Cogent Medicine

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Does family involvement in patient education improve

hypertension management? A single-blind randomized,
parallel group, controlled trial

Masumeh Hemmati Maslakpak, Behrooz Rezaei & Naser Parizad |

To cite this article: Masumeh Hemmati Maslakpak, Behrooz Rezaei & Naser Parizad | (2018)
Does family involvement in patient education improve hypertension management? A single-
blind randomized, parallel group, controlled trial, Cogent Medicine, 5:1, 1537063, DOI:
10.1080/2331205X.2018.1537063

To link to this article: https://doi.org/10.1080/2331205X.2018.1537063

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Maslakpak et al., Cogent Medicine (2018), 5: 1537063
https://doi.org/10.1080/2331205X.2018.1537063

PUBLIC HEALTH & PRIMARY CARE | RESEARCH ARTICLE

Does family involvement in patient education
improve hypertension management? A
single-blind randomized, parallel group,
Received: 11 May 2018 controlled trial
Accepted: 13 October 2018
First Published: 16 October 2018 Masumeh Hemmati Maslakpak1, Behrooz Rezaei2 and Naser Parizad3*

*Corresponding author: Naser Abstract: This study aimed to evaluate the effectiveness of family involvement in
Parizad, Urmia University of Medical
Sciences, Urmia, IR Iran patient education on hypertension (HTN) management. This single-blind rando-
E-mail: [email protected]
mized, parallel group controlled trial was conducted in Sayyed-Al Shohada hospital
Reviewing editor: in Urmia. One hundred participants who met inclusion criteria were selected by
Albert Lee, Centre for Health
Education and Health Promotion, convenience sampling and randomly allocated into control, patient-oriented,
The Chinese University of Hong
Kong, Hong Kong family-oriented and patient and family-oriented groups. Interactive educational
interventions were given to three intervention groups for four months. The control
Additional information is available at
the end of the article group received routine care. The Hill-Bone Compliance to High Blood Pressure
Therapy Scale and a mercury manometer were used to collect data. Data was
analyzed using SPSS V20. The results showed a significant difference in the mean
scores of the medical treatment compliance (primary outcome) and blood pressure
(BP) among four study groups after the intervention (p < 0.0001). Tukey’s test
revealed that medical treatment compliance significantly improved in the patient
and family-oriented group compared to other groups after the intervention

ABOUT THE AUTHORS PUBLIC INTEREST STATEMENT

Masumeh Hemmati Maslakpak has a Ph.D. in “Hypertension is quite prevalent among the
nursing. Currently, she is an associate professor Iranian population. The awareness of hyperten-
in the Urmia nursing and midwifery faculty. She is sion is generally low in Iranians. Despite strong
also working as an educational deputy of faculty recommendations for prescribed therapy only
and active member of the Maternal and 40–50% of patients adhered to their treatment.
Childhood Obesity Research Center with an Poor medical treatment compliance prevents the
interest in study design, data analyzing and patients from controlling their blood pressure. An
manuscript writing and editing. uncontrolled blood pressure, in turn, results in
Behrooz Rezaei has a master of science innur- frequent visits to medical centers, reduction in
sing. He works full-time as an RN in a hospital the quality of life of patients, and an increase in
who actively participated in designing, collecting medical costs. This study aimed to evaluate the
and writing of the manuscript. effectiveness of family involvement in patient
Naser Parizad has Ph.D in nursing. He is work- education on hypertension management. In this
Naser Parizad ing as an assistant professor in Urmia nursing study, 100 eligible participants, including patients
and midwifery faculty and an interest in a num- and their family members were investigated in
ber of areas of nursing research who worked four different groups. The results showed that
closely with the research team to design the trial, interactive educational interventions have a
write, edit and approve the final manuscript. beneficial effect on treatment compliance.
Patient education with the presence of a family
member will promote adopting a healthier life-
style, better managing blood pressure and
eventually reduces the medical cost for patients
and healthcare systems”.

© 2018 The Author(s). This open access article is distributed under a Creative Commons
Attribution (CC-BY) 4.0 license.

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(p < 0.0001). Family involvement in patient education had a beneficial effect on

treatment compliance and patient outcomes. Patients education with the presence
of a family member will promote adopting a healthier lifestyle and better managing
BP in patients with HTN. It will eventually reduce the medical cost for patients and
healthcare systems.

Subjects: Nursing; Nurse Education & Management; Nursing Research; Primary Care
Nursing

Keywords: hypertension management; patient; family members; education; randomized

controlled trial; Iran

1. Introduction
Cardiac vascular diseases (CVDs) have been found to be the number one cause of death worldwide.
An estimated 17.7 million individuals died from CVDs in 2015, demonstrating 31% of all interna-
tional deaths (World Health Organization [WHO], 2017). Of these, complications of hypertension
(HTN) account for 9.4 million deaths worldwide every year (Lim et al., 2012). Of these deaths, an
estimated 7.4 million were due to coronary heart disease and 6.7 million were due to stroke (WHO,
2017). HTN is a worldwide epidemic (Stamler, 2013). Globally, around 20% of females and 24% of
males aged 18 and older had a raised blood pressure (BP) in 2015 (World Health Organization
[WHO], 2018). Having HTN is defined as blood pressure (BP) which exceeds of 140/90 mm Hg,
having a physician telling someone twice that they have HTN or if they take anti-hypertensive
medications (Roger et al., 2012). Further, because of weak health systems, the numbers of people
with HTN who are undiagnosed, untreated and uncontrolled are higher in low- and middle-income
countries compared to high-income countries (World Health Organization [WHO], 2013). HTN is
quite prevalent among the Iranian population (Aghaei Meybodi, Khashayar, Rezai Homami,
Heshmat, & Larijani, 2014). Estimation of the overall prevalence of HTN in those ages 30–55 of
the Iranian population was around 23% and 50%, respectively (Haghdoust, Sadeghirad, &
Rezazadeh, 2008). HTN was reported as the most significant risk factor for CVDs in an Iranian
population (Sarrafzadegan et al., 2011).

Despite effective pharmacologic and non-pharmacologic therapies, HTN of approximately half of

adults remains uncontrolled (Magid & Green, 2013; Mozaffarian et al., 2016). According to available
data, the awareness, treatment and control rate of HTN in Iranians are generally low and
estimated to be approximately 50%, 35% and, 16%, respectively (Khosravi et al., 2010). Despite
strong recommendations for prescribed therapy adherence by caregivers, only roughly 40–50% of
those with chronic diseases such as HTN adhered to their medications worldwide (Roberts et al.,
2014). Patient compliance to medical treatment can be defined as following through on the
dietary, medication and lifestyle changes recommended by the health care providers (Leiva
et al., 2010). Poor medication compliance prevents the patients from achieving the goals of their
treatment plans and, ultimately, controlling their BP. An uncontrolled BP, in turn, results in frequent
visits to medical centers, reduction in the quality of life of patients, and an increase in medical
costs (Vervloet et al., 2011).

It is well known that lifestyle factors play a crucial role in the development of HTN and future
steps need to be taken to provide interventions that improve lifestyle factors in economically
developed and developing countries (Bromfield & Muntner, 2013). Several reports have documen-
ted the importance of lifestyle modifications (exercise, a diet rich in fruits and vegetables and low
in fat and sodium, weight control/reduction, restricting alcohol consumption, especially excessive
drinking) in the prevention and treatment of high BP (Baena et al., 2014; Khalesi, Irwin, & Sun,
2018; Weber et al., 2014). A clinical practice guideline by the American Society of Hypertension and
the International Society of Hypertension for the management of HTN recommend lifestyle
modification as an important and effective first-line treatment strategy (Weber et al., 2014). The

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current challenge to clinicians is implementing lifestyle changes in the context of routine medical
care (N. Huang & Duggan, 2008).

Patient education regarding medication compliance along with teaching healthy lifestyle beha-
viors is an effective tool for BP management in the hypertensive population (Hacihasanoğlu &
Gözüm, 2011). A wide range of different strategies and interventions have been used to support
the patients in adherence to treatment plans, although the results are not consistent (Bobrow
et al., 2014). Finding better ways of communicating with patients, such as actively listening to the
patient and including the patient in the decision-making process has been demonstrated to
effectively reduce patient anxiety, along with improving treatment adherence and lifestyle
changes (Cobos, Haskard-Zolnierek, & Howard, 2015). A possible strategy to improve HTN manage-
ment is an extensive education program for the public and people with HTN (Campbell & Sheldon,
2010). Effective change in behavior occurs when learners actively interact with the content to be
learned, with the teacher and with each other (MacKeracher, 2004). Group discussion allows for an
ideal level of interaction and improves communication skills (Meo, 2013). Westberg and Jason
(2004) cite several compelling reasons for using group discussion to promote learning. They believe
learners are more likely to learn from each other in a supportive, nonjudgmental environment. All
group members can both give and receive peer-oriented feedback and they can practice skills that
can be applied later in real-life situations (Westberg & Jason, 2004).

Enhancement of community-wide BP control rates and HTN prevention can only be achieved via
multilevel and multicomponent approaches that include families and many other community
organizations (Beato, 2004). Family-oriented patient education defines as involvement of family
members or significant others in education of patients and may be useful in the control of HTN
(Chobanian, 2003). Family members should be involved in training programs to understand and
identify the needs of patients and to comply with treatment plans and provide care support (Hinkle
& Cheever, 2015). Family involvement plays a significant role in HTN treatment, by encouraging the
acceptance of self-care practices such as proper diet, medication adherence and physical exercise.
Thus, it was considered as a facilitating agent of adherence to treatment (Barreto & Marcon, 2014).
Long-term BP control requires intervention that includes training and reminders about medication,
medical appointments and follow-up to support adherence and persistence on treatment (Bobrow
et al., 2014). This study primarily aimed to evaluate the effectiveness of interventions (small group
discussion) based on a healthy lifestyle on HTN management (medication adherence, low sodium
regimen adherence, medical appointments adherence and the overall treatment compliance) in
four groups (control, patient-oriented, family-oriented, patient and family-oriented groups). The
second objective of the study is to evaluate the effectiveness of interventions on the controlling of
systolic and diastolic BP in patients with HTN. Our hypothesis was that the interactive group
discussion might have an effect on patients’ scores on HTN management and systolic and diastolic
BP in three intervention groups.

2. Methods

2.1. Research design and setting

This single-blind randomized, parallel group controlled trial study was conducted at the Urmia
clinical-educational center of Sayyed-Al Shohada in Iran between December 2015 and March 2016.
The institutional review board of Urmia University of Medical Sciences approved the study
(Research ethical code IR.UMSU.ac.ir.2013.284). The study was carried out in accordance with
the code of ethics of the world medical association (Declaration of Helsinki). This study was
registered in the Iranian Registry of Clinical Trials (Registration number IRCT2015122317059N4).

2.2. Participants
Patients with HTN and their family member were considered as participants in this study. Patients
referring to the clinical-educational center of Sayyed-Al Shohada, were included in the trial if they
met the following criteria: (1) had a known history of HTN for at least a year, (2) aged between 18

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and 60 years, (3) had no underlying health problem such as a history of psychological disorders,
cognitive impairment, hearing problems, chronic kidney failure, or CVDs, and (4) both the patient
and the family member were literate and willing to cooperate in the study. Exclusion criteria
consisted of: (1) patients’ or family members’ failure to participate regularly in the educational
sessions, (2) unwillingness to participate further in the study, (3) having underlying health condi-
tions such as CVDs, cognitive impairment, hearing problems, psychological disorders and chronic
kidney failure and (4) having no family. After consulting with a statistician and considering the
findings of a similar study by Sadeghi et al (SBP = 154.43 ± 16.16 in the intervention group,
SBP = 152.62 ± 14.40 in the control group) the sample size was calculated at 100 participants
for four groups by using the Power Analysis Software. Considering the probability of attrition in the
study, 108 participants were recruited based on the convenience method and assessed for elig-
ibility. Eight participants were excluded due to not meeting the inclusion criteria or not willing to
participate in the study (Sadeghi, Mohseni, & Khanjani, 2014).

Primarily these 100 selected participants were invited to a meeting with researchers. All of them
were given informed consent to sign and participate in the study. At the introductory meeting, the
researchers introduced the objectives of the study and explained the steps involved in the research
process, and recorded participants’ telephone numbers. In the next step, 100 selected participants
were randomly allocated into 4 equal, 25-member groups: control group, patient-oriented group,
family-oriented group and patient and family-oriented group by using four different-colored
envelopes. Patient-oriented group included patients with HTN. Family-oriented group included
designated family members. Patient and family-oriented group included both patients and desig-
nated family members. The participants in the three interventional groups (patient-oriented,
family-oriented and patient and family-oriented groups) were invited to attend another meeting
to select an appropriate time for their interactive educational sessions (Figure 1).

Figure 1. The sampling frame-

Assessed for
work of the study.
eligibility (n = 108)

Excluded (n = 8) , Not
meeting inclusion criteria
(n = 5), Declined to
participate (n =3), Other
reasons (n =0)

Allocated to Allocated to Allocated to

Allocated to control
patient-centered family centered patient- family
group
group (n = 25) groups (n = 25) centered group
(n = 25)
(n = 25)

Lost to follow –up Lost to follow -up Lost to follow –up

Lost to follow –up
(n=0)
(n=0) (n=0) (n=0)

Analyzed (n= 25) Analyzed (n= 25) Analyzed (n= 25) Analyzed (n= 25)
Excluded from Excluded from Excluded from Excluded from
analysis (n=0) analysis (n=0) analysis (n=0) analysis (n=0)

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2.3. The primary outcome measures

All study variables were measured twice: at baseline and after the intervention. The primary
outcome measure was the Hill-Bone Compliance to High Blood Pressure Therapy Scale, as devel-
oped by Kim et al in 2000 (Kim, Hill, Bone, & Levine, 2000). The questionnaire consists of 14
questions which fall into three categories: medication adherence, low sodium regimen adherence
and medical appointments adherence. Nine of 14 questions measured medication adherence such
as “How often do you forget to take your HBP medicine?”. Two items asked about medical
appointments-keeping such as “ How often do you miss scheduled appointments?”. Three ques-
tions calculated low sodium regimen adherence, for example “How often do you eat salty food?”.
Each item was a four-point Likert scale: never (1), occasionally (2), often (3) and always (4); the
maximum and minimum possible scores were 56 and 14, respectively. Higher scores indicate lower
adherence. In the questionnaire, there was also a section for participants’ demographics including
age, gender, marital status, number of children, level of education, place of residence, employment
status, level of income (for patient and family member), how long they have had the disease,
history of HTN in the family, and whether or not the patient has any other major underlying health
problems. In both phases of the study, three researchers interviewed all the participants face-to-
face, going through each question and completing the questionnaires themselves. Interviewing
researchers had been already briefed about and oriented to the questionnaires by the lead
researcher.

This scale has been validated in many investigations, one of which was in a South African
primary health care setting. Lambert et al. verified the criterion validity and internal consistency
of the Hill-Bone Scale; their results were compared favorably with those from an urban African-
American setting (Standardized Cronbach’s alpha was 0.74–0.84) (Lambert, Steyn, Stender,
Everage, & Fourie, 2006). In Iran, Taher et al. confirmed the validity of the scale based on the
content validity approach and under the supervision of 12 faculty members at the Shahid Beheshti
School of Nursing. Moreover, the reliability of the scale was confirmed by calculating the
Cronbach’s alpha coefficient of the scores of 20 patients with HTN; the alpha was found to be
0.80 (Taher, Abredari, Karimy, Abedi, & Shamsizadeh, 2014). In the present study, the content
validity of the scale was verified by 10 nursing faculty members and 5 cardiovascular specialists,
and the reliability of the instrument was calculated to be 0.87, 0.94, 0.79, 0.88, respectively for
total treatment, medication, low sodium regimen and medical appointments adherence using
Cronbach’s alpha.

2.4. The secondary outcome measures

In addition to our primary outcome measures, we also calculated means and standard deviations
(SD) of the six measured BPs. BP was measured by using a mercury manometer (MA-166) which
was fixed on the left arm of participants. Systolic blood pressure (SBP) and diastolic blood pressure
(DBP) measurement were taken while the participants were seated with their right arm at heart
level. In the test session, SBP and DBP were taken three times in the morning and three times in
the evening within 5 minutes apart (Jade, 2018). The average of six measured SBP and DBP was
considered. The same instruments were used for the baseline and follow-up measures.

2.5. Procedure
The content of group discussion was about eating healthy food and decreasing the salt in the diet,
maintaining a healthy weight, increasing physical activity, managing stress, quitting smoking,
monitoring BP at home, adhering medical appointments and adhering medication regime. In this
study, the same educational content was used to educate the three interventional groups. The
participants in the patient-oriented, family-oriented and patient and family-oriented groups, were
subsequently scheduled to attend the educational classes held at the clinical-educational center of
Sayyed-Al Shohada in Urmia.

After consulting with the cardiologist and considering educational content volume, the
research team decided to hold 48 training sessions during the following 4 months. After

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conferring with the participants, the classes were scheduled as follows: The classes were held
four times a week in the first month. They were held three times a week in the second and
third month and twice a week in the fourth month. These interactive educational classes were
held between 8 A.M. and 2 P.M. during working days. Patients and their designated family
members in family-oriented and patient and family-oriented groups (one fixed member for
each patient) chose an appropriate time according to their convenience. These classes lasted
around 50 minutes. In each 50 min session, in addition to group discussion, a combination of
didactic methods such as a short lecture, eliciting experience of individual participants, small
group work, experiential exercises and individual work is also used. The last session included
action planning by writing a “‘letter to oneself’”, which every participant received 4 months
after education. Didactic materials included overhead transparencies, flip charts, handouts
and worksheets. The aims of this program included providing information regarding lifestyle
and health, initiating self-reflection on healthy lifestyles, changing attitudes, enhancing posi-
tive emotions regarding lifestyle changes and encouraging action planning. All interactive
educational group discussions were led by three researchers who had been trained and
coordinated by a research group leader before the intervention. They had also involved in
developing the intervention and used peer supervision for any difficulties while conducting the
intervention.

To assure the treatment integrity, samples from all courses at each site were observed by
external judges using a structured observational sheet. It contained a checklist regarding contents,
the didactic methods sequence, and duration of each of the sessions as well as the proportion of
patients participating actively. These checks confirmed that the intervention was delivered as
prescribed by the manual. It showed that the majority of the participants was actively taking
part during a session. The participants in the control group were given routine education. The
control group received the paper-based educational materials and all participants completed the
Hill-Bone Scale and their BP was measured six times at the end of the intervention.

2.6. Data analysis

Analysis was performed on 100 participants who completed both the baseline and 4-month
follow-up assessments (Figure 1). We used the Shapiro–Wilk test to determine the normal dis-
tribution of the data. The analysis of variance (ANOVA) was used in the case of normal distribution.
Whenever there were significant differences among four groups with regard to normal distribution,
we used Tukey’s test to make statistical comparisons among intervention groups. The alpha level
of significance for all inferential statistics was set at 0.05. Data was analyzed by the researcher
who was blinded to the data using IBM SPSS software (version 20.0 SPSS Inc., Chicago, IL, USA).

3. Results

3.1. Demographic characteristics

Chi-square and Fisher exact test showed no significant difference in the patients’ demographic
characteristics (gender, education, marital status, employment status, and smoking). ANOVA test
showed that the difference in the mean number of age, disease duration and BMI was not
statistically significant (p < 0.05) (Table 1).

3.2. Primary outcomes(treatment compliance)

The ANOVA analysis showed no significant differences among the four study groups regarding the
medication adherence score in the pre-intervention period (p = 0.352). However, there were
significant differences among the four groups’ mean medication adherence scores at the end of
the study (control group: 21.72 ± 2.20, family-oriented group: 13.44 ± 3.26, patient-oriented group:
16.64 ± 2.59 and patient and family-oriented group: 12.36 ± 2.36; p < 0.0001). At the beginning of
the study, the results of ANOVA showed no significant differences among the four groups in mean
scores of low sodium regimen adherence. However, after the intervention, analysis showed a
significant difference in mean low sodium regimen adherence scores of control group

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Table 1. Demographic characteristics of participants in the four study groups

Variable Control, N (%) Family- Patient- Patient-and- p Value
oriented oriented family-
group, N (%) group, N (%) oriented
group, N (%)
Gender Female 10(40) (64) 16 14(56) 15(60) p = 0.341 *

Male 15(60) 9(36) 11(44) 10(40)

Marital status Married 24(96) 25(100) 25(100) 25(100) p = 0.287 **

Single 1(4) 0(0) 0(0) 0(0)

Employment Currently 8(32) 6(24) 5(20) 1(4) p = 0.212 **

status unemployed
Employed 16(64) 18(72) 18(72) 23(92)

Retired 1(4) 1(4) 2(8) 1(4)

Education Primary and 21(84) 21(84) 24(96) 25(100) p = 0.071 **

level secondary
school
High school & 4(16) 4(16) 1(4) 0(0)
University
Smoking Yes 5(20) 2(8) 6(24) 7(28) p = 0.622 *

No 20(80) 28(92) 19(76) 18(72)

Age Mean)SD) 53.20 ± 10.05 51.88 ± 8.58 54.28 ± 8.82 49.96 ± 8.27 p = 0.363 ***

BMI(SD) 24.77 ± 2.9 24.92 ± 3.18 24.10 ± 2.1 24.64 ± 3.03 p = 0.104 ***

Disease duration Mean)SD) 5.33 ± 1.66 5.67 ± 2.89 5.26 ± 1.47 5.62 ± 1.11 p = 0.322 ***

* Chi-square. ** Fisher exact test. *** Analysis of variance.

(7.48 ± 1.12), family-oriented group (4.68 ± 1.18), patient-oriented group (5.24 ± 1.16) and patient
and family-oriented group (3.80 ± 0.81) (p < 0.0001). With regard to the medical appointments
adherence scores, the results of the ANOVA indicated no significant differences among the four
study groups in the pre-intervention period (p = 0.608). Nevertheless, there were significant
differences among the four groups’ mean medical appointments adherence scores after the
intervention (control group: 5.16 ± 0.80, family-oriented group: 3.12 ± 0.88, patient-oriented
group: 3.80 ± 0.81 and patient and family-oriented group: 3.48 ± 0.71; p < 0.0001). No significant
differences were observed among the four groups in mean scores of the overall treatment
compliance before the intervention. However, a significant difference was observed in mean the
overall treatment compliance scores of (control group: 34.36 ± 2.78, family-oriented group:
21.24 ± 3.62, patient-oriented group: 25.68 ± 3.59 and patient and family-oriented
group:19.46 ± 2.73) (ES = 1.8, p < 0.0001,) (Table 2).

3.3. Secondary outcomes

The results of the ANOVA showed that means and SDs of SBP and DBP were not different among the
four study groups before the intervention. The interventions decreased mean of SBP (5.00
± 4.53 mmHg in the family-oriented group, 7.32 ± 2.54 mmHg in the patient-oriented group and
8.40 ± 6.11 mmHg in the patient and family-oriented group). After the intervention means and SDs of
SBP were significantly different among the four study groups (p < 0.0001). Similar results were
observed for DBP values (4.84± 2.77 mmHg in the family-oriented group and 8.72± 6.20 mmHg in
the patient-oriented group and 8.76 ± 6.20 mmHg in the patient and family-oriented group). After the
intervention means and SDs of DBP were different among the four study groups (p < 0.0001) (Table 3).

Tukey’s test revealed that medication adherence (p < 0.0001), low sodium regimen adherence
(p < 0.0001), medical appointments adherence (p < 0.019) and treatment compliance (p < 0.0001)
significantly improved in the patient and family-oriented group compared to other groups after the
intervention (Table 4).

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Table 2. Comparison of treatment compliance and its domains among the four groups at the
beginning and at the end of the study
Variable Control group Family- Patient- Patient-and- p Value
oriented group oriented group family- ANOVA
oriented group

Mean ± SD Mean ± SD Mean ± SD Mean ± SD

Medication Pre-intervention 19.40 ± 2.02 18.64 ± 1.52 18.96 ± 1.54 19.68 ± 2.03 F = 1.856
adherence p = 0.142
Post- 21.72 ± 2.20 13.44 ± 3.26 16.64 ± 2.59 12.36 ± 2.36 F = 74.658
intervention p < 0.0001
Low sodium Pre-intervention 7.76 ± 1.85 7.20 ± 1.19 7.48 ± 1.26 7.60 ± 1.15 F = 0.625
regimen p = 0.601
adherence
Post- 7.48 ± 1.12 4.68 ± 1.18 5.24 ± 1.16 3.80 ± 0.81 F = 52.983
intervention p < 0.0001
Medical Pre-intervention 5.24 ± 0.87 4.96 ± 0.88 4.76 ± 0.83 5.16 ± 1.17 F = 1.270
appointments p = 0.289
adherence
Post- 5.16 ± 0.80 3.12 ± 0.88 3.80 ± 0.81 3.48 ± 0.71 F = 30.617
intervention p < 0.0001
Treatment Pre-intervention 32.40 ± 3.60 30.80 ± 2.06 31.20 ± 2.02 32.44 ± 3.30 F = 0.58
compliance p = 0.981
Post- 34.36 ± 2.78 21.24 ± 3.62 25.68 ± 3.59 19.46 ± 2.73 F = 26.129
intervention p < 0.0001

Table 3. Comparison of systolic and DBP among the four groups at the beginning and at the
end of the study
Variable Control group Family- Patient- Patient-and- ANOVA
(Mean ± SD) oriented group oriented group family-
(Mean ± SD) (Mean ± SD) oriented group
(Mean ± SD)
(SBP) Pre-intervention 13.28± 152.48 143.08 ± 11.01 8.83 ± 147.32 14.18± 146.80 73. F = 7
062.0 = p
Post- 154.68 ± 13.27 138.08± 9.70 140.00± 9.12 138.40± 11.43 03. F = 24
intervention p < 0.0001
Pre minus post −2.20± 2.06 5.00± 4.53 7.32± 2.54 8.40± 6.11 36. F = 60
p < 0.0001
(DBP) Pre-intervention 85.48± 7.51 81.48± 9.93 88.32± 6.83 83.96± 10.24 71. F = 7
0.057 = p
Post- 86.88± 8.00 76.64± 9.63 79.60± 6.75 75.20± 8.35 14. F = 22
intervention p < 0.0001
Pre minus post −1.40± 2.12 4.84± 2.77 8.72± 6.20 8.76± 6.20 82. F = 56
p < 0.0001

4. Discussion
Study results were discussed in three separate sections: first, interactive group discussions had a
significant affect on treatment compliance (medication, low sodium regimen and medical appoint-
ments adherence) of patients with HTN. Second, the affect of interactive educational intervention
on medical treatment compliance was more significant in patients and family-oriented group
compared to others. Third, family-oriented patient education resulted in improving BP control
and ultimately reduced systolic and DBP in patients with HTN.

In line with our results previous studies have confirmed that educational interventions improved
patients’ knowledge about their disease, general comprehension of medications and their beliefs
about medicines and ultimately would increase their active participation in treatment (Magadza,
Radloff, & Srinivas, 2009; Rubin, 2005). Similar to our findings, Kayima et al. mentioned one of the
ways to improve treatment compliance in patients with high BP is to educate patients (Kayima,

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Table 4. Pairwise comparison of self-care and its domains among the four groups at the
beginning and at the end of the study
Variable Groups Control Patient- Patient-and- Family-
oriented family- oriented
oriented
Medication Family-oriented p < 0.0001 p = 0.476 p < 0.0001 –
adherence
Patient-oriented p < 0.0001 – p < 0.0001 p = 0.476
Patient-and-family- p < 0.0001 p < 0.0001 – p < 0.0001
oriented
Control group – p < 0.0001 p < 0.0001 p < 0.0001
Low sodium Family-oriented p < 0.0001 p = 0.025 p = 265 –
regimen
Patient-oriented p < 0.0001 – p < 0.0001 p = 0.025
adherence
Patient-and-family- p < 0.0001 p < 0.0001 –
oriented
Control group – p < 0.0001 p < 0.0001 p < 0.0001
Medical Family-oriented p < 0.0001 p = 0.394 p = 0.019 –
appointments
Patient-oriented p < 0.0001 – p = 0.499 p = 0.394
adherence
Patient-and-family- p < 0.0001 p = 0.499 – p = 0.019
oriented
Control group – p < 0.0001 p < 0.0001 p < 0.0001
Treatment Family-oriented p < 0.0001 p = 0.298 p < 0.0001 –
compliance
Patient-oriented p < 0.0001 – p = 0.001 p = 0.298
Patient-and-family- p = 0.007 p = 0.001 – p < 0.0001
oriented
Control group -– p < 0.0001 p = 0.007 p < 0.0001
(SBP) Family-oriented p < 0.0001 p = 1.000 p = 0.926 –
Patient-oriented p < 0.0001 – p = 0.956 p = 1.000
Patient-and-family- p < 0.0001 p = 0.956 – p = 0.926
oriented
Control group – p < 0.0001 p < 0.0001 p < 0.0001
(DBP) Family-oriented p < 0.0001 p = 0.926 p = 0.585 –
Patient-oriented p < 0.0001 – p = 0.241 p = 0.926
Patient-and-family- p = 0.013 p = 0.241 – p = 0.585
oriented
Control group – p < 0.0001 p = 0.013 p < 0.0001
*Tukey’s test

Wanyenze, Katamba, Leontsini, & Nuwaha, 2013). Through patient education, all misunderstand-
ings that patients have about their treatment can be explained. This can improve patients’
adherence to treatment (Saounatsou et al., 2001) and may then possibly lead to improved BP
control (Gwadry-Sridhar et al., 2013; Park et al., 2011).

The results also showed that patients’ treatment compliance has promoted more in the patient
and family-oriented group compared to other intervention groups. Consistent with our findings, a
study result indicated that poor family support along with other factors as causes of poor treat-
ment compliance among patients with HTN (Olowookere et al., 2015). Shen et al. revealed that the
family member-based educational intervention has positive effects on patients’ adherence to BP
monitoring and hypertensive medications (Shen et al., 2017). Implementing of a family member-
based management in patients with HTN in rural China shows satisfactory effects with respect to
improved treatment compliance and BP control (S. Huang, Chen, Zhou, & Wang, 2014). Thus, family
caregivers need information and training to ensure that patients’ needs are met and this requires
developing patient/family education materials and training programs (Houts, Nezu, Nezu, &

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Bucher, 1996). A systematic review reported that interventions including patients and families
education through individual and group discussion improved patients’ knowledge of medications,
anti-hypertensive therapy and BP control (Gwadry-Sridhar et al., 2013). Similar to our findings, the
positive effect of family-based education on appointment-keeping behavior, BP monitoring in
patients with HTN has been confirmed in an earlier study (Morisky, DeMuth, Field-Fass, Green, &
Levine, 1985). Barreto and Marcon reported that the family facilitates patients’ adherence to
treatment. Patients perceive the family as a safety, sympathetic and supportive sources. Thus,
recognizing the strengths and weaknesses of patients’ families can help nurses to adopt proper
strategies in their care in a therapeutic process (Barreto & Marcon, 2014). Miller et al. confirmed
that family support had an important impact on treatment adherence in patients with chronic
diseases. They also, reported that non-adherence to medical treatment increased in patients,
when there were no family members involved in patient education and daily care (Miller &
DiMatteo, 2013).

In this study, interactive educational group discussions in all intervention groups (family-oriented,
patient-oriented and patient and family-oriented groups) led to decreased systolic and diastolic BP in
patients. Talking to patients and their families about changing lifestyle and encouraging them to
have a healthy lifestyle, exercising appropriately for their age, consuming proper nutrition with a low
salt diet was an effective step in reducing BP. An experimental evidence has suggested that support
from family can help patients take their anti-hypertensive medications correctly and their systolic or
diastolic BP were decreased significantly after 6 months intervention (Shen et al., 2017). Consistent
with our result, Morisky et al. revealed that the family member support educational program had
significant effects on decreasing in DBP variability (Morisky et al., 1985). A recent study in Iran,
investigated the effects of group discussion with mail high school students on their parents’ lifestyle
and HTN control showed positive effects of the intervention on patients regarding controlling HTN,
decreasing BP, adhering to diet and anti-hypertensive medications (Ezzati, Anoosheh, &
Mohammadi, 2012). Implementation of the family-centered empowerment model for elderly people
with HTN has been associated with controlling and improving the BP (Keshvari, Hedayati, Moeini, &
Alhani, 2015). This fact can also be observed in the present study, as family involvement in patient
education was reported as facilitating BP management in patients with HTN.

Our study has several possible limitations. First, our study population was limited to a select group of
patients with HTN and their family members living in Urmia, and these patients may not represent all
other hypertensive patients. Second, our sample size calculated 100 patients for four groups that are
relatively low. Therefore, our study findings should be generalized to the clinical situation with caution.
Third, patients selected one family member to participate in educational sessions, and it is more likely
that family members participating in the groups were more supportive of patients than family
members not participating. There was also a possibility of confounding variables, including uncontrol-
lable variables, such as the psychomental characteristics and the cultural background of patients and
their families, as well as their motivation to learn that could affect their learning ability.

5. Conclusion
The results revealed that family involvement in patient education plays a significant role in HTN
management, by encouraging the patients to adhere to medication, low sodium diet and medical
appointments. The results also indicate that iteractive educational interventions based on a
healthy lifestyle with the patient or family are effective in increasing treatment compliance and
reducing systolic and diastolic BP. However, if education is held with the presence of both the
patient and the family, the greater effect on treatment compliance and BP control will be
observed.

5.1. Implication for practice

Therefore, it is suggested that iteractive educational interventions such as small group discussions
to be held with the presence of a family member to promote adopting a healthier lifestyle and
better managing BP in patients with HTN. Health system managers and policy makers can include

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and mandate family-oriented education in the routine nursing care and clinical services in order to
promote HTN management. It ultimately reduces the medical cost for both patients and health-
care systems.

Acknowledgements Bromfield, S., & Muntner, P. (2013). High blood pressure:

This research is derived from a Master thesis in nursing. The leading global burden of disease risk factor and
The authors would like to thank study participants, as well the need for worldwide prevention programs. Current
as, Dr. Vahid Alinejad, statistician, for his valuable com- Hypertension Reports, 15(3), 134–136. doi:10.1007/
ments on data analysis and Mariam Angelica Parizad for s11906-013-0340-9
her review of the manuscript and writing assistance. They Campbell, N. R., & Sheldon, T. (2010). The Canadian effort
also appreciate the cooperation of Urmia University of to prevent and control hypertension: Can other
Medical Sciences. countries adopt Canadian strategies? Current Opinion
in Cardiology, 25(4), 366–372. doi:10.1097/
Funding HCO.0b013e32833a3632
This research did not receive any specific grant from fund- Chobanian, A. V. (2003). National heart, lung, and blood
ing agencies in the public, commercial, or not-for-profit
institute joint national committee on prevention,
sectors.
detection, evaluation, and treatment of high blood
pressure; national high blood pressure education
Author details
program coordinating committee: The seventh report
Masumeh Hemmati Maslakpak1
of the joint national committee on prevention,
E-mail: [email protected]
detection, evaluation, and treatment of high blood
Behrooz Rezaei2
pressure: The JNC 7 report. Jama, 289(19), 2560–
E-mail: [email protected]
2572. doi:10.1001/jama.289.19.2560
Naser Parizad3
Cobos, B., Haskard-Zolnierek, K., & Howard, K. (2015).
E-mail: [email protected]
White coat hypertension: Improving the patient–
ORCID ID: http://orcid.org/0000-0001-7393-3010
1 Health care practitioner relationship. Psychology
Department of Medical Surgical Nursing, Maternal and
Research and Behavior Management, 8, 133–141.
Childhood Obesity Research Center, Urmia University of
doi:10.2147/PRBM.S61192
Medical Sciences, Urmia, Iran.
2 Ezzati, E., Anoosheh, M., & Mohammadi, E. (2012). The
Department of Medical Surgical Nursing, Urmia
impact of group discussion with high school youth on
University of Medical Sciences, Urmia, Iran.
3 lifestyle of their parents having high blood pressure.
Department of Medical-Surgical Nursing, Nursing and
Journal of Kermanshah University of Medical Sciences
Midwifery School, Urmia University of Medical Sciences,
(J Kermanshah Univ Med Sci), 16(6), 445–456.
Urmia, Iran.
doi:10.22110/jkums.v16i6.927
Gwadry-Sridhar, F. H., Manias, E., Lal, L., Salas, M., Hughes,
Competing interest
D. A., Ratzki-Leewing, A., & Grubisic, M. (2013).
The authors declare no conflicts of interest.
Impact of interventions on medication adherence
and blood pressure control in patients with essential
Citation information
hypertension: A systematic review by the ISPOR
Cite this article as: Does family involvement in patient
medication adherence and persistence special inter-
education improve hypertension management? A sin-
est group. Value in Health, 16(5), 863–871.
gle-blind randomized, parallel group, controlled trial,
doi:10.1016/j.jval.2013.03.1631
Masumeh Hemmati Maslakpak, Behrooz Rezaei & Naser
Hacihasanoğlu, R., & Gözüm, S. (2011). The effect of
Parizad, Cogent Medicine (2018), 5: 1537063.
patient education and home monitoring on medica-
tion compliance, hypertension management, healthy
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