analyzed by descriptive statistics and Pearson’s

product moment correlation.

Findings revealed that participants had high level of health promoting

behaviors (M = 81.07, SD = 11.85). Health promotion behaviors had a high positive

correlation with perceived self-efficacy (r = .55, p < .01), had low positive correlation

with perceived benefits (r = .26, p < .01) and perceived social support (r = .27, p <

.05), and had moderate negative correlation with perceived barriers (r = -.47, p < .01).

From the results, health promotion behaviors could be enhanced by findings

of the study suggested that nurse can design nursing intervention to promote health

behaviors of hypertensive patients by focusing on strengthening self-efficacy and

decreasing perceived barriers.

CONTENTS

Page

ABSTRACT ............................................................................................................ iv

CONTENTS ............................................................................................................ v

LIST OF TABLES .................................................................................................. vii

LIST OF FIGURES ................................................................................................ viii

CHAPTERS

1 INTRODUCTION ...................................................................................... 1

Background and significance ................................................................ 1

Objectives of the study.......................................................................... 8

Research hypotheses ............................................................................. 9

Scope of the study ................................................................................. 9

Conceptual framework .......................................................................... 9

Definition of terms ................................................................................ 11

2 LITERATURE REVIEW ........................................................................... 13

Overview of hypertension ..................................................................... 13

The health promotion model ................................................................. 28

Factors related to health promotion behaviors of patients with

hypertension .......................................................................................... 30

Health promoting behaviors of Bhutanese patients with hypertension 33

3 RESEARCH METHODOLOGY ................................................................ 36

Research design .................................................................................... 36

Research setting .................................................................................... 36

Population and sample .......................................................................... 37

Research instruments ............................................................................ 38

Quality of instruments........................................................................... 40

Protection of human subjects ................................................................ 41

Data collection procedure ..................................................................... 42

Data analysis ......................................................................................... 43

vii

CONTENTS (CONTINUED)

CHAPTER Page

4 RESULTS ..................................................................................................... 44

Part 1 Description of demographic characteristics and medical

information of the participants .............................................................. 44

Part 2 Description of perceived self-efficacy, perceived benefits,

perceived barriers and perceived social support ................................... 48

Part 3 Description of health promoting behaviors of the participants .. 48

Part 4 Relationships between perceived self-efficacy, perceived

benefits, perceived barriers, perceived social support and health

promoting behaviors ............................................................................. 50

5 CONCLUSION AND DISCUSSION .......................................................... 51

Summary of the study ........................................................................... 51

Results of the study ............................................................................... 52

Discussion ............................................................................................. 53

Implications........................................................................................... 59

Recommendations for future research .................................................. 60

Conclusion ............................................................................................ 60

REFERENCES ....................................................................................................... 61

APPENDICES ........................................................................................................ 70

APPENDIX A ................................................................................................... 71

APPENDIX B ................................................................................................... 83

APPENDIX C ................................................................................................... 87

APPENDIX D ................................................................................................... 90

APPENDIX E ................................................................................................... 92

BIOGRAPHY ......................................................................................................... 96

viii

LIST OF TABLES

Tables Page

1 Frequency, percentage, mean, standard deviation of demographic

characteristics of the participants ............................................................... 45

2 Frequency, percentage, mean, standard deviation of medical information

of the participants ....................................................................................... 46

3 Mean, standard deviation, range of perceived self-efficacy, perceived

benefits, perceived barriers, and perceived social support ........................ 48

4 Mean, standard deviation, range of health promoting behaviors ............... 49

5 Pearson’s product moment correlation coefficient between health

promoting behaviors and related factors .................................................... 50

viiii

LIST OF FIGURES

Figures Page

1 Research framework of the study ............................................................... 11

2 Health promotion model ............................................................................. 29

CHAPTER 1

INTRODUCTION

Background and significance

Hypertension, also known as high or raised blood pressure, is a preventable

chronic disease affecting millions of people worldwide. Due to its increased

prevalence, morbidity, and mortality, hypertension is a global health problem.

According to World Health Organization [WHO] (2013), approximately 40 % of

adults aged 25 years and above were diagnosed with hypertension in 2008.

The number of people with hypertension has increased from 600 million in 1980 to

one billion in 2008, and it is projected to increase to 1.56 billion by 2025

(WHO, 2013). Bhutan, a country in South East Asia, with approximate population of

0.7 million people, is experiencing the double burden of communicable and

non-communicable diseases. Among the non-communicable diseases, hypertension is

the most important cause of an increasing number of strokes, heart attack and chronic

kidney diseases in Bhutanese adults (Wangdi, 2013). National Health Survey [NHS]

(2012) reported a 16 % prevalence of hypertension in Bhutan and the incidence of

hypertension has increased to 375/ 10,000 population in 2012 comparing to

303/ 10,000 population in the year 2008 (Annual Health Report, 2013).

Hypertension is defined as a Systolic Blood Pressure (SBP) more than

140 mmHg or a Diastolic Blood Pressure (DBP) more than 90 mmHg (WHO, 2013).

The major problem of hypertensive patients is inability to control their blood pressure

leading to devastating consequences. Hypertension that is not kept under control leads

to several complications like; stroke, myocardial infarction, hypertensive retinopathy,

hypertensive nephropathy and paralysis (American Heart Association [AHA], 2013;

Velagaleti & Vansan, 2007). Globally, cardiovascular disease accounts for

approximately 17 million deaths a year of which, complications of hypertension

account for 9.4 million deaths worldwide every year (WHO, 2013). Hypertension is

responsible for at least 45 % of deaths due to heart disease and 51 % of deaths due to

stroke (WHO, 2013). Beside, hypertension is responsible for increased number of

renal failure and other complications in patients. The prevalence of hypertension is

2

high in low and middle income countries, as a result many people are exposed to

dangerous complications of hypertension (Pereira, Lunet, Azevedo, & Barros, 2009;

Whitworth, 2003). The impact of hypertension leads to premature death, disability,

personal and family disruption, loss of income, and increased healthcare expenditure.

Further, families face catastrophic health expenditure and often push tens of millions

of people into poverty (World Health Organization [WHO], 2011).

Bhutan NHS (2012) reported 16 % prevalence of hypertension among adults

in Bhutan. Similarly, the non-communicable disease survey reported 26 % prevalence

of hypertension in the capital city Thimphu, Bhutan (Cowan, Dorji, & Pelzom, 2009).

Hypertension is responsible for a large number of strokes, heart attacks and chronic

kidney diseases. In 2014, the National Referral Hospital treated 105 cases with

complication of hypertension. The data from the National Referral Hospital shows an

overwhelming number of strokes and acute myocardial infarction with 89 patients

diagnosed with stroke and 12 patients with acute myocardial infarction in the year

2012 (Wangdi, 2013). Cardiovascular and cerebrovascular diseases account for

14.9 % of total morbidity and non-communicable diseases account for 50 % of

inpatient mortality (Giri, Sharma, Chapagai, & Pelzom, 2013). It shows that the risk

of complications among hypertensive population is increasing.

Hypertension is a chronic condition and cannot be control by medications

alone. According to Joint National Committee on Prevention, Detection, Evaluation,

and Treatment of High Blood Pressure [JNC 7] (2003), the gold standard of treatment

for hypertension includes medication and life style modification, which are integral

part of treatment recommended by the physicians to prevent complications and in

enhancing quality of life. Lifestyle modifications are healthy activities that can

enhance ones quality of life and aid in the prevention of cardiovascular disease.

Effective lifestyle modifications are the most important part of management of

chronic disease including hypertension (WHO, 2013). Practicing healthy behaviors

and avoiding harmful habits promotes one’s health and wellbeing.

Health promoting behaviors, defined as self-initiated and enduring actions,

based on an active approach, that serve to maintain or enhance the level of personal

wellness (Walker, Sechrist, & Pender, 1987). Health promoting behaviors are integral

part of treatment for patients with hypertension and must be integrated as a regular

3

part of patient’s daily living (WHO, 2011). In terms of hypertension, health

promoting behaviors include; taking medication, physical activity, nutrition, stress

management, limiting alcohol consumption, weight management, and smoking

cessation (JNC 7, 2003; Lee et al., 2010). Engagement in health promoting behavior

is considered useful strategies to enhance functional capacity, prevent complications,

improve social networks and enhance quality of life (Pender, Murdaugh, & Parsons,

2006). Several studies have demonstrated positive effects of healthy behaviors on

hypertension control and in improving health of individuals with hypertension

(Joint National Committee on Prevention, Detection, Evaluation, and Treatment of

High Blood Pressure [JNC 8], 2014). Research on the effects of diet and nutrition on

health, has demonstrated that by maintaining a diet with more fruits and vegetables,

low in sodium, and low in fat is effective in controlling blood pressure and preventing

cardiovascular disease (Appels et al., 2006; Huang, Duggan, & Harman, 2008).

Dietary approaches to stop hypertension (DASH) diet is effective in lowering on an

average 11 mmHg systolic blood pressure and 5.5 mmHg diastolic blood pressure in

hypertensive patients (Appel et al., 1997; Appel et al., 2006). Similarly, reducing

dietary intake of sodium to 2.4 grams per day can lower systolic blood pressure by

4-5 mmHg in hypertensive individuals and 2 mmHg in normotensive individuals

(Huang et al., 2008).

The impact of physical activity is associated with improving health in people

of all ages. Regular physical activity has many health benefits including decreasing

the risk of cardiovascular diseases, obesity, and diabetes. According to research and

recommendation from the Centers for Disease Control and Prevention [CDC] (2011),

it is suggested that people with hypertension perform moderately intense exercise

30 minutes a day, most days of the week. Research has shown that 30 minutes of

exercise a day can lower systolic blood pressure by 4-9 mmHg (Chobanian et al.,

2003). For those who drink alcohol, reduction in drinking can reduce systolic blood

pressure by 4 mmHg and diastolic blood pressure by 2.5 mmHg (Centers for Disease

Control and prevention, National Institute of Health, 2000; Chobanian et al., 2003).

Research has proven that all types of tobacco have negative effects on the body.

Smoking increases the risk of cardiovascular diseases, and is damaging to one’s

health. Similarly, research has shown that, weight reduction of 5-10 kg and

4

maintaining a normal Body Mass Index (BMI) under 25 can decrease systolic blood

pressure by 5-20 mmHg (American Heart Association, 2005; Chobanian et al., 2003).

Furthermore, taking regular medications and appropriate stress management helps

individual to control blood pressure (Sharma, Kulkarni, Mishra, & Srivastava., 2013).

Although health promoting behaviors are widely accepted to benefit

individuals with hypertension, the practice is limited in people with hypertension

(Lee et al., 2010; Viera, Kshirsagar, & Hinderliter, 2008; Warren-Findlow, Seymour,

& Huber, 2012). Studies suggested that long-term reduction of 5-6 mmHg in blood

pressure is associated with 35-40 % fewer strokes and 20-25 % less coronary heart

diseases (Collins et al., 1990). The JNC 7 report showed that a decrease of systolic

blood pressure by 5 mmHg would result in a 14 % reduction in mortality due to

stroke, 9 % reduction in mortality due to coronary heart diseases, and a 7 %

decrease in all-cause mortality (Chobanian et al., 2003). However, despite known

benefits, many people do not comply with suggested recommendations and often fails

to improve their behavior, to control their blood pressure (Chobanian et al., 2003).

A study by Warren-Findlow et al. (2012), found only 52.2 % of people with

hypertension adhered to prescribed physical activities recommendation. Practices

related to weight management was less frequent, (30.1 %) and adherence to low-salt

diet recommendations was also low (22.0 %). In Bhutan, according to the report on

Survey for Risk Factors and Prevalence of Non-communicable Diseases in Thimphu,

two third of the population (66.6 %) were not eating enough fruits and vegetables, and

58.6 % do not attain a minimum requirement of health enhancing physical activities

(Cowan et al., 2009). Thus, one of the most important roles for nurses is to help

individuals with hypertension to improve their health promoting behaviors and

improve quality of life.

Health promoting behaviors are one of the integral parts of therapy to

control hypertension and prevent complications (Chobanian et al., 2003). In order to

help patients improve their ability to control blood pressure, nurses need to

understand the theory and the associated factors related to health promoting

behaviors. The health promotion model (Pender, Murdaugh, & Parsons, 2011), has

been used as a framework for research aimed at examining health-promoting lifestyle

behaviors. Within health promotion model, health promoting behavior is

5

an expression of the human tendency to actualize and is directed at elevating

the individual’s level of well-being, enhancing self-actualization, and maximizing

personal fulfillment (Pender et al., 2006). There are three major concepts in Pender’s

health promotion model. The major concepts are individual characteristics and

experiences, behavior-specific cognitions and affect, and behavioral outcome.

According to Pender et al. (2011), the model proposed that performing health

behaviors can be achieved through the direct and indirect effects of factors. Perceived

self-efficacy is the judgment of personal capability to organize and execute

a particular health behavior; perceived benefits of action are the positive perception of

individual to undertake or reinforce a health behavior; perceived barriers to action are

perceptions of blocks, hurdles, personal costs of undertaking a specific health

behavior; interpersonal influences includes norms, social support, role models

perceptions concerning the behaviors, beliefs, or attitudes of relevant others in regard

to engaging in a specific health behavior; and health promoting behavior is identified

as the ultimate outcome of the model. Perceived self-efficacy, perceived benefits,

perceived barriers, and perceived social support, were chosen as variables for

the study based on the literature review.

Number of studies indicated that these factors affect health promotion

behaviors of hypertensive patients (Ho, Pathumarak, & Hengudomsub, 2012;

Kemppainen et al., 2011; Kwong & Kwan, 2007). However, factors studied in other

countries may not be generalized to the Bhutanese population, with diverse and

unique cultural and traditional values. In Bhutan, traditional Bhutanese dietary

behavior is more likely unhealthy including fat-rich and spicy. Rice forms the staple

diet with meat, poultry, cheese, chilies, and is often salty and spicy. People also prefer

rice with locally made pickle with added salt and butter tea locally called as suja and

is widely taken as breakfast. Further, Bhutan being a mountainous country,

geographical barrier and climatic condition may indicate some restrain in practicing

health promoting behaviors (Cowan et al., 2009). People often face difficulty in

getting recommended food items primarily due to unavailability of resources. An

extreme weather condition like cold winters and rainy summer seasons also inhibits

people from practicing health promoting behaviors. Cold winter months are usually

considered as inactive months during which people are inactive and often use alcohol

6

as a source of warmth exposing them to unhealthy behaviors. Further, Bhutan has four

seasons and finding suitable foods like fruits and vegetables is limited. Therefore, it is

necessary to understand the behavior and identify factors related to health promotion

in patients with hypertension in Bhutan.

A number of studies found that perceived self-efficacy is associated in

initiating behavior change and to develop healthy behavioral practice among patients

with hypertension. Perceived self-efficacy, the confidence of individuals in

performing a specific behavior is one of the most important factors influencing health

promotion behaviors in people with hypertension. Self-efficacy provides

the confidence to overcome barriers, whereas outcome expectations provide

the motivation for behavior (Bandura, 1997). In a study of older Chinese perceived

self-efficacy was positively related (r = .57, p < .001) to health promoting behavior

(Kwong & Kwan, 2007). Jaiyungyuen, Suwonnaroop, Priyatruk, and Moonpayak

(2008) found similar result, where self-efficacy had positive relationship (r = .59, p <

.01) with health promoting behaviors in population of Thai people with hypertension.

In study of 445 middle aged Korean Americans with hypertension, self-efficacy

contributed significantly and was the highest predictor (β = .25) of physical activity

and diet (Lee et al., 2010). Similarly, in the study of the association between

perceived self-efficacy and health behaviors of 190 African-American adults with

hypertension, the result demonstrated that people with high perceived self-efficacy

had higher prevalence of engaging in physical activities and eating low salt diet

(Warren-Findlow et al., 2012). Perceived self-efficacy has shown to be the strongest

factor associated to health promotion behaviors in hypertensive patients.

Understanding the relationship of health promoting behaviors and perceived self-

efficacy in Bhutanese patients with hypertension is not yet available. Therefore, to

understand and confirm relationship between self-efficacy and health promoting

behavior in Bhutanese population is necessary.

Perceived benefits are mental representations of positive or reinforcing

consequences of a behavior (Pender et al., 2011). Individual’s expectations to engage

in a particular behavior depend on the anticipated benefits. Perceived benefits directly

and indirectly motivate behavior through determining the extent of commitment to

a plan of action to engage in behaviors. Hypertensive patients get benefits from health

7

promoting behaviors because it reduces blood pressure and prevent complications.

In a study of 198 hypertensive patients, the result indicated that perceived benefits

significantly related (r = .27, p < .01) to health promoting behaviors (Nangyaem,

Deenan, & Chunlestskul, 2007). The benefits hypertensive patients get from health

promotion behavior are reduced blood pressure, loss weight, being healthy and

improved quality of life. Preventing complications, improving quality of life,

controlling weight, being fit and live longer are some of the benefits acquired from

health promoting behaviors.

Perceived barriers are viewed as blockages, hurdles, and personal costs to

perform a specific type of behaviors. When individuals come across difficulties, they

are confronted with doubts about their ability to perform a specific behavior (Pender,

et al., 2006). Lucas, Orshan, and Cook (2000), as cited in Kwong and Kwan (2007)

have identified several barriers such as, fear of harming oneself, lack of self-

motivation, lack of knowledge, the cost and require effort of activities, and lack of

support from family and significant others. There are wide range of barriers to health

promoting behaviors. The individual knowledge and beliefs that hypertension runs in

the family and nothing could be done are some of the common examples cited in the

literature (AHA, 2013). In several studies it was found that, the common barriers in

health promotion to control hypertension were time and budgetary constraints, lack of

motivation, and social influences (Khatib et al., 2014). The above studies show

relationship between perceived barriers and health promoting behaviors. However, in

Bhutanese context, there is still no information and study done. Thus, it is necessary

to understand and find the relationship.

Perceived social support play a very significant role in health promotion

behavior. Perceived social support acts as a protective mechanism of health promoting

behaviors. Loss of social support exposed individuals to variety of diseases and

reduce individuals ability to engage in health promoting behaviors to manage diseases

and improve health (Pender et al., 2011). Social influence is critical, as individuals

consider engaging in health promoting behaviors. Previous studies showed that

perceived social support was the determinant to enhance health promoting behaviors

among patients with hypertension. Jaiyungyuen et al. (2008) in study of older people

with hypertension found that social support was positively related to health promotion

8

behavior in hypertensive patients (r = .38, p < .01). Similar study found that social

support was significant predictor of health promotion behavior (β = .27, p < .01) in

adult patients with hypertension (Ho et al., 2012). Further, similar study in low

income women with hypertension found that social support had positive relation

(r = .44, p < .001) with health behaviors (Yang, Jeong, Kim, & Lee, 2014).

Furthermore, understanding the role of social support and health promoting behaviors

among Bhutanese people with hypertension still needs to be explored.

In conclusion, health promoting behaviors are crucial to optimize health of

hypertensive patients by identifying factors affecting health promotion behaviors.

Although perceived self-efficacy, perceived benefits, perceived barriers and perceived

social support, are widely studied, and discussed in the literature, little or no

information is available in context to the Bhutanese population with hypertension.

In fact, no study has been carried out till date in Bhutan to understand the factors

related to health promoting behaviors in hypertensive patients. Further, with

difference in culture, values, beliefs, physical, and social characteristics of Bhutanese

population with hypertension, the findings from other studies may not be same with

Bhutanese population. This lack of information in relation to hypertensive population

suggested investigation, in order to develop effective nursing intervention.

Understanding the relationships of factors to health promoting behaviors would

provide a deeper insight for the nursing professionals and other health care providers

to develop effective nursing strategies to help individuals with hypertension to engage

in health promotion to control hypertension and prevent complications.

Objectives of the study

The objectives of this study were:

1. To describe the health promoting behaviors of patients with hypertension

in Bhutan.

2. To examine the relationships of perceived self-efficacy, perceived

benefits, perceived barriers, and perceived social support on health promoting

behaviors of Bhutanese patients with hypertension.

9

Research hypotheses

Health Promotion Model of Pender et al. (2011) was used as a theoretical

base for this study, and the hypotheses were as follows:

Hypotheses 1 There is a positive relationship between perceived self-

efficacy and health promoting behaviors among Bhutanese patients with hypertension.

Hypotheses 2 There is a positive relationship between perceived benefits and

health promoting behaviors among Bhutanese patients with hypertension.

Hypotheses 3 There is a negative relationship between perceived barriers

and health promoting behaviors among Bhutanese patients with hypertension.

Hypotheses 4 There is a positive relationship between perceived social

support and health promoting behaviors among Bhutanese patients with hypertension.

Scope of the study

The proposes of the study were to describe the health promoting behaviors

of hypertensive patients in Bhutan, and to examine the relationships of perceived

self-efficacy, perceived benefits of action, perceived barriers to action, and perceived

social support on health promoting behaviors of Bhutanese patients with

hypertension. The population of this study included 123 patients with hypertension

visiting medical outpatient department at Jigme Dorji Wangchuck National Referral

Hospital (JDWNRH), Thimphu, Bhutan. The study was conducted in February and

March 2015. Variables for the study include perceived self-efficacy, perceived

benefits of action, perceived barriers to action, perceived social support, and health

promoting behaviors.

Conceptual framework

Pender’s Health Promotion Model (2011) was used to guide this research.

The Health Promotion Model has been used as a framework for research aimed at

examining health promoting behaviors. In this study, health promoting behaviors of

hypertensive patients include taking medication, physical activity, nutrition, stress

management, limiting alcohol consumption, weight management, and smoking

10

cessation. These behaviors are viewed as health promoting behaviors and must be

integrated into daily living.

According to Health Promotion Model (Pender et al., 2011), the success of

motivating individuals to maintain and enhance health promoting behaviors depends

on numerous factors through the direct and indirect effects of factors. Perceived

self-efficacy, perceived benefits of action, perceived barriers to action, and perceived

social support are variables within the concept of behavior specific cognition and

affect and are considered to have major motivational influence on health promoting

behaviors. Perceived self-efficacy is one of the variables in behavior-specific

cognition that affects the health promotion model and is considered the major

motivation for performing health behaviors. Perceived benefits are proposed to

directly and indirectly motivate behavior through determining the extent of

commitment to a plan of action to engage in health promoting behaviors. Perceived

barriers are obstacles that inhibit involvement of an individual in health promoting

behaviors. Anticipated barriers have been found to affect intentions to engage in

particular behavior. Similarly, social environments are known to affect health

promoting practices in people with hypertension and include support from significant

others. These variables have major motivational significance within the health

promotion model and are considered modifiable through interventions.

The relationship between perceived self-efficacy, perceived benefits, perceived

barriers, and interpersonal influences on hypertension and health promoting behaviors

in Bhutanese patients may be demonstrated by using the health promotion model.

Therefore in this study, the researcher used the Pender’s health promotion

model (2011) as a research framework to examine the relationships between

perceived self-efficacy, perceived benefits of action, perceived barriers to action, and

perceived social support as independent variables and health promoting behaviors as

dependent variable. The research framework for this study is shown in Figure 1.

11

Figure 1 Research framework of the study

Definition of terms

Hypertensive patient

Hypertensive patient is defined as individual with primary hypertension as

diagnosed by physician with a systolic blood pressure of more than 140 mmHg or

a diastolic blood pressure of more than 90 mmHg, or taking antihypertensive

medication.

Health promoting behaviors

Health promoting behaviors were defined as enduring activities that

hypertensive patients performed to manage hypertension and enhance the level of

personal wellness. Health promoting behaviors included; taking medication, physical

activity, nutrition, stress management, weight management, smoking cessation, and

limiting alcohol consumption. Health promoting behaviors were measured by health

promoting behaviors questionnaires which were developed by the researcher.

Perceived self-efficacy

Perceived self-efficacy referred to the confidence in ability of hypertensive

patients to perform specific health promoting behaviors to manage hypertension.

Specific health promoting behaviors referred to nutrition, psychological well-being,

exercise and health responsibility. Perceived self-efficacy was measured by Self

Rated Abilities for Health Practice Scale developed by Becker, Stuifbergen, Oh, and

Hall (1993).

Health Promoting Behaviors

Perceived self-efficacy

Perceived barriers to action

Perceived social support

Perceived benefits of action

12

Perceived benefits of action

Perceived benefits of action were perceptions of hypertensive patient that

performing health promoting behaviors would help them to control blood pressure

and prevent complications. Perceived benefit of action was measured by the Benefits

Assessment Scale developed by Murdaugh and Verran (1987).

Perceived barriers to action

Perceived barriers were hypertensive patient’s perceptions of obstacles that

inhibit them to practice health promoting behaviors. Perceived barriers to health

promotion include inconvenience, lack of time, expensive, and lack of support.

Perceived barriers were measured by Barriers to Health Promoting Activities Scale

developed by Becker et al. (1993).

Perceived Social support

Perceived social support was defined as hypertensive patient’s perception of

attachment, social integration, nurturance, reassurance of worth, and availability of

assistance from others in managing hypertension. Perceived social support was

measured by Personal Resource Questionnaire (PRQ 2000) developed by Weinert

(2003).

13

CHAPTER 2

LITERATURE REVIEW

In this chapter, the researcher reviewed literature covering hypertension,

health promoting behaviors and factors related to health promoting behaviors.

The researcher reviewed concepts of hypertension and impacts of hypertension to

individuals, family, and community. The order of presentation is as follows:

1. Overview of hypertension

1.1 Definition of hypertension

1.2 Classification of hypertension

1.3 Pathophysiology of hypertension

1.4 Complications of hypertension

1.5 Impact of hypertension

1.6 Management of hypertension

2. Pender’s health promotion model

3. Factors related to health promoting behaviors of patients with

hypertension

3.1 Perceived self-efficacy

3.2 Perceived benefits of action

3.3 Perceived barriers to action

3.4 Perceived social support

4. Health promoting behaviors of Bhutanese patients with hypertension

Overview of hypertension

Hypertension is a global health problem. According to WHO (2013),

approximately 40 % of adults aged 25 years and above were diagnosed with

hypertension in 2008. The number of people with hypertension has increased from

600 million in 1980 to one billion in 2008, and it is projected to increase to

1.56 billion by 2025 (WHO, 2013). Hypertension is a major problem responsible for

at least 45 % of deaths due to heart disease and 51 % of deaths due to stroke (WHO,

2013).

14

1. Definition

Hypertension or high blood pressure is understood as the force exerted by

the blood on the walls of the arteries, when the heart pumps the blood from the left

ventricle (AHA, 2007 as cited in Philips, 2014). The Seventh Report of the Joint

National Committee on Prevention and Detection of High Blood Pressure (JNC 7,

2003), and the WHO provides appropriate definitions to understand hypertension

which are popularly used all over the world. According to the JCN 7 (2003) report,

classification of hypertension is based on the mean of two or more seated blood

pressure readings, on two or more consecutive office visits (AHA, 2013; CDC, 2011;

Chobanian et al., 2003). According to WHO (2013), hypertension is defined as

a Systolic Blood Pressure (SBP) of 140 mmHg or more, Diastolic Blood Pressure of

(DBP) of 90 mmHg or more or taking antihypertensive medication. The definition

provided by the JNC 7 (2003) report provides clear information as it is represented

with the classification of hypertension based on the blood pressure reading for adults

older than 18 years and is classified according to the stage as:

Normal: Systolic lower than 120 mmHg, diastolic lower than 80 mmHg.

Pre-hypertension: Systolic 120-139 mmHg, diastolic 80-89 mmHg.

Stage 1: Systolic 140-159 mmHg, diastolic 90-99 mmHg.

Stage 2: Systolic 160 mmHg or greater, diastolic 100 mmHg or greater.

Therefore, hypertension among adult is a sustained systolic or diastolic

blood pressure greater than 139/89 mmHg. The systolic reading between

120-139 mmHg and diastolic blood pressure between 80-89 mmHg is termed as

pre-hypertension, as this reading usually provides the opportunity to involve

individuals in health promotion to improve blood pressure control (JNC 7, 2003).

As per the JNC 7 guidelines, Stage 1 hypertension is now a systolic blood pressure

between 140-159 mmHg and diastolic between 90-99 mmHg. Stage 2 hypertension is

a systolic blood pressure greater than 160 mmHg or diastolic greater than

100 mmHg. Treatments at each stage depend on compelling indications. These

include heart failure, post-myocardial infraction, diabetes, chronic kidney disease,

high coronary disease risk, or recurrent stroke prevention (Chobanian et al., 2003).

It is important to note that the JNC 7 has introduce the term pre-hypertension, which

is used to classify individuals with systolic blood pressure of 120-139 mmHg and

15

diastolic blood pressure of 80-89 mmHg. The goal of the new classification is to

identify individuals at risk to be hypertensive and provide an opportunity for health

care providers for early interventions by promoting their behaviors (JNC 7, 2003).

2. Classification of hypertension

Hypertension is classified as primary hypertension and secondary

hypertension. Primary hypertension is the most common type of hypertension and

represents 90-95 % of all cases of hypertension (Chobanian et al., 2003; Eckman &

Kirk, 2013; Hajjar & Kotchen, 2003). The specific cause to explain primary

hypertension is unknown and yet no single specific cause has been identified.

However, several genetic and environmental factors could contribute to this

phenomenon. Its pathogenesis is believed to be the interaction between genetic and

environmental or lifestyle factors (Fagard, 2005). Further, environmental and lifestyle

factors have been identified to explain an elevated blood pressure and include

increased consumption of sodium, alcohol and caloric intake, stress and physical

inactivity (Adeniyi, Idowu, Ogwumike, & Adeniyi, 2012; CDC, 2011). Primary

hypertension has no definite cause, or clear identifiable etiology, which differentiates

it from the secondary hypertension, in which the blood pressure elevation occur

secondary to identifiable cause.

Approximately 5-10 percent hypertension cases are due to identifiable

causes with renal diseases being the most common contributor to 2.5- 6 % of all

causes of secondary hypertension (Catala-Lopez, Sanfelex- Gimeno, Garcia-Torris,

Ridao, & Periso, 2012; O'Brien, Beevers, & Lip, 2007). Other causes of secondary

hypertension include; endocrine conditions, such as Cushing’s syndrome,

hyperthyroidism, hypothyroidism, acromegaly, hyperaldosteronism,

hyperparathyroidism and pheochromocytoma (O’Brien et al., 2007). Other causes

contributing to secondary hypertension include obesity, sleep apnea, and pregnancy,

certain prescription medicines, herbal remedies and illegal drugs (Eckman & Kirk,

2013).

3. Pathophysiology of hypertension

In the present study, pathophysiology of hypertension was focused on

primary hypertension. The pathogenesis of primary hypertension is multifactorial and

highly complex (Gandhi et al., 2001). Multiple factors modulate the blood pressure

16

for adequate tissue perfusion and include humeral mediators, vascular reactivity,

circulating blood volume, vascular caliber, blood viscosity, cardiac output, blood

vessel elasticity, and neural stimulation. A possible pathogenesis of essential

hypertension has been proposed in which multiple factors, including genetic

predisposition, excess dietary salt intake, and adrenergic tone, may interact to cause

hypertension. Although genetics appears to contribute to essential hypertension,

the exact mechanism has not been established. The pathophysiology mechanisms of

hypertension are as follows:

3.1 Genetic factors

Primary hypertension is a complex, multifactorial, with genetically

determined characteristics contributing to between 30 % and 50 % of the variation in

blood pressure among individuals (Ward, 1990 as cited in Dominiczak, Negrin, Clark,

Brosnan, & Alexander, 1999). About 50 % of the patients with family history of high

blood pressure or history of premature death in the family are at greater risk of

developing hypertension (O’Brien et al., 2007). The exact identification of

hypertension and genes has not been clear because of the multifactorial nature of the

disease and the presence of many major pathogenetic pathways. Major genes that

cause primary hypertension are yet to establish. Although a number of individual

genes and genetic factors have been linked to the development of primary

hypertension, it is likely that multiple genes contribute to the development of the

disease in any given individual. It is extremely difficult to accurately determine the

relative contributions of each of these genes. However, genetic factors probably play a

role in the alterations of various physiologic parameters that have been identified in

hypertensive patients (Rana et al., 2007).

3.2 Cardiac output and peripheral resistance

Regulation of normal blood pressure is a complex process and is

a product of cardiac output and peripheral vascular resistance. The balance between

the cardiac output and peripheral vascular resistance is essential to maintain normal

blood pressure. Cardiac output is the volume of blood flowing through systemic or

pulmonary circulation in a minute. An increase in cardiac output without a decrease in

peripheral resistance will cause both arterial volume and arterial pressure to increase

(Huether & McCance, 2012). Peripheral resistance is determined by both large

17

arteries and the capillaries and small arterioles and found in some young individuals

with borderline hypertension. Most patients with primary hypertension have increased

peripheral vascular resistance and a normal cardiac output. The cardiac output may be

increased in the early stages of primary hypertension, where peripheral resistance

slowly increases in order to maintain normal tissue perfusion. As the hypertension

progress, the left ventricular function diminishes, as a result the cardiac output is

decreased and the blood pressure is maintained by the increase in peripheral vascular

resistance (Beevers, Lip, & O’ Brien, 2007).

3.3 Renin-angiotensin-aldosterone

The renin-angiotensin-aldosterone system is the main systems that affect

the blood pressure control. Renin is secreted from the juxtaglomerular apparatus of

the kidneys in response to glomerular hypo-perfusion as a result of reduce salt intake

or due to stimulation from the sympathetic nervous system. Renin is responsible for

converting angiotensinogen to angiotensin I. Angiotensin I then is transformed into

angiotensin II by Angiotensin Converting Enzymes (ACE). Angiotensin II is a potent

vasoconstrictor and thus, causes a raise in blood pressure. It may also cause some of

the manifestation of hypertensive target organ damage, like left ventricular

hypertrophy and atherosclerotic vascular disease. In addition it stimulates the release

of aldosterone from the zona glomerulosa of the adrenal gland, which further results

in raised blood pressure related to sodium retention (Beevers et al., 2007). However,

the renin- angiotensin system is not responsible directly for the increase in blood

pressure in patients with primary hypertension. Many patients with hypertension have

low levels of circulating endocrine renin and angiotensin II. In these patients the drugs

that block the renin-angiotensin-aldosterone system is less effective (Beevers et al.,

2007).

3.4 Autonomic nervous system

Autonomic nervous system is another factor contributing to development

of hypertension. It has an important role in maintaining a normal blood pressure

because its stimulation causes both arteriolar constriction and dilatation.

The autonomic nervous system mediates the short term changes in blood pressure in

response to stress and physical activity (Beevers et al., 2007). Thus, has an important

role in maintaining a normal blood pressure.

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4. Complications of hypertension

Complication of hypertension are the outcome of persistent elevation of

blood pressure and is a major risk factor for various complications to vital organs like;

heart, brain, kidney, blood vessels and eyes (White, 2009). The major complications

includes

4.1 Cardiac complication of hypertension

Hypertension is the most important risk factor for premature

cardiovascular disease and accounts for 47 % of all ischemic heart disease globally

(Lawes, Vander, & Rodgers, 2008). Uncontrolled and prolonged blood pressure

elevation can lead to changes in the myocardial structure, coronary vasculature, and

conduction system of the heart, leading to the development of Left Ventricular

Hypertrophy (LVH). Other complications include coronary artery disease, and

systolic and diastolic dysfunction of the myocardium, which manifest clinically

as angina or myocardial infarction. In addition, the increased size of heart muscle

increases the oxygen demand and impaired the contractibility of the heart, resulting in

systolic heart failure (Huether & McCance, 2012).

Atherosclerotic coronary artery or micro vascular disorder, or cardiac

arrhythmias are often seen as cardiac complications of hypertension. Left ventricular

hypertrophy in patients with hypertension could be the result of sudden death and

manifestation of stroke in patients with hypertension. In hypertensive patients,

abnormalities of diastolic function, which range from asymptomatic heart disease to

heart failure, are commonly seen (Verma & Solomon, 2009). Diastolic dysfunction is

an early consequence of hypertension related heart disease and is exacerbated by left

ventricular hypertrophy and ischemia (Fukuta & Little, 2007).

4.2 Cerebral complication of hypertension

Blood pressure is a powerful determinant of risk for ischemic stroke and

intracranial hemorrhage. In fact, long-standing hypertension may manifest as

hemorrhagic and atheroembolic stroke or encephalopathy. Both the high systolic and

diastolic pressures are harmful; a diastolic pressure of more than 100 mmHg and

a systolic pressure of more than 160 mmHg are associated with a significant incidence

of strokes (AHA, 2013). Hypertension accounts for an estimated 54 % of all strokes

events globally (Lawes et al., 2008). The stroke events increase with raising systolic

19

blood pressure levels in individuals more than 65 years. Development of

atherosclerosis and hypertension affects the arteries whereby, decreasing the flow of

blood or ruptured of weak blood vessels within the brain resulting in stroke. The risk

for transient ischemic attacks and the incidence of any type of stroke including

ischemic stroke and intracerebral hemorrhage are greater in person with hypertension

comparing to individuals with normal or borderline hypertension (Rigaud, Seux,

Staessen, Birkenhager, & Forette, 2000). Further, hemorrhagic stroke results in

increased morbidity and mortality.

4.3 Renal complication of hypertension

Hypertension is responsible for renal complications in people with

hypertension and is related to systolic blood pressure (Marín, Gorostidi, Fernández-

Vega, & AlvarezNavascués, 2005). The complications of hypertension include

parenchymal damage, nephron sclerosis, renal arteriosclerosis and renal insufficiency

or failure. The early signs of renal complication include micro albuminuria, in

10-15 % of individuals with primary hypertension. The artherosclerotic, hypertension

related vascular lesions, in the kidneys primarily affects the pre-glomerular arterioles,

resulting in ischemic changes in the glomeruli and post glomerular structures.

Damage to glomerulus allows large molecules of protein to pass through to the urine

in presence of proteinuria and is reflective of increased glomerular permeability and

an early sign of hypertensive renal injury. If intervention for blood pressure control is

not initiated, it leads to renal impairment and finally to end stage renal disease (Marín

et al., 2005).

4.4 Retinal complication of hypertension

Hypertensive retinopathy is complication associated with loss of vision,

and is characterized by retinal vascular changes including alteration of light reflexes,

retinal hemorrhage, retinal edema, and blurred disc margin (Wong & Mitchell, 2004).

When the blood pressure increases, the retinal circulation responds by changing

pathophysiology. Vasospasm and increased retinal arteriolar tone owing to local

auto-regulation is seen in the beginning. Persistent elevation of blood pressure

disrupts blood-retina barrier leading to necrosis of smooth muscles and retinal

ischemia. These changes are manifested in the retina as micro aneurysms,

hemorrhage, and cotton-wool spots (Wong & Mitchell, 2004). Atherosclerosis also

20

contributes to the retinal injury produce by hypertension, resulting in retinal

detachment leading to blindness (Eckman & Kirk, 2013).

Complication of hypertension, such as heart failure, strokes, renal failure

and hypertensive retinopathy leads to serious impact on the individual patients, their

families and the community.

5. Impacts of hypertension

Hypertension is the most important risk factors for premature cardiovascular

diseases and accounts for approximately 54 % of all strokes and 47 % of all ischemic

heart disease events globally (Lawes et al., 2008). Complications of hypertension

account for 9.4 million deaths worldwide every year (WHO, 2013). Hypertension is

responsible for at least 45 % of deaths due to heart disease and 51 % of deaths due to

stroke (WHO, 2013). In the United States, 77.9 million that is, 1 in every 3 adults

have hypertension and contributes nearly 1000 deaths per day which are preventable

and the number is more in developing countries (AHA, 2013; Philips, 2014).

These devastating consequences of hypertension have several impacts on individual,

family, health care system and nation as a whole.

5.1 Impact of hypertension on individual

Since there are no symptoms associated with hypertension and is

considered as a “silent killer” (AHA, 2013). People often do not seek medical care,

leaving it undetected and untreated. Further, it is recognized only when complications

has already occurred. The presence of hypertension causes serious problems affecting

the quality of life of individuals with hypertension. The major complications

associated with hypertension include; coronary heart disease, stroke, heart failure,

chronic kidney disease, visual problems and peripheral vascular diseases. The risk of

coronary disease and stroke increases with age above 60 years and is significant factor

for mortality (JNC 7, 2003). Mild to moderate hypertension, if left untreated, is

associated with a risk of atherosclerotic disease in 30 % of people and organ damage

in 50 % of people within 8-10 years after onset. Death from ischemic heart disease

and stroke increases progressively as BP increases. For every 20 mmHg systolic or

10 mmHg diastolic increase in BP above 115/ 75 mmHg, the mortality rate for both

ischemic heart disease and stroke doubles (Chobanian et al., 2003). Hypertension

21

affects individual’s work, their activities of daily living, and quality of life resulting in

poor income and low socioeconomic status.

5.2 Impact on family

Hypertension is responsible for increased number of renal failure and

other complications in patients with hypertension. Treatment for the complication of

hypertension usually are costly and requires long term therapy like dialysis to

sustained living with decreased quality of life. Prolonged and costly treatment results

in draining individual and government budgets. The impact of hypertension leads to

premature death, disability, personal and family disruption, loss of income, and

increased healthcare expenditure. Further, families face catastrophic health

expenditure and often push tens of millions of people into poverty (WHO, 2011).

Hypertension as a chronic illness requires prolonged care resulting in increased health

care expenditure affecting the entire family. Further caring patient with complication

of hypertension will impose a greater burden to the family, as they are constantly

exposed to stress and other health related behaviors, risking their own health.

5.3 Impact on health system

Managing hypertension and its resultant complications constitutes

a great financial burden on individual patient, family, and the health system in many

countries. These costs are usually borne by the individuals, governments, and

the private sector (Gaziano, 2008). Further, hypertension often is associated with

other co-morbid conditions, where it further increases the costs of managing

the disease. The direct and indirect costs of hypertension in the United States is

estimated to be more than $93.5 billion per year, and that cardiovascular disease and

stroke account for 17 % of the total health expenditures annually (Heidenreich,

Trogdon, & Khavjou, 2011). The impact of hypertension to each individual, family

and the community are large. It costs a lot of financial implications at every stage of

disease progression and treatment. Therefore, early management of high blood

pressure by participating in health promotion becomes an important step in preventing

complications. Thus, reducing the burden and negative impact to individual, family

and the community.

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6. Management of hypertension

Not all patients diagnosed with hypertension needs medication. Individuals

with medium to high risk of developing cardiovascular complications need one or

more essential medicines to lower their blood pressure (JNC 8, 2014). As per

the recommendation of the JNC 7 (2003), the management of hypertension includes

pharmacological and non-pharmacological.

6.1 Pharmacological management

Pharmacological management by taking prescribed medication is of

immense importance for hypertensive individuals in controlling blood pressure

(JNC 7, 2003; WHO, 2013). Individuals need to take medications according to

the recommendations from the health care provider and must continue irrespective of

the blood pressure reading. All antihypertensive medications have their own

mechanism of actions which influences on blood pressure. Medications influence

blood pressure by increasing excretion of sodium and water and reducing cardiac

output. Regular medications are associated with blood pressure control and reduce

complications of hypertension (WHO, 2013). Pharmacological management includes

a number of drugs, which are currently available for hypertension treatment. There are

seven main groups of antihypertensive drugs use for the treatment of hypertension and

are classified below:

6.1.1 Thiazide diuretics are used as monotherapy, or they can be

administered adjunctively with other antihypertensive agents. Thiazide diuretics

inhibit reabsorption of sodium and chloride mostly in the distal tubules. Long-term

use of these drugs may result in hyponatremia. They also increase potassium and

bicarbonate excretion and decrease calcium excretion and uric acid retention.

Thiazides do not affect normal blood pressure (Leung, Wright, Pazo, Karson, &

Bates, 2011). Thiazide diuretics are cheap, easy to use and can be given once daily

and is more effective and are drug of choice for the elderly. However, most of

the drugs in this group possess a sulfonamide group and must be cautious to use in

individuals with allergies to sulfonamide.

6.1.2 Beta-blockers are use when patient has compelling cardiac

indications like heart failure, myocardial infarction, and patients with diabetes.

23

This group of drugs is generally not used as first line drugs for the treatment of

hypertension. This group of drugs must be use cautiously in patients with asthma or

severe Chronic Obstructive Pulmonary Disease (COPD). Dose must be reduce

gradually, as sudden withdrawal of drug results in exacerbations of angina and, in

some cases, myocardial infarction have been reported.

6.1.3 Calcium channel blockers binds to L-type calcium channels in

the vascular smooth muscle, which results in vasodilatation and a decrease in blood

pressure. They are effective as monotherapy in black patients and elderly patients.

Non-dihydropyridines calcium channel blockers, such as verapamil and diltiazem

bind to L-type calcium channels in the sinoatrial and atrioventricular node, as well as

exerting effects in the myocardium and vasculature. These agents constitute a more

effective class of medication for black patients (Cummings, Amadio, Nelson, &

Fitzgerald, 1991).

6.1.4 Angiotensin Converting Enzyme (ACE) inhibitors are

the treatment of choice in patients with hypertension, chronic kidney disease, and

proteinuria. ACE inhibitors reduce morbidity and mortality rates in patients with heart

failure, patients with recent myocardial infarctions, and patients with proteinuric renal

disease. ACE inhibitors appear to act primarily through suppression of the renin-

angiotensin-aldosterone system. ACE inhibitors prevent the conversion of angiotensin

I to angiotensin II and block the major pathway of bradykinin degradation by

inhibiting ACE. Accumulation of bradykinin has been proposed as an etiologic

mechanism for the side effects of cough and angioedema. It is important to note that

the blood-pressure-lowering effects of ACE inhibitors and thiazides are

approximately additive, and there is also the potential for hyperkalemia when ACE

inhibitors are co-administered with potassium supplements or potassium-sparing

diuretics. Careful monitoring of serum potassium levels is warranted when these

agents are used in combination (Cummings, et al., 1991).

6.1.5 Angiotensin II receptor antagonists or angiotensin receptor

blockers (ARBs) are used for patients who are unable to tolerate ACE inhibitors.

ARBs competitively block binding of angiotensin-II to angiotensin type I receptors,

thereby reducing effects of angiotensin II–induced vasoconstriction, sodium retention,

24

and aldosterone release. If monotherapy with an ARB is not sufficient, adding

a diuretic should be considered (Beevers et al., 2007).

6.1.6 Alpha-blockers are generally not recommended as initial

monotherapy. This group of drugs selectively blocks postsynaptic alpha 1-adrenergic

receptors and dilates arterioles and veins, thus lowering blood pressure. These drugs

can be combined with other anti-hypertensive. Common side effects seen in this drug

class include dizziness, headache, and drowsiness, in addition to orthostatic and first-

dose hypotension.

6.1.7 Vasodilators acts directly on the muscles in the walls of arteries,

preventing the muscles from narrowing. Vasodilators relax blood vessels to improve

blood flow, thus, decreasing blood pressure.

6.2 Non-pharmacological management

As the rates of hypertension continues to raise, health promoting

behaviors plays a crucial role in reversing the trend of increasing cases of

hypertension around the world. Research has indicated that persons with hypertension

can make multiple lifestyle changes that lower their blood pressure and reduce

the risk for cardiovascular complications. The Seventh Report of the Joint National

Committee of Prevention, Detection, Evaluation, and Treatment of High Blood

Pressure (JNC 7, 2003), AHA (2013), and the WHO (2013) recommends therapeutic

lifestyle modifications in lowering blood pressure and decrease cardiovascular risk.

The non-pharmacological interventions to reduce blood pressure include

the following.

6.2.1 Physical activity

According to Walker and Hill-Polerecky (1996), physical activity

consists of regular participation in activities at light, moderate, and vigorous intensity,

which may be planned or integrate as a part of daily life or leisure activities. Regular

physical activity has many health benefits including decreasing the risk of

cardiovascular diseases, obesity, and diabetes. Exercise aids in weight control and is

a key component of weight loss. It increases muscle and bone strength, decreases

body fat, and enhances psychological well-being. Exercise is also beneficial in

controlling and reducing hypertension. According to research and recommendation

from the Centers for Disease Control and Prevention (CDC), it is suggested that

25

people perform moderately intense exercise 30 minutes a day, most days of the week.

Some research has shown that 30 minutes of exercise a day can lower systolic blood

pressure 4-9 mm Hg (Chobanian et al., 2003). Regular aerobic exercise lasting 30-60

minutes and reduce consumption of salt in diet can lower systolic blood pressure on

an average of 5 mmHg and diastolic blood pressure on an average of 4 mmHg

(JNC-7, 2003; Whelton, Chin, & Xin, 2002). Similarly, in a randomized control trial

by Lee, Arthur, and Avis (2007) on people with hypertension showed that patients

who followed recommended physical activities decreased systolic blood pressure of

15.4 mmHg. Similarly, Fagard (2005), in the study of effects of exercise, found that

there was reduction in systolic blood pressure by 3.6 mmHg and diastolic blood

pressure of 2.7 mmHg. Patients with hypertension, who engaged in regular exercise,

can control their blood pressure (Fagard, 2005).

6.2.2 Nutrition

Nutrition involves selection and consumption of foods essential for

health and well-being in knowledgeable and appropriate way (Walker & Hill-

Polerecky, 1996). A healthy eating plan can both reduce the risk of developing high

blood pressure and lower a blood pressure that is already too high. Since blood

pressure is influenced by the amount of potassium and magnesium, a healthy diet with

potassium, magnesium and lipid intake are essential to help patients manage their

blood pressure and prevent complications. A land mark study, the Dietary Approaches

to Stop Hypertension [DASH] trials (Appel et al., 1997), demonstrated the effects of

diet on decreasing hypertension. The diet in this trial encouraged a high amount of

vegetables and fruits, which provide high levels of potassium, magnesium, and fiber.

The diet also consisted of low-fat dairy products, and foods low in total and saturated

fat, cholesterol, and approximately 2.4 grams of sodium or 6 grams of sodium

chloride per day. The DASH diet was most effective on people with prehypertension

to moderate hypertension. The following DASH diet plan is recommended to

the patients with hypertension (Chobanian et al., 2003).

Grains and grain products 6-12 servings per day includes 1 slice of bread,

1 cup of ready to eat cereal or half cup of cooked rice or any other cereals.

The servings is calculated based on the requirements of 2000 calories per day and

usually includes 3 whole grain foods.

26

Fruits 4-6 servings per day include 1 medium fruit, ¼ cup dried fruits and

6 ounces of fruit juice.

Vegetables 4-6 servings per day include 1 cup raw leafy vegetables, half cup

of cooked vegetables and 6 ounces vegetable juice.

Low fat or non-fat dairy foods 2-4 servings per day include 8 ounces milk,

1 cup yogurt and 1.5 ounces cheese.

Lean meat, fish and poultry 1.5-2.5 servings per day include 3 ounces

cooked lean meat, skinless poultry or fish.

Nuts, seeds and legumes 3-6 servings per week include one-third cup nuts

and half cup cooked dry beans.

Fats 2-3 servings and includes 1 teaspoon vegetable oil and 2 tablespoon

light salad dressing.

Diet low in sodium includes consuming not more than 2.4 grams of sodium

a day, which equals 6 grams (1 teaspoon) of salt a day.

Further the AHA recommends a diet that is low in sodium, is high in

potassium, and promotes the consumption of fruits, vegetables, and low-fat dairy

products for reducing BP and lowering the risk of complications. Study have shown

that DASH diet lowered blood pressures in hypertensive participants on average

11 mmHg systolic blood pressure and 5.5 mmHg diastolic blood pressure (Appel

et al., 1997, 2003, 2006; JNC 7, 2003). Similar, study on effect of diet on

hypertension found reduction of systolic blood pressure by 5.9 mmHg and diastolic

blood pressure by 4.2 mmHg (Fagard, 2005).

6.2.3 Weight management

One of the leading lifestyle modifications for all diseases is weight

reduction. The classification of overweight is a Body Mass Index (BMI) in excess of

25 and a BMI over 30 is considered obese (AHA 2005; Chobanian et al., 2003).

Research has provided strong evidence that being overweight or obese predisposes

individuals to many chronic diseases like type 2 diabetes, hypertension, high blood

cholesterol, cardiovascular diseases, stroke and many other illnesses and diseases.

The current recommendations are to maintain a normal body weight, a BMI between

18.5 and 24.9 to reduce the risk for cardiovascular and other diseases. Weight

reduction not only helps to normalize blood pressure by reducing strain on the heart,

27

it also lowers blood cholesterol. According to research, weight reduction of 5-10 kg

and maintaining a normal BMI under 25 can decrease systolic blood pressure 5-20

mmHg (AHA, 2005; Chobanian et al., 2003). A well balanced diet is also important in

aiding weight reduction and preventing obesity.

6.2.4 Smoking cessation

Chronic and heavy smoking is associated with hypertension and

patients must be strongly counseled to quit smoking (JNC 7). Blood pressure

increases acutely during smoking and has adverse effect on cardiovascular risk.

People who stop smoking rapidly reduce their risk of cardiovascular complications by

50 % after one year (Beevers et al., 2007). Smoking of tobacco causes several

immediate responses within the heart and its blood vessels within minutes after

inhaling smoke and increases heart rate. It is partially attributed to nicotine which

stimulates the body to produce adrenaline, thus increasing heart rate and blood

pressure (Beevers et al., 2007).

6.2.5 Limiting alcohol consumption

Limiting alcohol intake is another lifestyle modification. High dose of

alcohol ingestion have a dose related effect on blood pressure, both on hypertensive

and normotensive people. According to JNC 7 (2003), hypertensive patients should

limit alcohol consumption to not more than 30 mls, equivalent of 2 drinks per day for

men and not more than 15 mls for women. Hypertensive patients who are heavy

drinkers are more likely to have hypertension resistant to drugs treatment. High dose

of alcohol ingestion have a dose related effect on blood pressure, both on hypertensive

and normotensive people. Therefore, the only way to reduce blood pressure in this

group of people is to reduce or stop consuming alcohol. However, there still remains

conflicting research on alcohol consumption, in moderation, and its health benefits.

The majority of the research states that limiting consumption of alcohol to no more

than two drinks per day for men and 1 drink per day in women is acceptable. Systolic

blood pressure reductions of 2-4 mmHg have been shown as a result of limiting

alcohol consumption (Centers for Disease Control and Prevention, National Institutes

of Health, 2000; Chobanian et al., 2003).

28

6.2.6 Stress management

Although the precise mechanisms linking stress reactivity and

cardiovascular risk status are yet to be determined, it is evident that stress can

temporarily induce blood pressure. Stress is substantially connected to manifestation

of hypertension, cardiovascular disease, metabolic syndrome, obesity and emotional

overeating. Further it fuels 50 % of depression cases through disturbances of

hypothalamic–pituitary–adrenal axis and increased cortisol levels. It is important to

manage stress appropriately to avoid complications (Sharma et al., 2013). According

to Walker and Hill-Polerecky (1996), stress management is behaviors to identify and

utilize psychological and physical resources to effectively control and reduce tension.

Similarly, stress management refers to behaviors or activities that help individuals to

release stress with enough rest and sleep, and sharing emotional feelings appropriately

(Pender et al., 2011). Patients with hypertension face with physical, mental and social

changes about life when they get the disease and its complication. Therefore, to

manage stress among patients with hypertension, support and motivation from family

and friends is key to prevent complications. It is necessary to practice relaxation and

other ways to manage stress. Study by Kaushik and colleagues found that stress

management techniques like mental relaxation and slow breathing resulted in a fall in

systolic blood pressure and diastolic blood pressure (Kaushik, Kaushik, & Mahajan,

2006).

Pender’s health promotion model

Pender’s health promotion model is one of the most frequently used models

for health promotion which serves as a multivariate paradigm for explaining and

predicting health promoting component of lifestyle (Pender et al., 2011). The model is

used to assess an individual’s background and perceived perceptions of self among

other factors to predict health behaviors. Pender’s model serves as a guide for

exploration of the complex bio psychosocial processes that motivate individuals to

engage in behaviors directed toward the enhancement of health (Pender et al., 2011).

Within health promotion model, health promoting behavior is an expression of the

human tendency to actualize and is directed at elevating the individual’s level of well-

being, enhancing self-actualization, and maximizing personal fulfillment.

29

Two theories underlie Pender’s model which are important for understanding the

concepts she describes. These two theories are the expectancy-value theory and the

social cognitive theory. The expectancy-value theory is based on the idea that the

course of action will likely lead to the desired outcome, and that this outcome will be

of positive personal value. The social cognitive theory describes the concept of

perceived self-efficacy which is a judgment of one’s ability to carry out a particular

course of action (Pender et al., 2011). Pender predicts that a high confidence level will

lead to greater likelihood that the behavior will be performed. There are three major

concepts in Pender’s model which are further subdivided into narrower, more specific

concepts. The major concepts are individual characteristics and experiences,

behavior-specific cognitions and affect, and behavioral outcome.

Figure 2 Health promotion model

The model proposed that performing health behaviors can be achieved

through the direct and indirect effects of factors. The general individual characteristics

and experiences generally influence behavior indirectly and behavior-specific

30

cognitions and affects influence behavior directly. According to Pender et al. (2011),

individual characteristics are personal general such as age, health status, personality

structure, race, ethnicity, and socio economic status. Prior experiences are frequency

of the similar health behavior in the past. Behavioral-specific cognitions and affect

consists of following factors: perceived benefits of action are the positive perception

of individual to undertake or reinforce a health behavior; perceived barriers to action

are perceptions of blocks, hurdles, personal costs of undertaking a specific health

behavior; perceived self-efficacy is the judgment of personal capability to organize

and execute a particular health behavior; activity- related affect is the subjective

feeling states or emotions occurring before, during and after following a specific

health behavior; interpersonal influences includes norms, social support, role models

perceptions concerning the behaviors, beliefs, or attitudes of relevant others in regard

to engaging in a specific health behavior; situational influences are the perceptions of

the compatibility of life context or the environment with engaging in a specific health

behavior; commitment to a plan of action means the intention to carry out a particular

health behavior including the identifications of specific strategy to do successfully

and immediate competing demands and preferences. Health promoting behavior is

identified as the ultimate outcome of the model.

Factors related to health promotion behaviors of patients with

hypertension

Several studies on health promotion behaviors have used Pender’s Health

Promotion Model to examine and explore such behaviors (Ho et al., 2012;

Jaiyungyuen et al., 2008; Kwong & Kwan, 2007; Warren- Findlow et al., 2012).

Numbers of factors are related to health promotion behaviors. These factors may

impede or facilitate health promoting behaviors of hypertensive patients. These

factors include perceived self-efficacy, perceived benefits, perceived barriers and

perceived social support.

Perceived self-efficacy

Perceived self-efficacy refers to the confidence in performing a specific

behavior. Perceived self-efficacy affects one’s health promoting behaviors. People

31

with high perceived self-efficacy tends to involve in the health promoting behaviors

whereas, people with low perceived self-efficacy would surrendered when faced with

challenges and difficulties while performing such behaviors (Pender et al., 2011).

Individual who feels capable and efficacious in managing their health has a greater

chance of engaging in more frequent health promoting behaviors than an individual

who feels unskilled. Greater perceived self-efficacy leads to an increased probability

of commitment and action to a health promoting behavior (Pender et al., 2006).

Therefore, perceived self-efficacy is an important construct that enhances

the behavioral outcome associated with commitment to health promoting behavior.

Studies have investigated the role of self-efficacy on health promotion

behaviors in hypertensive patients. Jaiyungyuen et al. (2008) found that perceived

self-efficacy had positive relationship with health promotion behaviors in population

of people with hypertension (r = .59, p < .01). Similarly, in the study of 190 African-

American adults with hypertension, the result demonstrated that people with high

perceived self-efficacy had higher prevalence of engaging in physical activities and

eating low salt diet. Warren-Findlow et al. (2012) interviewed 190 hypertensive

patients and found that 59 % of participants reported to have high perceived self-

efficacy to manage hypertension. The result showed that individuals with high

perceived self-efficacy had 64 % higher prevalence ratio (PR) of eating low salt diet

(PR = 1.64, 95 % CI: 1.07-2.20), 27 % of individuals in engaging in physical

activities (PR = 1.27, 95 % CI: 1.08-1.39). Those with high perceived self-efficacy

also had higher prevalence of not smoking (PR = 1.10, 95 % CI: 1.01-1.15) and had

higher prevalence of following good weight management (PR = 1.63, 95 %

CI: 1.30-1.87). Similar study by Ho et al. (2012), of 107 patients with hypertension

found that perceived self-efficacy explained most variance in health promotion

behaviors (β = .31, p < .01). In a study of 234 elderly women with hypertension, Yang

et al. (2014), found that self-efficacy contributed most significantly and yielded the

largest standardized regression coefficient (β = .69).

The role of self-efficacy in health promotion behaviors has been widely

investigated and findings revealed that self-efficacy have a strong relationship with

health promotion behaviors in hypertensive patients. Therefore, to understand and

32

confirm relationship between self-efficacy and health promotion behavior in

Bhutanese population is necessary.

Perceived benefits of action

Perceived benefits of action are belief that a course of action will lead to

expected outcomes. Perceived benefits directly and indirectly motivate behavior

through determining the extent of commitment to a plan of action to engage in

behaviors (Pender et al., 2011). Individuals tend to invest time and resources in

activities that have a high likelihood of positive outcomes. Benefits may be intrinsic

or extrinsic. Intrinsic benefit includes increased alertness and energy and increased

perceived attractiveness. Extrinsic benefits include monetary rewards or social

interactions possible as a result of engaging in the behavior (Pender et al., 2011).

In a study of 198 hypertensive patients, the result indicated that perceived benefits

significantly related (r = .27, p < .01) to health promoting behavior (Nangyaem et al.,

2007). In similar study in women by Thanavaro and colleagues, they found that

perceived benefit was positively related to health promotion behavior (r = .38,

p < .01) (Thanavaro, Moore, Anthony, Narsavage, & Delicath, 2006).

Perceived barriers to action

Perceived barriers are perceptions (real or imagined) related to engaging in

action or inhibit commitment to a behavior. Barriers may include time, cost,

inconvenience, access, and actual performance. Many studies demonstrated that

perceiving either environmental or personal barriers was inversely associated with

health promotion behavior. A high barrier can constrain commitment to action and on

the other hand, when the barrier is low and the willingness is high, behavior is likely

to follow (Pender et al., 2006). Kwong and Kwan (2007) have identified several

barriers such as, fear of harming oneself, lack of self-motivation, lack of knowledge,

the cost and require effort of activities, and lack of support from family and

significant others as barriers in the domain of diet, physical activities and stress

management. A study by Murimi and Harpel (2010), in a population of low income

population found that fear of the unknown, and lack of companionship or support

were common barriers to health promotion. In similar study of 198 patients with

hypertension, it showed that perceived barriers was related to health promoting

behaviors (r = -.17, p < .01) (Nangyaem et al., 2007). Khatib et al. (2014) in their

33

systematic review of barriers to hypertension control found that, stress and anxiety

contributes to health promotion behaviors. Emotion includes lack of money and jobs,

single parenting, and living in unsafe neighborhoods. Barriers to following a healthy

diet included absence of nearby stores that sell healthy foods, limited healthy food

choices when eating out, and lack of guidance and dietary counseling from clinicians

are some of the barriers reflected in the literature.

Perceived social support

Individuals is likely to engage in health promoting behaviors when they

perceives the availability of social support, whereas, perception of lack of support can

interfere with successful engagement and maintenance of healthy behaviors (Pender

et al., 2011). Social support from family reinforced positive behavioral changes and

influenced healthy behaviors among people with hypertension. Interpersonal

influence are cognition concerning behaviors, beliefs, or attitudes of the others and

include norms (expectations of significant others) and social support. Primary sources

of interpersonal influences are families (Pender et al., 2006). Waite and Lehrer (2003)

found that those people receiving social support from their significant others were

more confident in engaging in healthy dietary practices than unmarried individuals.

The study by Ashida, Wilkison, and Koehly (2012), found that having at least one

network member who encourages one to eat more fruits and vegetables and to engage

in regular physical activity was associated with motivation to change the relevant

behavior. In Jaiyungyuen et al. (2008) study of older people with hypertension found

that social support was positively related to health promotion behavior in hypertensive

patients (r = .38, p <.01). Similar study, Ho et al. (2012) found that social support

was significant predictor of health promotion behaviors in adult patients with

hypertension (β = .27, p < .01). Further, similar study Yang et al. (2014) in low

income women with hypertension found that social support had positive relation with

health promoting behaviors(r = .48, p <.001).

Health promoting behaviors of Bhutanese patients with hypertension

In Bhutan, hypertension and its complications are on a consistent rise over

the years. The referral expenditure for the treatment of complications, outside Bhutan

has increased in recent years (Annual health report, 2013). Bhutan NHS (2012)

34

reported 16 % prevalence of hypertension among adults in Bhutan. Similarly, the

survey on prevalence of non-communicable disease in the capital city of Bhutan

revealed a 26 % prevalence of hypertension among adults (Cowan et al., 2009).

Hypertension is responsible for a large number of strokes, heart attacks and chronic

kidney diseases. In 2014, the National Referral Hospital treated 105 cases with

complication of hypertension. The data from the National Referral Hospital shows an

overwhelming number of strokes and acute myocardial infarction with 89 patients

diagnosed with stroke and 12 patients with acute myocardial infarction in the year

2012 (Wangdi, 2013). Cardiovascular and cerebrovascular diseases account for

14.9 % of total morbidity and non-communicable diseases account for 50 % of

inpatient mortality (Giri et al., 2013).

Although no studies are available regarding health promoting behaviors of

Bhutanese people, few studies revealed that traditional Bhutanese diet is high in fats,

is spicy and contains a lot of salt, although exact amount is not known. The traditional

national dishes of Bhutan are red rice, chilli pepper, cheese stew, and salted butter tea.

Chilli pickles called ezay are frequently served as appetizers and are consumed

in large quantities. Generally, large amounts of salt are added to both the curry and

the pickle or paste (Wangdi, 2013). According to the risk factors survey (Cowan et al.,

2009), two-third of the population (66.6 %) were not eating enough fruits and

vegetables. Prevalence of smoking was low, possibly due to strict regulation. It was

observed that 30.8 % respondents drank alcohol at least once in 30 day, males

drinking more than females. Majority of population (58.6 %) did not attain

a minimum requirement of health enhancing physical activity and the prevalence of

obesity (BMI > 30) was 12.1 % while 52.5 % population were overweight

(BMI > 25). The combination of a high carbohydrate intake in the form of thrice-daily

rice, salty butter tea and cheese curry, fat-rich meat and poultry dishes, together with

an increasingly sedentary lifestyle, especially among urban dwellers, contributes to

the high prevalence of overweight in adults leading to hypertension. Further, in recent

years rural urban migration of people is increasing, and there is possibility that people

must be living under constant stress contributing to hypertension.

Although, the studies focus on some of the behaviors of Bhutanese

population, no study has been undertaken in relation to health promotion behaviors of

35

hypertensive patients in Bhutan. Hence, further understanding of health promoting

behaviors is necessary to improve nursing knowledge and develop appropriate nursing

interventions.

In conclusion, the literature review suggests that, perceived self-efficacy,

perceived benefit, perceived barriers and perceived social support to have positive

relationship. Nursing professionals can help individuals to improve healthy behaviors

as these factors are modifiable by nurses. Although health promoting factors have

been widely discussed in the literature, little is known in relation to Bhutanese

population with hypertension. In fact, no study has been carried out till date in Bhutan

to understand the factors related to health promoting behaviors in hypertensive

patients. Further, with difference in culture, values, beliefs, physical and social

characteristics of Bhutanese population with hypertension, the findings from other

studies may not be same with Bhutanese population. This lack of information in

relation to hypertensive population suggests investigation, in order to develop

effective nursing intervention. Understanding the factors and their relationships to

health promoting behaviors will provide a deeper insight for the nursing professionals

and other health care providers to develop effective nursing strategies to help

individuals with hypertension to engage in health promotion to control hypertension

and prevent complications. Therefore, this research aimed to study whether perceived

self-efficacy, perceived benefits, perceived barriers, and perceived social support have

any relationship with health promoting behaviors among Bhutanese population with

hypertension.

36

CHAPTER 3

RESEARCH METHODOLOGY

This chapter presents the research methodology including research design,

setting, population, sample, instruments, protection of human subjects, data collection

procedures, and data analysis.

Research design

A descriptive correlational design was used in this study to examine

the relationships of perceived self-efficacy, perceived benefits, perceived barriers,

perceived social support, and health promoting behaviors of Bhutanese patients with

hypertension.

Research setting

Sample for the research was gathered from the general medical outpatient

department of Jigme Dorji Wangchuck National Referral Hospital (JDWNRH), which

is an apex hospital catering, services to all Bhutanese population. It is a 350 bedded

hospital, where patients from all over the country visit for their health needs.

The hospital is located in the capital city of Bhutan, where people from all part of

country resides as employees of different organizations. For the convenience of

the relatives, their dependents with chronic illness lives together to get easy access to

health care facilities. The general outpatient department of the hospital sees

approximately 30 adult hypertensive patients per day and provides treatment and

other counseling services for the patients. The outpatient department working time is

from 8.30 am till 3.00 pm daily from Monday to Friday and 8.30 am to 1.00 pm on

Saturdays. The patients registers at 8.30 am, takes the registration number and wait

for the physician, while nurse conducts routine task of blood pressure monitoring and

provide information on healthy behaviors to patients.

37

Population and sample

Population

Population for this study was patients with primary hypertension as

diagnosed by the physician, visiting the outpatient department of Jigme Dorji

Wangchuck National Referral Hospital (JDWNRH) for follow up treatment. Sample

was selected based on the inclusion criteria as follows:

1. Adult patients age 18 years and above.

2. Have been diagnosed with primary hypertension for at least 1 month.

3. No serious complications of hypertension such as paralysis, and NYHA

(New York Heart Association) stage four heart failure.

4. Be able to read and write English language.

Sample size

The sample size was determined by using power analysis, a method to

reduce the risk of type II errors (wrongly accepting false null hypotheses). G* power

software was used to calculate the sample size. An effect size of 0.25, power of .80

with four variables and alpha level of .05 was used to calculate the sample size (Faul,

Erdfelder, & Lang, 2009). Effect was necessary to ensure that the phenomenon exists

and to determine that the samples were enough to prevent accepting false null

hypothesis. Therefore, the minimum number of samples in the study was 123.

Sampling techniques

In this study, a simple random sampling method was used. Patients who met

the inclusion criteria were randomly selected from the list of patients who came for

follow up treatment. Method of recruitment was as follow:

1. Participants were recruited in the study by using simple random

sampling technique. The sampling frame was attained by collecting the registration

numbers distributed during the period from 8.30 am to 9.30 am after screening those

meeting the inclusion criteria.

2. On the days of data collection, the list of patient’s registration numbers

who come for follow-up at outpatient department were obtained.

3. The registration numbers of patients who met the eligible criteria were

put in a container and mixed well.

38

4. The researcher then randomly drew out the registration numbers from

the container one at a time to obtain the study sample.

5. The selected participant’s number was immediately replaced in

the container before the next number was picked to provide exactly equal

opportunities for each subject to be selected.

6. On average approximately 10-12 participants were recruited each day.

Research instruments

There were six instruments and all instruments were self-administered

questionnaires and in English version.

1. Demographic Questionnaire

Demographic Data Questionnaire (DDQ) was developed by the researcher.

The questionnaire was used to collect patient’s demographic information.

Demographic characteristics included gender, age, education level, marital status,

occupation, income, co-morbidity, blood pressure, duration of hypertension, and body

mass index.

2. Health Promoting Behaviors Questionnaires (HPBQ)

Health promoting behaviors was measured by 26 items health promoting

behaviors questionnaires, developed by the researcher based on Pender’s Health

Promotion Model (Pender et al., 2011) and literature review. The instruments used

a 4 point Likert-type scale “1” = never, “2” = sometimes, “3” = often, “4” = routinely.

This 26 item include seven subscales to measure specific health promoting behaviors:

Taking medication (1-5), physical activity (6-7), nutrition (8-12), weight management

(13-17), smoking cessation (18-19), limiting alcohol (20-21) and stress management

(22-26). Total score range from 26-104. Score for sub scale for taking medication,

nutrition, weight management and stress management range from 5-20 while for

physical activity, smoking cessation and limiting alcohol, the score range from 2-8.

A higher score close to the highest score indicated greater health promoting behaviors

performance. Scores are transformed from the highest possible score minus the lowest

possible score and divided by 3 to get the range as low, moderate and high (Polit &

Beck, 2010). The interpretation of the total score is described as low (26-52),

moderate (53-78), and high (79-104). The interpretation of the score of subscales for

39

taking medication, nutrition, weight management and stress management is described

as low (5-10), moderate (11-15) and high (16-20), while for physical activity,

smoking cessation and limiting alcohol, it is described as low (2-3), moderate (4-5)

and high (6-8).

3. Self-Rated Abilities for Health Practices Scale (SRAHPS)

Self-Rated Abilities for Health Practices Scale, developed by Becker et al.

(1993) was used to measure perceived self-efficacy. This 28 item included four

subscales, with 7 items in each subscales specific to measure self-perceived ability to

perform the following health promoting behaviors: Nutrition (items 1-7),

Psychological well-being (items 8-14), exercise (items 15-21), and health

responsibility (items 22-28). Each item was rated on a 5-point scale score as follows:

“1” = not at all, “2” = a little, “3” = somewhat, “4” = mostly, “5” = completely.

A total score range from 28-140 and was calculated by totaling the responses. Score

for sub scale range from 7- 35. The score close to the highest score reflected a higher

level of perceived self-efficacy. The scale had been tested in health fair attendees and

has established reliability. The Cronbach’s alpha for the health fair attendees was .94

for the entire scale, .92 for the exercise subscale, .81 for the nutrition subscale, .90 for

psychological well-being subscale, and .86 for the responsible health practice subscale

(Becker et al., 1993). For validity, the scores on the general self-efficacy scale

(Sherer et al., 1982) were moderately correlated with total scores on the SRAHP (r =

.43). General self-efficacy scale scores were most highly correlated with the

responsible health practices and psychological well-being subscale of the SRAHP (r =

.44 and r = .43 respectively). All correlations were significant at the p < .01 level.

4. The Benefits Assessment Scale (BAS)

The Benefit Assessment Scale developed by Murdaugh and Verran (1987)

was used to measure perceived benefits of health promotion behaviors. The BAS is

a self-report questionnaire consisting of 12 statements describing benefits to

undertaking preventive health behaviors. Participants indicated the extent of their

agreement or disagreement with each statement in a 4-point Likert-type scale.

Reponses range from “1” = strongly disagree to “4” = strongly agree for each item on

the BAS. Items 2, 8 and 12 have negative score and responses range from “4”

40

(strongly disagree) to “1” (strongly agree). The total possible scores ranged from

12 to 48. The score near to the highest score, the participant has on the BES,

the greater the participant’s perceived benefits. The reported reliability coefficient of

the BAS was 0.72-0.79, and the 2-week-test-retest in a healthy population was

0.52-0.71, indicating the BES as a reliable tool for assessing perceived benefits to

undertaking preventative health behaviors (Murdaugh & Verran, 1987).

5. Barriers to Health Promoting Activities Scale (BHPAS)

The Barriers to Health Promoting Activities Scale developed by Stuifbergen

and Becker, (1994) was used to measure perceived barriers to health promotion

behaviors. It is an 18 item, 4-point Likert-type scale “1”= never, “2” = sometimes,

“3” = often, “4” = routinely, that requests individuals to indicate how often the listed

barriers kept them from taking responsibility for their health. The score range from

18-72. The higher the score an individual received on this summated rating scale,

the greater the perceived barriers. The scale has established validity and reliability

with internal consistency reliability of .82, with a 2 week test-retest reliability of .75.

Discriminate validity is supported by t-test analysis establishing significant

differences in scores between disabled persons and a comparison group of non-

disabled individuals (Stuifbergen & Becker, 1994).

6. Personal Resource Questionnaire (PRQ2000)

Personal Resource Questionnaire (PRQ2000) developed by Weinert (2003)

was used to measure perceived social support in performing health promoting

behaviors. This instrument consisted of 15 items and each item was rated on a 7-point

scale ranging from “1” = strongly disagree to “7” = strongly agree. A total score was

obtained by totaling responses ranging from 15-105. Higher score indicated higher

level of perceived social support. The scale has established reliability with Cronbach’s

alpha ranging from .87 to .93. Construct validity is also confirmed by factors analysis

and discriminant validity (Weinert, 2003).

Quality of the instruments

Validity

The researcher used the original version of the instruments with qualified

validity, for the four instruments; therefore, content validity was not tested. The health

41

promoting behaviors questionnaires was tested for validity by panel of five experts

with experience in cardiovascular nursing and expert in Pender’s health promotion

model. Experts were asked to rate each items on a four point likert scale “1” = not

relevant to “4” = very relevant. Their opinion on possible revision was taken into

consideration. To ascertain validity of the instrument, a content validity index was

used to calculate the validity using Content Validity Index formula. Content Validity

Index = Number of agreed items/ Total number of items (Burns & Grove, 2005).

The content validity of the instrument was .70.

Reliability

A pilot study was carried out at Jigme Dorji Wangchuck National Referral

Hospital on 30 hypertensive patients who met the same inclusion criteria with

the sample in the study to test for the internal consistency reliability of

the questionnaires. The results identified that the Cronbach’s alpha coefficient of

the HPBQ was .95. For subscales of this instrument, the Cronbach’s alpha were .83

for taking medication, .70 for physical activity, .88 for nutrition, .85 for weight

management, .70 for smoking cessation, .78 for limiting alcohol consumption, and .80

for stress management. The SRAHPS questionnaire presented the Cronbach’s alpha

of .97. The Cronbach’s alpha for BAS was .70. The Cronbach’s alpha for BHPAS and

the PRQ2000 were .91 and .89 respectively.

Protection of human subjects

The study was submitted for approval to the Institutional Review Board

(IRB), Faculty of Nursing, Burapha University. Upon availing approval from IRB,

Faculty of Nursing, Burapha University, the researcher approached the chairperson of

the Research Ethic Board of Health, Ministry of Health, Thimphu, Bhutan for

approval to collect data at Jigme Dorji Wangchuck National Referral Hospital.

The letter from Burapha University was presented to the Medical Director of

the hospital to seek permission for data collection. Participants were explained about

research purpose, procedures and benefits of the study. Informed consent was

reviewed and signed by each participant prior to data collection. The participants were

assured that they had the right to refuse to participate or withdraw from the study at

any time without any penalty. Anonymity and confidentiality of the participant were

42

assured and no personal information was disclosed to any other persons. All data was

stored in a secure place and only utilized for the purpose of the research. The data

would be destroyed after one year of publication of the study.

Data collection procedure

Data collection was conducted after the research proposal was approved

by the IRB of Faculty of Nursing, Burapha University. The researcher submitted

the proposal and the IRB approval letter to the chairperson, Research Ethic Board of

Health, Ministry of Health, for approval. Upon getting approval from the chairperson,

Research Ethic Board of Health, Ministry of Health, the researcher approached

the Medical Superintendent of Jigme Dorji Wangchuck National Referral Hospital

with the letter from Burapha University to seek permission for data collection. After

receiving the permission, the researcher met with the nursing superintendent, head

nurse, and the nurses of outpatient department to inform them about data collection

procedures. The procedures of data collection were as follow:

1. On the data collection days, the researcher was present at the outpatient

department of the hospital at 8.30 am.

2. The researcher screened the patients who came for follow-up treatment

as per the inclusion criteria and collected the registration numbers distributed during

the period between 8.30 am to 9.30 am of patients who met the inclusion criteria.

3. Registration numbers of patients who met the inclusion criteria were

written on a piece of paper and put in a container and mixed well.

4. The researcher then randomly drawn out the registration numbers to

obtain the study sample. The selected participant’s number was immediately replaced

in the container before the next number was picked to provide equal opportunities for

each subject to be selected.

5. The selected patient was approached by the researcher about

participation in the study. The researcher explained about human protection, purpose

and method of the research, their rights to withdraw from the study. Patients were also

ensured that they can see the doctor as soon as they finish answering the

questionnaires and also their medications would be collected by the nurse. If the

patient agreed to participate; a written consent form was obtained from the patient.

43

6. The data were collected, while the patients were waiting for

the physician check-up or after visiting the physician for follow-up treatment. Prior

answering the questionnaires, patient’s blood pressure, height and weight was taken

and recorded.

7. Data were collected by using self-reported questionnaires.

The researcher explained direction to respond to the questionnaires and then allow

the participants to fill out the questionnaires in the room adjacent to the doctor’s

chamber. Each participant took approximately 40-60 minutes in answering all

the questions.

8. The researcher continued the data collection until the required sample

size was obtained.

9. Finally, each filled questionnaire was checked for completeness by

the researcher before allowing the participant to leave.

10. Finally code number was put on each questionnaire and entered the data

into the statistical program for data analysis.

In order to maintain quality of data collection, 10-12 participants were

recruited each day.

Data analysis

All data was analyzed by the statistical software. An alpha level for

statistical significance was set at .05. Following statistical procedure was performed

to analyze the data:

1. Descriptive statistics including frequency, percentage, mean, and

standard deviation (SD) was used to describe the demographic characteristics of the

sample, the independent variables (perceived self-efficacy, perceived benefits,

perceived barriers and perceived social support) and the dependent variable (health

promoting behaviors).

2. Pearson’s product moment correlation coefficient was used to examine

the relationships of perceived self-efficacy, perceived benefits, perceived barriers,

perceived social support and health promoting behaviors.

44

CHAPTER 4

RESULTS

This chapter presents the findings of data analysis which describes

the demographic characteristics, medical information of the participants, health

promoting behaviors, and examined the relationships between perceived self-efficacy,

perceived benefits, perceived barriers, perceived social support, and health promoting

behaviors of Bhutanese patients with hypertension. The findings are presented based

on the objectives and the hypotheses of the study. The results of the study are

presented below.

Part 1 Description of demographic characteristics and medical information

of the participants.

Part 2 Description of perceived self-efficacy, perceived benefits, perceived

barriers and perceived social support.

Part 3 Description of health promoting behaviors of the participants

Part 4 Relationships between perceived self-efficacy, perceived benefits,

perceived barriers, perceived social support and health promoting behaviors.

Part 1 Description of demographic characteristics and medical

information of the participants

A total of 123 sets of questionnaires were distributed, all questionnaires

were completed and returned yielding a 100 % return rate. The demographic

characteristics and the medical information of the participants are described in

Table 1.

45

Table 1 Frequency, percentage, mean, standard deviation of demographic

characteristics of the participants (n = 123)

Variables Number (n) Percentage (%)

Gender

Male 59 48

Female 64 52

Age (M = 54.1, SD = 10.9, min = 23, max = 79)

20-40 16 13.1

41-60 78 63.4

61-80 29 23.5

Education

Primary 44 35.8

Secondary 25 20.3

High school 26 21.2

Undergraduate 11 8.9

Graduate 17 13.8

Occupation

Government service 51 41.5

Business 19 15.4

Agriculturist 6 4.9

Housewife 28 22.8

Retired 19 15.4

Marital status

Single 3 2.4

Married 107 87

Divorced 3 2.4

Widowed 10 8.2

46

Table 1 (Cont.)

Variables Number (n) Percentage (%)

Income

Less than Nu. 10,000 32 26

Nu.10,000-Nu. 20,000 32 26

More than Nu. 20,000 59 48

Table 1 showed that the numbers of male and female participants in the

study were almost equal with male representing 48 % and female 52 %. Age of

participants ranged from 23 to 79 years with mean age of 54.1 (SD = 10.9). Majority

of the participants were in the age group of 41-60 and consisted of 63.4 %. Most of

the participants had attended primary school and consisted of 35.8 %. Majority of

the participants in the study were government employees and consisted of 41.5 %,

followed by housewives with 22.8 %. 87 % of the participants were married. Majority

of the participants earn more than Nu. 20,000 ($ 320) and consisted of 48 % of

the total participants.

The description of medical information which includes co-morbidities,

current blood pressure, duration of hypertension, and body mass index of

the participants are described in Table 2.

Table 2 Frequency, percentage, mean, standard deviation of medical information of

the participants (n = 123)

Variables Number (n) Percentage (%)

Co-morbidity

No 74 60.2

Yes 49 39.8

Diabetes 40 32.5

Renal failure 5 4.1

Heart disease 4 3.3

47

Table 2 (Cont.)

Variables Number (n) Percentage (%)

Current systolic blood pressure (M = 144.2, SD = 20.8, min = 101, max = 200)

< 140 mmHg 50 40.6

≥ 140 mmHg 73 59.4

Current diastolic blood pressure (M = 86.9, SD = 13.2, min = 50, max = 123)

< 90 mmHg 63 51.2

≥ 90 mmHg 60 48.8

BMI (M = 26.9, SD = 4.1, min = 17.5, max = 38.8)

< 18.5 3 2.4

18.5-24.9 36 29.4

25-29.9 60 48.7

> 30 24 19.5

Duration of hypertension (M = 6.69, SD = 4.81, min = 1, max = 25)

< 1 year 2 1.6

1-5 years 62 50.4

6-10 years 43 35

> 10 years 16 13

Table 2 showed that 39.8 % of the participants had some forms of

co-morbidity, with 32.5 % of participants reported diabetes as the most frequent

diagnosis. The mean systolic and diastolic blood pressure was 144.2/ 86.9 mmHg and

showed that more than 50 % of the participants had uncontrolled blood pressure. The

mean of body mass index (BMI) was 26.9 (SD = 4.1) with majority of the participants

(48.7 %) were overweight and 19.5 % were obese. Majority of the participants

(50.4 %), were diagnosed with hypertension for 1-5 years with mean score of 6.7

(SD = 4.8).

48

Part 2 Description of perceived self-efficacy, perceived benefits,

perceived barriers and perceived social support

The descriptions of the independent variables are described in Table 3.

Table 3 Mean, standard deviation, range of perceived self-efficacy, perceived

benefits, perceived barriers, and perceived social support (n = 123)

Variables Range M SD

Possible Actual

Perceived self-efficacy 28-140 54-133 102.54 19.06

Perceived benefits 12-48 28-48 39.45 3.55

Perceived barriers 18-72 24-64 43.16 8.68

Perceived social support 15-105 66-103 89.41 7.99

Table 3 showed the possible score range from 28-140 and the mean score of

perceived self -efficacy of sample was 102.54 (SD = 19.06) in the mid margin

indicating that participants had moderate perceived self-efficacy. The mean score of

perceived benefits of participants was 39.54 (SD = 3.55) in the higher margin

indicating that participants overall had high level of perceived benefits of health

promoting behaviors. For perceived barriers, mean score was 47.04 (SD = 8.35)

in the mid margin indicating that participants perceived moderate barriers to perform

health promoting behaviors. Similarly, the mean score of perceived social support in

the study was 89.41 (SD = 7.99) in the higher margin indicating that participants had

high level of perceived social support.

Part 3 Description of health promoting behaviors of the participants

The health promoting behaviors consisting of seven dimension as taking

medication, physical activity, nutrition, weight management, smoking cessation,

limiting alcohol and stress management are describe in Table 4.

49

Table 4 Mean, standard deviation, range of health promoting behaviors (n = 123)

Variables Range M SD

Possible Actual

Health promoting Behaviors 26-104 53-103 81.07 11.85

Taking medication 5-20 11-20 16.03 2.65

Physical activity 2-8 3-8 6.0 1.28

Nutrition 5-20 8-20 14.49 2.78

Weight management 5-20 9-20 14.88 2.75

Smoking cessation 2-8 2-8 7.37 1.148

Limit alcohol 2-8 2-8 7.11 1.137

Stress management 5-20 6-20 15.24 2.68

The health promoting behaviors consisting of seven dimensions as taking

medication, physical activity, nutrition, weight management, smoking cessation,

limiting alcohol and stress management are described in Table 4. It showed that

the possible score range from 26-104 and the mean score of health promoting

behaviors of the participants was 81.07 (SD = 11.85) in the higher margin indicating

that sample had high level of health promoting behaviors. The subscales of health

promoting behaviors of taking medication (M = 16.03, SD = 2.65); physical activity

(M = 6.0, SD = 1.28); smoking cessation (M = 7.37, SD = 1.14); limiting alcohol

(M = 7.11, SD = 1.13); and stress management (M = 15.24, SD = 2.68) were at higher

margin indicating high level in these domains. However, nutrition (M = 14.49,

SD = 2.75) and weight management subscales (M = 14.88, SD = 2.75) were at

moderate level.

50

Part 4 Relationships between perceived self-efficacy, perceived

benefits, perceived barriers, perceived social support and health

promoting behaviors

To examine the relationships between perceived self-efficacy, perceived

benefits, perceived barriers, perceived social support and health promoting behaviors,

Pearson’s product moment correlation coefficient was used. Assumptions of

normality, linearity, homoscedasticity and randomization were initially explored to

test the assumption for using Pearson correlation. The assumptions for using

Pearson’s product moment correlation coefficient were met. Pearson’s product

moment correlation coefficient was used to test the relationships between perceived

self-efficacy, perceived benefits, perceived barriers, perceived social support and

health promoting behaviors. The relationships between dependent variable and

independent variables are shown in Table 5.

Table 5 Pearson’s product moment correlation coefficient between health promoting

behaviors and related factors (n = 123)

Independent Variables Correlation coefficient (r)

Perceived self-efficacy .55**

Perceived benefits .26**

Perceived barriers -.47**

Perceived social support .27*

* p < .05, ** p < .01

The results showed that there was high positive correlation between health

promoting behaviors and perceived self-efficacy (r = .55, p < .01); moderate negative

correlation between health promoting behaviors and perceived barriers (r = -.47,

p < .01), low positive correlation between health promoting behaviors and perceived

social support (r = .27, p < .05) and low positive correlation between health

promoting behaviors and perceived benefits (r = .26, p < .01).

51

CHAPTER 5

CONCLUSION AND DISCUSSION

This chapter presents the summary of the study and findings, discussion of

the findings, limitations, implication and recommendation for further research.

The results are discussed according to the objectives and hypotheses of the study.

Summary of the study

The objectives of the study were to (1) describe the health promoting

behaviors of patients with hypertension, and (2) to examine the relationships of

perceived self-efficacy, perceived benefits, perceived barriers, and perceived social

support on health promoting behaviors of Bhutanese patients with hypertension.

Pender’s health promotion model provided a conceptual framework for the study.

Simple random sampling was used to recruit the sample of 123 participants who

visited the outpatient department of Jigme Dorji Wangchuck National Referral

Hospital, Thimphu, Bhutan. Data were analyzed using descriptive statistics and

Pearson’s correlation.

Data were obtained by self- reported questionnaires and included

the demographic questionnaires and Health Promoting Behaviors Questionnaires

developed by the researcher; Self-rated Abilities for Health Practice Scale (Becker et

al., 1993), Benefits Assessment Scale (Murdaugh & Verran, 1987), Barriers to Health

Promoting Activities Scale (Becker et al., 1993), and the Personal Resource

Questionnaires (Weinert, 2003). The reliabilities of the questionnaires were:

Cronbach’s alpha coefficient of .95 for health promoting behaviors scale, .97 for Self-

rated Abilities for Health Practice Scale, .70 for Benefits Assessment Scale, .91 for

Barriers to Health Promoting Activities Scale, and .89 for Personal Resource

Questionnaires.

52

Results of the study

1. Description of demographic characteristics and medical information:

The findings of the present study showed that the mean age of the participants was

54.1 (SD = 10.9), ranging from 23 years to 79 years. 52 % of the participants were

female. 87 % of the participants were married. 63.4 % participants were in the age

group of 41-60 years and most of the participants had attended primary school

(35.8 %). 41.5 % of the participants in the study were government employees with

monthly income of more than Nu. 20,000 ($ 320).

The result also showed that 39.8 % of the participants had co-morbidity,

with 32.5 % of participants reported diabetes as the most frequent diagnosis.

The mean systolic and diastolic blood pressure was 144.2/ 86.9 mmHg. The mean

body mass index (BMI) was 26.9 (SD = 4.1) with majority of the participants

(48.7 %) Majority of the participants (50.4 %), were diagnosed with hypertension for

1-5 years with mean score of 6.7 (SD = 4.8).

2. Description of perceived self-efficacy, perceived benefits, perceived

barriers, and perceived social support: The mean score of perceived self-efficacy of

sample in the study was 102.54 (SD = 19.06) indicating that participants had moderate

level of perceived self-efficacy. The mean score of perceived benefits of participants

was 39.54 (SD = 3.55) indicating that participants overall had high level of perceived

benefits of health promoting behaviors. For perceived barriers, mean score was 47.04

(SD = 8.35) indicating that participants perceived moderate barriers to perform health

promoting behaviors. Similarly, the mean score of perceived social support in

the study was 89.41 (SD = 7.99) indicating that participants had high level of

perceived social support.

3. Description of health promoting behaviors: The mean score of health

promoting behaviors of the participants was 81.07 (SD = 11.85). The results revealed

that sample had high level of health promoting behaviors (M = 81.07, SD = 11.85).

The subscales of health promoting behaviors of taking medication (M = 16.03,

SD = 2.65); physical activity (M = 6.0, SD = 1.28); smoking cessation (M = 7.37,

SD = 1.14); limiting alcohol (M = 7.11, SD = 1.13); and stress management

(M = 15.24, SD = 2.68) were at higher level. While, nutrition (M = 14.49, SD = 2.75)

and weight management subscales (M = 14.88, SD = 2.75) were at moderate level.

53

4. Relationships between perceived self-efficacy, perceived benefits,

perceived barriers and perceived social support: The results from Pearson’s product

moment correlation coefficient analysis suggested that there were high positive

correlation between health promoting behaviors and perceived self-efficacy (r = .55,

p < .01); moderate negative correlation between health promoting behaviors and

perceived barriers (r = -.47, p < .01); low positive correlation between health

promoting behaviors and perceived benefits (r = .26, p < .01); and low positive

correlation between health promoting behaviors and perceived social support (r = .27,

p < .05).

Discussion

The discussions of the findings are based on the objectives and hypotheses

of the study. First objective was to describe the health promoting behaviors and

the second objective was to examine the relationships between perceived self-

efficacy, perceived benefits, perceived barriers, perceived social support and health

promoting behaviors of hypertensive patients in Bhutan.

1. Health promoting behaviors

The results revealed that participants had high level of health promoting

behaviors (M = 81.07, SD = 11.85). The subscales of health promoting behaviors of

taking medication, physical activity, smoking cessation, limiting alcohol and stress

management were at higher level while nutrition and weight management were at

moderate level. The possibility of moderate to high level of health promoting

behaviors in the present study could be explained by several reasons.

The high level of health promoting behaviors could be explained by the fact

that majority of the participants were married (87 %). Marital status could be

the reason for explaining the high level of health promoting behaviors. Spousal

assistance may be associated with high level of health promoting behaviors for

hypertensive patients through providing practical support like helping to follow

regular exercise, healthy diet and reminding to take medications (Shumaker & Hill,

1991). Trivedi, Ayotte, Edelman, and Bosworth (2008), found that being married was

associated with better compliance to healthy recommendations of taking medication

(r = .19, p < .001), exercise recommendations (r = .10, p < .001) and lower incidences

54

of smoking (r = -.18, p < .001). Further, study by Yang et al. (2014) also found that

marital status was related to health promoting behaviors in hypertensive patients

(r = -.25, p < .001).

Another reason for explaining high level of health promoting behaviors

might relate to duration of hypertension. The result showed that 50.4 % of participants

were diagnosed with hypertension for 1-5 years. High level of health promoting

behaviors could be explained by longer duration of hypertension because patients had

the opportunity to gain more experiences and knowledge which facilitate them to

engage in health promoting behaviors. Longer duration provides participants to get

more healthy recommendations and counseling from the health workers which help

them to change behaviors (Heyman, Gross, Tabenkin, Poter, & Porath, 2011). Similar

study by Kumar Elayaraja, Shailaja and Ramasamy on 100 hypertensive patients

found that longer duration of hypertension and individual who received healthy

recommendations and counseling from health workers improved their health

behaviors in the domain of taking medications, smoking cessation and reducing

alcohol consumption (Kumar, Elayaraja, Shailaja, & Ramasamy, 2011). The result of

the previous study also confirmed for this explanation. For example, study by Peters

and Templin (2008) on 306 hypertensive participants found that participants with

a longer history of hypertension had significantly higher level of health promoting

behaviors (r = .19, p < .01) (Peters & Templin, 2008).

Further, other possible reasons could be socioeconomic status, since most of

the participants at least had primary education, work as government employees

(41.5 %), and earn more than Nu. 20,000 ($ 320). They have better understanding

about the importance of eating healthy foods, taking medications, exercise and

avoidance of unhealthy behaviors like smoking and drinking alcohol. In addition, this

present study was conducted in the capital and the biggest city in the country. This

could have provided participants, an access to practice the recommended health

promoting behaviors because the city has access to availability of resources.

Although participants had high level of health promoting behaviors, more

than 54.1 % of participants had uncontrolled blood pressure. Uncontrolled blood

pressure is found in patients who did not follow health promoting recommendations

specifically nutrition and weight management in present study. This could be

55

explained by the reason that patients might have acquired knowledge on health

promoting behaviors from health care providers but they might not have real

behaviors. Another possible contributing factor for participant’s uncontrolled blood

pressure was most likely from the culture that Bhutanese consume three meals daily

consisting of huge portion of rice which cause overweight resulting in increased blood

pressure (Sasaki, 2011). Further, the traditional Bhutanese dishes are red rice, chilli

pepper, cheese stew, and salted butter tea. Chilli pickles called ezay are frequently

served as appetizers and are consumed in large quantities. Generally, large amounts

of salt are added to both the curry and the pickle or paste (Wangdi, 2013). It was

evident that cultural backgrounds served as important influences on health promoting

behaviors (Pender et al., 2006). In addition having cultural environment in which

the offer of food is practiced as a social norm restricted health promoting behaviors

specifically dietary restriction or adherence which most likely resulted in poor control

of blood pressure.

2. Factors related to health promoting behaviors

There was high positive correlation between health promoting behaviors and

perceived self-efficacy (r = .55, p < .01); low positive correlation between health

promoting behaviors and perceived benefits (r = .26, p < .01); moderate negative

correlation between health promoting behaviors and perceived barriers (r = -.47,

p < .01) and low positive correlation between health promoting behaviors and

perceived social support (r = .27, p < .05) of patients with hypertension. This finding

was supported by theoretical basis. According to Health promotion Model (Pender

et al., 2011), these factors are the motivational mechanisms for individual’s

acquisition and maintenance of health promoting behaviors. They can both directly or

indirectly impact on patient’s practice of such behaviors.

2.1 Perceived self-efficacy and health promoting behaviors

The present study points out that perceived self-efficacy had a significant

high positive correlation with participant’s health promoting behaviors. It is in line

with the hypotheses that the present study had positive correlation with health

promoting behaviors among Bhutanese patients with hypertension (r = .55).

Theoretically, individual demonstrating a high perceived self-efficacy tends to

practice health promoting behaviors. In contrast, low perceived self-efficacy may lead

56

to giving up such behaviors once challenging difficulties arises (Pender et al., 2011).

When a person highly believes in oneself, the perceived barriers will be lowered, thus

can overcome the challenges. Similarly, hypertensive patients have to change their

life style once they are diagnosed with hypertension. Therefore, high perceived self-

efficacy is the crucial factor, determining whether the patient can get over difficulties

in order to adhere to health promoting behaviors.

Findings from other studies also supported those of the present study.

Jaiyungyuen et al. (2008) found, that perceived self-efficacy had positive relationship

with health promotion behaviors in population of people with hypertension (r = .59,

p < .01). Similarly, Warren-Findlow et al. (2012) in the study of 190 African-

American adults with hypertension found that people with high perceived self-

efficacy had higher prevalence of engaging in physical activities and eating low salt

diet. Similar, study by Ho et al. (2012), of 107 patients with hypertension found that

perceived self-efficacy was positively related to health promoting behaviors of

hypertension patients and explained most variance in health promotion behaviors

(β = .31, p < .01). Furthermore, study of 234 elderly women with hypertension in

South Korea, Yang et al. (2014), also supported the finding of present study, that

perceived self-efficacy had positive relationship with health promoting behaviors

(r = .60, p < .001).

2.2 Perceived benefits and health promoting behaviors

There is positive relationship between perceived benefits and health

promoting behaviors among Bhutanese patients with hypertension. The results also

identified that perceived benefits had low positive relationship with health promoting

behaviors in hypertensive patients in this study (r = .26). According to Pender et al.

(2011), individuals tend to engage in health promoting behaviors if they perceived

positive outcomes. Likewise the participants demonstrated that they had a high level

of perceived benefits of health promotion behavior and hypertension control. All

agreed that regular exercise, eating low fat foods, maintain a normal weight, and

smoking cessation decreases the risk of complications and helps in preventing high

blood pressure. Similarly, all agreed that annual checkups were important for

detecting complications. These findings are similar to previous research. Thanavaro et

al. (2006), found that, perceived benefits was positively related to health promotion

57

behaviors (r = .38, p < .01). In their study, the participants identified improving

health, feeling better, and living longer as perceived benefits of health promotion

behaviors (Mosca et al., 2006; Thanavaro et al., 2006). Similarly, the study by

Nangyaem et al. (2007) among 198 hypertensive patients, the result supported the

finding that perceived benefits was significantly related to health promoting

behaviors among hypertensive patients (r = .27, p < .01).

2.3 Perceived barriers and health promoting behaviors

There is negative relationship between perceived barriers and health

promoting behaviors among Bhutanese patients with hypertension. The result

identified that there was moderate negative relationship between perceived barriers

and health promoting behaviors (r = -.47). According to Pender et al. (2011),

perceived barriers consists of perceptions about the unavailability, inconvenience,

expensive, difficulty, or time consuming nature of a particular action that affect health

promoting behavior directly by serving as blocks to action as well as indirectly

through decreasing commitment to a plan of action. Studies demonstrated that

perceiving either environmental or personal barriers was inversely associated with

health promotion behavior. In this study, maximum number of participants had at

least primary education, indicating that individuals with education perceived that they

experienced barriers less frequently than other participants. One reason for this is that

those with education have the means to seek care and know the value of health

promoting behavior, thus gaining the benefits that providers can contribute in

the form of education regarding health promotional behaviors (Lusk, Kerr, & Ronis,

1995). Further, in this study majority of participants were in between the age group

41-60 years which represented adult people who might have perceived minimal

barriers compared to elderly people (Wen, Parchman, & Shepherd, 2004).

The relationship between health promoting behaviors and perceived barriers in this

study is similar to the finding of Nangyaem et al. (2007), that perceived barriers was

related to health promoting behaviors (r = -.175, p < .01) (Nangyaem et al., 2007).

In contrast, the findings of present study were not consistent with Pierce (2005) which

found that there were no significant relationship between perceived barrier and health

promoting behaviors.

58

2.4 Perceived social support and health promoting behaviors

There is positive relationship between perceived social support and health

promoting behaviors among Bhutanese patients with hypertension. The results

revealed that there was low positive relationship between perceived social support and

health promoting behaviors (r = .27). This finding was supported by both theoretical

and studied basis. According to Pender et al. (2011), the support from others played

a crucial role to encourage patients in having health promoting behaviors. High level

of perceived social support leads to increased attachment, social integration,

nurturance, reassurance of worth, and perceived availability of assistance from others

in managing hypertension. Kanittha, Sukanya, Sutham, and Chokchai (2010) explored

341 hypertensive patients and reported that perceived social support was positively

related with health promoting behaviors (r = .40, p < .001). Jaiyungyuen et al. (2008),

in study of older people with hypertension also found that social support was

positively related to health promotion behavior in hypertensive patients (r =.38,

p < .01). Similar study by Ho et al. (2012), also found that social support was

significantly related to health promotion behaviors in adult patients with hypertension

which supports the findings of this study. The study found that better social support,

the better practice of health promoting behaviors. It can be explained that,

hypertension, as a chronic condition remains throughout in the lifetime. Therefore, the

disease requires the patients to change the lifestyle, habits and attitudes to their health.

Consequently, the patients need more support from significant others to deal with the

disease in their daily life.

In conclusion, for examining the health promoting behaviors of hypertensive

patients in Bhutan, it was apparent that sample in this study reported high level of

health promoting behaviors in order to manage hypertension. The study showed that

participants had high level of health promoting behaviors in the domain of taking

medications, physical activities, smoking cessation, limiting alcohol consumption and

stress management while nutrition and weight management had moderate level.

As expected, there were relationships between health promoting behaviors and

perceived self-efficacy, perceived benefits, perceived barriers and perceived social

support. Specifically, perceived self-efficacy found to have high correlation,

59

perceived barriers had moderate correlation and perceived benefits and perceived

social support had low correlation.

Implications

The findings of this study can be applied for clinical nursing practice,

nursing research and nursing education as follows:

For clinical nursing practice, the results of this study provided the nurses

an understanding about health promoting behaviors practices among hypertensive

patients in Bhutan. In addition, the confirmation of the relationships of health

promoting behaviors, perceived self-efficacy, perceived benefits, perceived barriers

and perceived social support provided the basis for clinical nurses to understand

the role of these factors while taking care for the patients with hypertension. Nurses

can provide information about benefits of health promoting behaviors and motivate

individuals to overcome barriers to practice health promoting behaviors. Enhancing

self-efficacy and support from other decreases barriers and helps in understanding

the benefits of health promoting behaviors. Further, nurses can also be confident in

developing nursing plans, for helping patients to have better behaviors in all domains

of health promoting behaviors, specifically in the domains of nutrition and weight

management that this study highlighted as moderate health promoting behaviors

among hypertensive patients.

For nursing education, the findings of this study identified factors including

perceived self-efficacy, perceived benefits, perceived barriers and perceived social

support can motivate the hypertensive patients in engaging and maintaining health

promoting behaviors. Thus, educating student nurses on these variables with focused

to Bhutanese culture may be needed.

For research, the findings identified the related factors of health promoting

behaviors among hypertensive patients in Bhutan. The results from this study may be

used for further research in health promoting behaviors of hypertensive patients and

explore the influences of these variables on health promoting behaviors as well as

develop nursing plan in order to modify health promoting behaviors of hypertensive

patients in Bhutan.

60

Recommendations for future research

Based on the results of the study, following are the recommendations for

future research:

1. Although this study was carried out in a national referral hospital, which

is an apex hospital in the country, it is acknowledged that the findings from a single

setting seem not to be strong enough to represent all the characteristics of Bhutanese

patients with hypertension. Thus, it is recommended that study should be replicated in

multiple settings in order to enhance the generalization of the findings. The results

from this study may also be used for further research to explore the influences of these

variables on health promoting behaviors as well as in order to modify health

promoting behaviors of hypertensive patients in Bhutan.

2. Future research should be predictive design aimed to enhancing patient’s

perceptions towards self-efficacy, perceived benefits, perceived barriers and perceived

social support for promoting and maintaining health promoting behaviors of patients

with hypertension.

Conclusion

With the hypotheses that perceived self-efficacy, perceived benefits,

perceived barriers, and perceived social support are associated with health promoting

behaviors of hypertensive patients; the present study was conducted with

123 participants. Data collected from the questionnaires proved the hypotheses. There

were relationships between perceived self-efficacy, perceived benefits, perceived

barriers, perceived social support and health promoting behaviors of hypertensive

patients. Thus, the findings of this study provided information to strengthen the roles

of perceived self-efficacy, perceived benefits, perceived barriers, and perceived social

support in determining hypertensive patient’s health promoting behaviors. The results

also highlighted a moderate score in nutrition and weight management domains of

health promoting behaviors. Thus, health care professionals, and nurses in particular

should motivate hypertensive patients to engage in proper nutrition and weight

management activities.

61

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70

APPENDICES

71

APPENDIX A

Questionnaires (English version)

72

QUESTIONNAIRES

Date…………………

Code number……….

Questionnaire 1

The Demographic Questionnaire

Direction: Please read each question carefully and answer all questions by

tick mark (√) in the box for your correct response.

Please fill out your information in the space below.

1. Gender Female Male

2. Age…………….. years

3. Education level

Primary school Undergraduate

Secondary School Graduate

High School

4. Occupation

Unemployed Agriculturalist

Governmental office Housewife

Business Retired

5. Marital Status

Single Divorced

Married Widowed

6. Income

Less than Nu.10, 000 Nu. 10,000-20,000

More than Nu. 20,000

73

7. Comorbidity Yes No

Diabetes

Renal failure

Heart disease

Stroke

Others……………………..please specify.

This part of the questionnaires will be filled by the researcher

8. Current blood pressure………………………..

9. Duration of hypertension since diagnosis………………

10. Body mass index………………………(calculated from weight and height)

74

Questionnaire 2

Health Promoting Behaviors Questionnaires (HPBQ)

Direction: This questionnaire contains statements of activities you perform

to manage hypertension and control blood pressure. Please respond to each item by

indicating the frequency of activities you engage in each behaviors. Please fill the

statements by mark (√) in the column.

Never = Means you never perform these activities in a week.

Sometimes = Means you perform these activities 1-2 times per week.

Often = Means you perform these activities 3-4 time per week.

Routinely = Means you perform these activities every day in a week

No.

STATEMENTS

Nev

er

Som

etim

es

Oft

en

Rou

tin

ely

1

Taking Medication

Taking medications at assigned time.

2 …………………………………….

3 …………………………………….

4 …………………………………….

5 Monitor blood pressure.

6

Physical Activity

Perform 30 minutes physical activity like walking,

bicycling, and aerobic dancing.

7 …………………………………………………………

…………………………………………………………

…………………

8

Nutrition

Avoiding fatty foods like fried foods, cheese and butter.

75

No.

STATEMENTS

Nev

er

Som

etim

es

Oft

en

Rou

tin

ely

9 …………………………………………………………

…………………………………………………

10 ……………………………………………………

11 …………………………………………………………

………………………………………………………

12 Avoid using extra salt at meals.

13

Weight Management

Check body weight.

14 Eat meals in smaller portion.

15 …………………………………………………………

16 …………………………………………………………

…………..

17 Avoid sugary and fizzy drinks like coco-cola, Pepsi etc.

18

Smoking Cessation

Quitting smoking at all time.

19 …………………………………………

20 Limit Alcohol

Not drinking alcohol or limit drinking alcohol at all

time.

21 ……………………………………………….

22 Stress Management

Avoid stressful situations

23 ………………………………………………..

24 …………………………………………………..

25 ……………………………………………

26 Practice relaxation or meditation for 15-20 minutes

daily

76

Questionnaire 3

Self-Rated Abilities for Health Practices Scale (SRAHPS)

Direction: The following scale asks your confidence in performing various

health promoting behaviors. Read each statement and use the following scale to

indicate how well you are able to perform each of the activities. Please fill the

statements by mark (√) in the column.

No Statement

Not

at

all

A l

ittl

e

Som

ewh

at

Most

ly

Com

ple

tely

1 2 3 4 5

1 Find healthy foods that are within my budget

2 Eat a balanced diet

3 Figure out how much I should weight to be

healthy

4 …………………………………………

5 …………………………………………

6 ………………………………………...

7 …………………………………………

8 ………………………………………....

9 …………………………………………

10 …………………………………………

11 …………………………………………

13 …………………………………………

14 ……………………………………………..

15 …………………………………………

16 ………………………………………………

17 Find ways to exercise that I enjoy

18 Find accessible places for me to exercise in the

community

77

No Statement

Not

at

all

A l

ittl

e

Som

ewh

at

Most

ly

Com

ple

tely

1 2 3 4 5

19 ……………………………………

20 ……………………………………

21 ………………………………………….

22 ……………………………………………………

……………………………

23 ……………………………………………………

……………………………………………..

24 ……………………………………………………

…………………….

25 …………………………………….

26 Find a doctor or nurse who gives me good advice

about how to stay healthy

27 Know my rights and stand up for myself

effectively

28 Get help from others when I need it

78

Questionnaire 4

The Benefits Assessment Scale (BAS)

Directions: The following questions ask about your perception of performing

health promoting behaviors. Please indicate how strongly you agree or disagree to

each statement. There is no right or wrong answers as the statements measure

perception. Please fill the statements by mark (√) in the column.

No Statement

Str

on

gly

Dis

agre

e

Dis

agre

e

Agre

e

Str

on

gly

A

gre

e

1 2 3 4

1 Regular exercise may decrease my chances of a heart

attack.

2 Even if I eat a low fat diet I will not reduce my chance of

heart disease.

3 Regular exercise helps reduce tension and stress.

4 ……………………………………………………

..............................

5 ……………………………………………………………

……………………………..

6 ……………………………………………………………

…………………

7 ……………………………………………………………

………………….

8 ……………………………………………………………

…………………..

9 ……………………………………………………………

……………………

79

No Statement

Str

on

gly

Dis

agre

e

Dis

agre

e

Agre

e

Str

on

gly

A

gre

e

10 Regular exercise can make me feel I have more energy.

11 If I stopped smoking I will lower my chances of heart

disease

12 If I have smoked for many years it is too late to stop now

80

Questionnaire 5

Barriers to Health Promoting Activities Scale (BHPAS)

Direction: People sometimes perceive that they are not able to perform or

practice health promoting behaviors to manage hypertension. Please fill the

statements by mark (√) in the column which best indicates how much each of these

problems keeps you from taking care of your health.

No Statement

Nev

er

Som

etim

es

Oft

en

Rou

tin

ely

1 2 3 4

1 Lack of convenient facilities

2 Too tired

3 Lack of transportation

4 Feeling what I do doesn't help

5 …………………………………

6 …………………………………

7 ………………………………..

8 ……………………………….

9 …………………………………………

10 …………………………………………

11 …………………………………..

12 ………………………………………

13 …………………………………………….

14 …………………………………………

15 Feeling I can't do things correctly

16 Difficulty with communication

17 Bad weather

18 Lack of help from health care professionals

81

Questionnaire 6

Personal Resource Questionnaire (PRQ2000)

Direction: Below are some statements with which some people agree and

others disagree. Please indicate how you perceive that you have adequate support

from other people. Please read each statement and respond which is most appropriate

for you. There is no right or wrong answer. Please fill the statements by mark (√) in

the column.

No Statement

Str

on

gly

dis

agre

e

Dis

agre

e

Som

ewh

at

dis

agre

e N

eutr

al

Som

ewh

at

agre

e

Agre

e

Str

on

gly

agre

e

1 2 3 4 5 6 7

1 There is someone I feel close to who makes

me feel secure

2 I belong to a group in which I feel important

3 People let me know that I do well at my work

4 ………………………………………………

…………………………

5 ………………………………………………

……………………….

6 ………………………………………………

……………………………………….

7 ………………………………………………

…………………………………

8 ………………………………………………

………………..

9 ………………………………………………

………………………………..

82

No Statement

Str

on

gly

dis

agre

e

Dis

agre

e

Som

ewh

at

dis

agre

e N

eutr

al

Som

ewh

at

agre

e

Agre

e

Str

on

gly

agre

e

1 2 3 4 5 6 7

10 ………………………………………………

……………………………

11 ………………………………………………

……………………………..

12 ………………………………………………

13 ………………………………………………

……………

14 I have people to share social events and fun

activities with

15 I have a sense of being needed by another

person

83

APPENDIX B

Permission letter to use instruments

84

Permission letter to use Benefits Assessment Scale

To

cmurdaugh@nursing.arizona.edu

Dec 28 at 12:38 PM

Dear Dr. Murdaugh,

I am Hem Kumar Nepal, a master student at Faculty of Nursing, Burapha

University, Thailand. As a partial requirement of master degree, I am conducting a

study “Factors related to health promoting behaviors among hypertensive patients in

Bhutan.

Therefore, I would like to seek your permission to use your instrument "The

Benefits Assessment Scale".

I would look forward to hearing from you soon.

Thanking you,

Yours Sincerely

Hem Kumar Nepal

Murdaugh, Carolyn L - (carolyn5)

To

me

Dec 28 at 8:40 PM

I apologize for the delay in responding. I am out of town and will return on

Monday, December 29. You have permission to use the instrument, so I will send you

the scale and scoring key when I return. Happy New Year. Carolyn Murdaugh

Carolyn Murdaugh RN PhD FAAN

Professor Emerita & Adjunct Professor

College of Nursing

University of Arizona

85

Permission letter to use Self- Rated Abilities for Health Practices Scale

(SRAHPS) and Barriers to Health Promoting Activities Scale

To

astuifbergen@mail.utexas.edu

Dec 24 at 3:46 PM

Dear Dr. Stuifbergen,

I am Hem Kumar Nepal, a master student at Faculty of Nursing, Burapha

University, Thailand. As a partial requirement of master degree, I am conducting a

study “Factors related to health promotion behaviors among hypertensive patients in

Bhutan".

Therefore, I would like to seek your permission to use your two instruments

1. Self- Rated abilities for Health Practices Scale (SRAHPS)

2. Barriers to Health Promoting Activities Scale

I would look forward to hearing from you soon.

Thanking you,

Yours Sincerely

Hem Kumar Nepal

Dr. Becker and I are happy to allow you to use the instruments. You are free to adapt

or translate as needed for your research. We ask only that you cite the original source

and reference for the instruments.

Best wishes,

Alexa K. Stuifbergen, PhD, RN, FAAN

Dean

Laura Lee Blanton Chair in Nursing

James R Dougherty Jr., Centennial Professor in Nursing

The University of Texas at Austin

School of Nursing

1700 Red River, Austin, TX 78701

(512) 471-4100

86

Permission letter to use Personal Resource Questionnaires (PRQ2000).

November 24, 2015

Hem Kumar Nepal

Burapha University

Thailand

Ms. Nepal:

Please let this letter serve as your permission to use the PRQ85 or PRQ2000.

Any changes to question stems or answer sets must be approved in advance.

Translation of the PRQ into other languages is acceptable and encouraged. A copy of

the translated version of the PRQ should be sent to me. If you do, in fact, use the PRQ

for data collection in your study, I ask that you send me an abstract of your findings.

Should you have any questions or need clarification, kindly write or e-mail

cweinert@montana.edu. I will try to respond in a timely manner.

Thank you for your interest in the PRQ. I hope that this social support measure will

be helpful in your research.

Sincerely,

Clarann Weinert, SC,PhD,RN,FAAN

Professor Emerita

www.montana.edu/cweinert

87

APPENDIX C

Participants consent form

88

PARTICIPANTS INFORMATION SHEET

Dear …………

I am Hem Kumar Nepal a master student at the Faculty of Nursing, Burapha

University, Thailand. I am conducting a study “Factors Related to Health Promoting

Behaviors among Hypertensive Patients in Bhutan”. The objectives of this study are to

examine the perceived self-efficacy, perceived benefits, perceived barriers, and

perceived social support and their relationships to health promoting behaviors of

hypertensive patients in Bhutan. Therefore, I would like to invite you to participate in

this study.

This study is a survey design, and your participation is voluntary. If you agree to

participate in this study, you will be asked to answer some questions which may take

approximately one hour. There are no personal benefits from the study. The findings

will be presented as a group of participants and not individual. The result will be used

to improve nursing knowledge for the benefits of patients. You have the right to end

your participation in this study at any time without any penalty, and not necessary to

inform the researcher. Any information received from this study, including your

identity, will be kept confidential. A coding number will be assigned to you and your

name will not be use. All data will be destroyed completely within 1 year after

publishing or presenting the findings. You will receive a further and deeper

explanation of the nature of the study upon its completion, if you wish. The research

will be conducted by Hem Kumar Nepal, under supervision of my major advisor,

Assistant Professor Dr. Wanlapa Kunsongkeit. If you have any questions, please

contact me at telephone number 17976636 by or email: hemlotus2003@yahoo.co.in

and /or my advisor’s email address: jawanlapa@gmail.com. Your cooperation is

highly appreciated. You will be given a copy of this consent form to keep.

Name of Researcher: Hem Kumar Nepal

89

CONSENT TO PARTICIPATE IN A RESEARCH STUDY

Title: “Factors Related to Health Promoting Behaviors among Hypertensive

Patients in Bhutan”.

IRB approval number 11-01-2556

Date of data collection ……………Month……………..Year……………

Before I give signature in below, I am informed and explained about the

purposes, method, procedures, and benefits of the study by researcher, Mr. Hem

Kumar Nepal. I understood all of that explanation. I agree to be a participant of the

study and have received a copy of this form.

I Mr. Hem Kumar Nepal, as researcher had explained all details about

purposes, methods, procedures, and benefits of this study to the participant with

honesty. All of data/ information of the participants will only be used for the purpose

of this study.

Name and signature of participant Date…………..

(……………………………..)

Name and signature of witness…………………………

(………………………………)

Name and signature of researcher………………………..

(………………………………)

90

APPENDIX D

List of experts

91

LIST OF EXPERTS

1. Assistant Professor Dr. Kanitha

Hanprasitkam

Faculty of Medicine,

Ramathibodi Hospital,

Mahidol University, Thailand.

2. Dr. Varin Bihosen

School of Nursing,

Rangsit University,

Pathum Thani, Thailand

3 Assistant Professor Dr. Waree Kangchai

Faculty of Nursing,

Burapha University, Thailand.

4. Assistant Professor Dr. Supaporn

Duangpaeng

Faculty of Nursing,

Burapha University, Thailand.

5. Associate Lecturer Mrs. Kinga Pemo School of Nursing and Midwifery,

Deakin University, Melbourne,

Australia.

92

APPENDIX E

IRB approval and data collection letters

93

94

94

95

95

96

BIOGRAPHY

Name Hem Kumar Nepal

Date of Birth October 7, 1974

Place of Birth Beldara, Pemathang, Samdrupcholing,

Samdrupjongkhar

Present address Regional Referral Hospital, Mongar, Bhutan

Email address hemlotus2003@yahoo.co.in

Position held

1999 General Nurse Midwife (GNM),

Jigme Dorji Wangchuck National Referral

Hospital, Thimphu Bhutan

2000-present General Nurse Midwife,

Regional Referral Hospital, Mongar, Bhutan

Education

1998 Diploma in Nursing and Midwifery,

Royal Institute of Health Sciences (RIHS),

Thimphu, Bhutan

2003 Certificate in Critical Care Nursing,

Boromorajonani College of Nursing,

Bangkok, Thailand

2009 Bachelor of Nursing Science,

RIHS in collaboration with LaTrobe University,

Australia

2015 Master of Nursing Science

(International Program)

Burapha University, Chonburi, Thailand