Current Issue

Hypertension (HTN) is a major risk factor of cardiovascular disease (CVD) among various populations (World Health Organization [WHO], 2013). Well-controlled blood pressure(BP) has proven to reduce the risk of stroke, cardiovascular, all-cause mortality and heart failure (Briasoulis, Agarwal, Tousoulis, & Stefanadis, 2014). However, the rate of patients with well-controlled BP has hardly improved from 11.7% in 2000 to 13.8% in 2010 (Mills et al., 2016).

In Korea, prevalence of HTN was higher in rural areas (38.3%) than in urban areas (32.5%) in 2016. The prevalence of HTN is much higher in the population aged 65 years or older (65.2%) than in the population 30 years or older (33.5%) (Korea Center for Disease Control and Prevention [KCDC], 2017). There is a proportionately larger number of older adults in rural areas of Korea where HTN is a major health problem (Jeon, 2003).

HTN patients are asked to take medicine and change their lifelong habits. They need to know the risk of raised BP and how to control it (WHO, 2013). Traditional didactic education informing knowledge about HTN to patients and warning them of negative results shows no significant change (Clement, 1995). Behavioral changes can be elicited when patient’s awareness, self-motivation, confidence are sufficient. Therefore, psychological influencers should be self-determined and show continuous efforts (Jo, Jung, & Lee, 2012). It requires a patient-centered approach for active involvement of patients and improvement of knowledge, higher compliance, and improved health (Hibbard, Greene, & Overton, 2013). Health counseling is known to be effective to change individual’s health behavior because it enables identifying specific problem, providing appropriate information, finding and eliminating barriers (Kim, 2002). Patient-centered approaches such as motivational interviewing (MI) are known to promote lasting behavioral changes. The principles of MI are to resist, to understand, to listen, and to empower patients. It lays emphasis on stage of change and ambivalence of change. MI uses the skills of open-ended questions, affirmations, reflective listening, and summaries (Rosengren, 2013).

Health coaching is also a method to improve self-care and patient involvement (Huffman, 2009). It empowers patients through self-determined goals, achievement of small successes, and tailored learning with support (Wolever & Dreusicke, 2016). Coaching skills include active listening, open-ended questions, feedback, attitudes, and so on. Opening, goal setting, action planning, practicing, and feedback can be considered as a process. Coaching also considers patient’s value and belief but it focuses more on patient’s own goal and their practice (Ito, 2002).

The purpose of this study is to investigate the effects of counseling program based on coaching on HTN patients in the process of lifestyle modification at Public Health Center (PHC) branches. These findings would help to develop a patient-centered program to manage chronic conditions and to plan an education program for community health workers (CHW).

The mean score of knowledge about HTN increased from 7.32±1.96 to 9.03±1.87 (p<.001). All the items except ‘Drinking alcohol lowers BP’ (p=.206) showed increased scores. Knowledge about diagnostic criteria of HTN of SBP increased from 0.28±0.45 to 0.63±0.48 (p<.001) and that of DBP also increased from 0.27±0.50 to 0.57±0.50<Table 3>.

Self-care score increased in both medication and diet. Medication day per week increased from 6.77±0.99 to 6.94±0.57 (p<.001) and timely medication per week also increased from 6.46±1.39 to 6.92±0.60 (p<.001). Score of not eating salted food increased from 5.22±2.35 to 6.24±1.41 (p<.001) and that of not adding salt increased from 6.55±1.22 to 6.91±0.56 (p<.001). Self-efficacy increased significantly. ‘I know well about HTN’ increased from 61.69±18.70 to 73.97±15.32 (p<.001). ‘I can manage HTN well’ increased from 65.34±18.20 to 75.52±15.67 (p<.001)<Table 3>.

Patients’ health status score increased significantly from 65.30±18.20 to 75.50±15.67 (p<.001). They also showed major improvements in health behaviors. The number of smokers decreased by 31.8% from 44 (9.1%) to 30 (6.1%) (p=.009). Daily amount of cigarettes decreased from 12.80±8.63 to 9.20±8.98 (p=.011). The number of alcohol drinkers decreased by 10.9% from 193 (39.5%) to 172 (35.2%) (p=.022). Frequency of drinking decreased from 7.60±9.23 to 5.40±7.41 per month (p=.001) and amount of alcohol intake also decreased from 0.70±0.49 to 0.60±0.47 bottles a time (p=.003). Therefore, monthly amount of alcohol intake decreased from 8.00±13.08 to 4.60±7.39 bottles (p=.001). People who exercise increased from 309 (63.2%) to 411 (84.0%) (p<.001), so 102 of 180 (56.7%) patients who had not exercised started to exercise after counseling. Frequency of exercise increased from 2.90±2.54 to 4.10±2.10 a week (p<.001) and amount of exercise also increased from 29.80±21.15 to 40.40±13.08 minutes at a time (p<.001). Thus, monthly amount of physical activity increased from 502.70±480.30 to 717.68±438.80 minutes (p<.001)<Table 4>.

The number of participants with well-controlled BP increased from 322 (65.8%) to 416 (85.1%) (p<.001). Mean of SBP decreased from 132.90±13.99 to 125.70±11.10mmHg (p<.001) and that of DBP also decreased from 78.10±9.71 to 74.70±9.33 mmHg (p<.001). BMI also decreased from 27.10±11.64 to 25.80±7.25 (p=.011)<Table 4>.

In multilevel logistic regression, gender, physical activity at the end and SBP control at the beginning showed significant OR in model I. Physical activity at the end and SBP control at the beginning presented significant OR also in model II. Patients who did not practice physical activity were less likely to have (OR=0.333) well-controlled SBP at the end compared to those who participated in physical activity. Patients who had well-controlled SBP at the start were more likely to have (OR=3.460) well-controlled SBP at the end in comparison to who did not start with well-controlled SBP from the beginning<Table 5>.

This study investigated the effects of counseling program on HTN patients lifestyle modification at PHC branches. It showed significant improvements in knowledge, medication compliance, diet, self-efficacy, health status, smoking, drinking alcohol, exercise, SBP, and DBP.

Positive changes were evident after the counseling program. Firstly, patients became more knowledgeable about HTN. Patients answered 10 out of items correctly except the ‘drinking alcohol lowers BP’ item. For items like ‘If your mother or father has HTN, your chance of getting it is higher’ and ‘HTN is not life-threatening’, only 30~40% of patients answered correctly before coaching but 60~70% of the patients learned the right answer. Meanwhile patients seem to already have a good level of knowledge since the average value of the sum of knowledge items changed from 7.32 to 9.03<Table 3>, coaching seems to contribute to raise patients’ knowledge of HTN. Improved knowledge itself does not elicit a behavioral change, but certainly provides the basis (Gu, Zhang, Wang, Zhang, & Chen, 2014).

Secondly, patients showed better medication compliance, diet, smoking, drinking alcohol, exercise, and weight loss with increased self-efficacy. Both the days of medication taken and the rate of timely medication increased. Reduced salt intake was encouraged but patients did not consume more fruits or vegetables than before. Gu et al. reported that patients who know the relation between BP and salt intake are more likely to control HTN (Gu et al., 2014). Unchanged intake of fruit or vegetable seems related to the high cost and lack of systemized supply of fruits in the rural area where the patients reside. A previous study reported that older adults in a rural area ate more vegetables but less fruits in comparison with those in urban area (Kim, Seo, Kwon, & Cho, 2012). Another study also reported that older adults have the difficulty of making salad with sauce (Bae et al., 2019). Thirty-two percent of patients quit smoking, 11% of patients quit alcohol, and 57% of patients started exercise through this program. These desirable changes in lifestyle seem to come from raised awareness and self-efficacy. Hypertensive patients who lack knowledge of the HTN disease are unlikely to adhere to recommended treatments strictly (Whelton et al., 2018). In self-efficacy, both items of ‘I know HTN well’ and ‘I can manage HTN well’ increased significantly. Ding et al. reported self-efficacy as a major clue to bring better self-management and HTN control (Ding, Li, Su, Yuan, & Lin, 2018). In this program, patients had the chance to make daily goals and receive assistance to achieve their goals. They experienced a sense of achievement in lifestyle modification and became more proficient on how to do so than before.

Thirdly, patients became more able to control both SBP and DBP. SBP decreased significantly from 133 mmHg to 126 mmHg and DBP decreased from 78 mmHg to 75 mmHg. In this study, the BP goal was 120/80 mmHg and the rate of reaching the goal increased from 66% to 85%. Patients taking the medicine regularly, consuming less salt, and doing more exercise also seem to have improved BP. It is unclear whether the decrease in BP is due to increased drug compliance or other behavioral changes. Besides pharmaceutical treatment, best-proven non-pharmacologic interventions for treatment of HTN are weight loss, healthy diet, reduced intake of sodium, enhanced intake of potassium, physical activity, and moderation in alcohol intake (Whelton et al., 2018). The following behavior change induces to lower SBP in hypertensive patients: 1) Weight loss, –5 mmHg; 2) healthy diet such as Dietary Approaches to Stop HTN (DASH) dietary pattern, –11 mmHg; 3) reduced intake of dietary sodium, –5 mmHg; 4) enhanced intake of dietary potassium, –4 mmHg; 5) physical activity, –4~6 mmHg; 6) moderation in alcohol intake (men≤two glasses of alcohol daily, women≤one glass of alcohol daily), –4 mmHg (Whelton et al., 2018). We analyzed additionally multilevel logistic regression to investigate factors associated with achieving well-controlled BP after the program. It showed no practice of physical activity at the end (OR=0.333) and SBP control at the start (OR=3.460) are statistically significant to achieve well-controlled SBP after adjusting branch level. Exercise training including endurance, dynamic resistance, and isometric resistance training is known to lower SBP and DBP (Carnelissen & Smart, 2013). However, we did not analyze the kind of exercise that the participants did. Maintaining well-controlled SBP and encouraging patients partake in physical activity would be helpful to manage SBP in community.

This study has some limitations. Firstly, it is difficult to conclude whether the effects are only owing to our counseling program because there is no control group. Some patients may show improvements solely by chance and some patients may get worse. This is a major limitation, but this study is based on a community program through PHC branches, making recruiting control group not possible. It is uncertain whether coaching is the best tools in counseling since there is no comparable group with other counseling approaches including motivational interviewing or cognitive behavioral therapy. We recognize the potential difficulty in CHWs’ drawing behavioral changes from the deep-intertwined psychological aspects of ambivalence or cognitive dissonance. It seems more convenient to apply coaching as a counseling tool that focuses on goal setting, making action plan, and supporting older adults in a rural area.

Secondly, most of the patients are older adults in the rural area, more than half of the patients are as same as seventy years old or older. Older adults are less likely to change their lifestyle even those with chronic diseases. PHCs are exceptional in urban areas, but older adults residing in the urban area are less likely to visit PHCs for their treatment of disease, making it difficult to apply the same program to them.

Thirdly, HTN control is meaningful when it prevents complications including heart attack, heart failure, stroke, and kidney failure (WHO, 2013). However, six month is relatively short to check whether complications of new onset. It is unknown whether BP control through the counseling program could ultimately prevent complications, a limitation of most educational program research. Through our study, we present BP control in this study but it is well known that if HTN is detected early and treated appropriately, mortality or morbidity risks can be minimized (WHO, 2013; Briasoulis et al., 2014).

Lastly, this counseling program did not include a detailed meal management. In this study, items used to check diet showed low internal consistency. Patients showed improvement in diet associated with salt but did not so in diet associated with fruits and vegetables. Various dietary modifications are known to be beneficial in the treatment of hypertension, including reduction of sodium intake; moderation of alcohol intake; and consumption of fruits, vegetables, legumes, and low-fat dairy products intake, and lowering snacks, sweets, meat, and saturated fat intake. DASH diet program by a professional nutritionist significantly reduces SBP from 136 mmHg to 126 mmHg in Korea (Jo et al. 2006). This program focuses on helping patients understand themselves and implement their own needs so that they may be free from having to adjust their meals. It would be better to provide a structured curriculum for BP-lowering meals, diet education, counseling protocol, or community meal program in the future.

We did not analyze relations between comorbidities and BP control. Some studies report the need for better BP control in patients with comorbidities (Bramlage et al., 2010; Yang et al., 2017). Another study reported failed HTN control in patients with comorbidities (Gu et al., 2014). We focus on patients without comorbidities but with risk factors.

This study has strengths in two perspectives. First is the training of CHWs as health coaches works. CHWs are professionals who support healthcare and have a close understanding of communities through shared culture, language, and life experiences (Centers for Disease Control and Prevention (US), 2015). Health coaching by health workers has emerged as an effective model for reduction of CV risks (Willard-Grace, Chen, Hessler, Bodenheimer, & Thom, 2015) including HTN (Margolius et al., 2012; Dye, Williams, & Evatt, 2015; Thom et al., 2015). One study demonstrated the improvement of HTN management among rural residents aged 60 years or older through education and support with trained community volunteers (Dye et al., 2015). There are studies that illustrate that health coaching improves BP control and more coaching encounters elicit a greater reduction in BP (Margolius et al., 2012), and health coaching improves medication compliance (Thom et al., 2015). This study develops a successful education and practice guide for CHWs in health coaching and it seems to work successfully, impliciting that we can increase the health indices of hypertensive patients by introducing health coaching with community resources. In addition, the program can be extended to the entire public health network.

The other strength is that coaching brings about desirable changes in lifestyle and BP control on older adults, changing the way of education into a patient-centered interactive form. In our coaching program, patients play an important role through increased level of knowledge, self-efficacy and changing lifestyle. Health coaching covers various setting such as clinical practice, primary care, and health promotion program (Yoon et al., 2013; Eom, & Lee, 2017). Health coaching incorporates patient education, navigation, collaborative goal setting, and personal support, which are components of the Chronic Care Model (Glasgow, Orleans, Wagner, Curry, & Solberg, 2001). It requires encouraging informed and activated patients who have the skills and confidence to manage their health and also prepared, proactive providers who have the information, resources, and time to ensure and deliver effective intervention (Glasgow et al., 2001).

A meta-analysis of randomized controlled trials practicing 6 months or more comparing the effect of implementation strategies versus usual hypertensive care on BP reduction clearly demonstrates that multi-component strategies at the health system, provider, and patient levels are essential for BP control (Mills et al., 2018). Implementation strategies on SBP reduction are as follows: team-based care with titration by non-physician, –7.1 mmHg; team-based care with titration by physician, –6.2 mmHg; multilevel strategy without team-based care, –5.0 mmHg; health coaching, –3.9 mmHg; electronic decision-support system, –3.7 mmHg; home BP monitoring, –2.7 mmHg; provider training, –1.4 mmHg; audit and feedback, –0.8 mmHg. Multilevel, multicomponent strategies may yield the best results, but we suggest that the patient-level strategies of health coaching, home BP monitoring combination are as effective due to limited resources (Mills et al., 2018).

In this study, we conduct a patient-centered counseling program that provides education through interactive communication between CHW and patients. A health coach and patient should be determined to collaborate on achieving common goals using self-discovery, self-monitoring, and active learning to improve lifestyle and BP. As the importance of management by patients themselves in daily life is increasing, it is desirable to provide coaching education. Despite some limitations, this program for hypertensive patients shows positive effects on knowledge, self-care, lifestyle modification, and BP control. This study also demonstrates that training and supporting health care workers for patient-centered counseling management program based on coaching can be implemented in the community.