Health Promotion International, Vol. 18, No. 3, 219-228,
September 2003
© Oxford University Press 2003
Behavioral change for blood pressure control among urban and rural adults in Taiwan
Department of Nursing, Fooyin University, Kaohsiung Hsien, 83101 Taiwan and 1School of Public Health, University of Texas Houston Health Science Center, Houston, TX, USA
Address for correspondence: Luna Chang, Fooyin University, 151 Chin-Hsueh Road, Ta-Liao Hsiang, Kaohsiung Hsien, 83101 Taiwan, E-mail: ns230{at}mail.fy.edu.tw
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SUMMARY |
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In exploring the mechanisms of behavioral change for hypertension control, a study based on the transtheoretical model was carried out in Taiwan in 2000, with a sample of 350 hypertensive adults living in Taipei urban and rural areas. The relationships among stages of change, processes of change, and demographic factors were analyzed for six health behaviors: low-fat food consumption, alcohol use, smoking, physical activity, weight control and routine blood pressure check-ups. The results showed that rural populations had greater difficulty than urban populations in avoiding smoking and engaging in physical activity, and the processes of change being used by urban populations were significantly greater than rural populations for diet, physical activity and routine blood pressure check-up. Individuals who use more processes of change will be more inclined to move from the pre-contemplation stage to the maintenance stage. Social liberation, self-reevaluation and counterconditioning were very important processes for changing diet behavior, engaging in physical activity and checking blood pressure on a regular basis.
Key words: hypertension control; lifestyle modifications; stages and processes of behavior change; urban and rural comparision
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INTRODUCTION |
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TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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Hypertension is a worldwide epidemic that affects all ages, but occurs primarily in adults. It is estimated that there are 3.45 billion adults (
20 years of age) in the world. Estimating a 20% prevalence for hypertension, ~690 million people are thought to have hypertension (Burt et al., 1995
). In China alone, the estimated prevalence is 90 million people (Tao et al., 1995). Analyses of data from the 1988–1991 National Health and Nutrition Examination Surveys (NHANES III) estimated that as many as 50 million Americans had high blood pressure [Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC), 1993]. Hypertension is one of the major risk factors for stroke, coronary heart disease and kidney failure. The World Health Organization (WHO) estimates there are 5 million deaths per year worldwide due to stroke. Another 30 million suffer from disabling complications of hypertension. About 30% of worldwide mortality, or 15 million people a year, die from cardiovascular diseases [Joint WHO/International Society of Hypertension (ISH), 1992].
The controlled rate of hypertension in Taiwan rural areas in 1982 was only 4.9%, compared with 12.3% in Taipei City in 1981 (Taiwan Department of Health, 1986). Also, the prevalence rate of hypertension has increased from 21.2% in 1989 to 43.1% in 1997 for people above the age of 40 years in Taiwan (Taiwan Department of Health, 1999). Although the Department of Health in Taiwan included the prevention and control of adult diseases in the National Health Promotion Plan, and also improved the quality of medical manpower and facilities in rural areas, it might not be enough to achieve health population goals. More targeted interventions such as improving health promotion programs and environments in Taiwan may be very important.
Distinction between rural and urban populations
Rural people are usually slower to adopt innovations than urban people. Rural people in the United States are less likely to take preventive health care measures. Only 28% of non-metropolitan elderly women in the US had a mammogram in the past year, compared with 36% in metropolitan areas (Van Nostrand et al., 1993). In Taiwan, for the vaccine-preventable diseases, the aboriginal areas had average disease rates that were 12.9 times greater than those in the cities (Knobel et al., 1994).
For social and economic status comparisons, one-half of the rural elderly population in the US has been shown to have persistent low incomes or to live in poverty, compared with 37% of the urban elderly (Lingg et al., 1993), with rural people depending heavily on farming (Rogers et al., 1993). The situation is similar in Taiwan. The increasing percentage of elderly and women in the rural areas and changing consumer habits have slowed agricultural development, which in turn has greatly affected farmers’ incomes in Taiwan. According to the report of the Taiwan Department of Budget (Taiwan Provincial Government, 2000), the differences in average personal income between farmers and non-farmers have increased significantly from 100 000 New Taiwan dollars (NT$; US$3000) in 1986 to NT$300 000 (US$9000) in 1995.
Lifestyle modifications
In general, weight loss, a reduction in sodium intake, increased physical activity and avoidance of tobacco and excessive alcohol consumption appear to be efficacious approaches towards preventing hypertension (McClellan and Wilber, 1985; Stamler et al., 1997). Hypertensive patients should be strongly encouraged to adopt these lifestyle modifications, particularly if they have additional risk factors for premature cardiovascular disease, such as dyslipidemia or diabetes mellitus (Neaton et al., 1993; Singer et al., 1995). Although the difficulty in achieving and maintaining lifestyle changes is recognized, a systematic team approach utilizing health care professionals, community facilities and family resources can be the most effective strategy in providing the necessary education, support and follow up (Becker et al., 1980; Haynes and Dantes, 1987).
Theoretical framework
The primary theoretical basis for this study is the transtheoretical model. The transtheoretical model of behavior change (‘stages of change’) was first proposed by Prochaska and DiClemente (Prochaska and DiClemente, 1984) as a means of integrating the stages and processes of behavior change. The core of the transtheoretical model is composed of four constructs. The four constructs are stage of change, process of change, decisional balance, and self-efficacy. Stage of change is the temporal, motivational aspect of an individual’s behavior change. The five distinct stages are as follows.
- Pre-contemplation: people have no intention to change behavior in the foreseeable future. Many individuals at this stage are unaware or not sufficiently aware of their problems.
- Contemplation: one is aware that a problem exists and thinks seriously about overcoming it, but has not yet made a commitment to take action.
- Preparation: comprises both intentional and behavioral criteria. Individuals at this stage intend to take action in the next month and have unsuccessfully taken action in the past year.
- Action: the stage where individuals modify their behavior, experiences or environment to overcome their problems. Action involves the most overt behavioral changes and requires considerable commitment of time and energy.
- Maintenance: a stage where individuals work to prevent relapse and consolidate gains attained during action. For addictive behaviors, this stage extends from 6 months to an indeterminate period following the initial action.
Process of change refers to strategies or mechanisms that move the individual through these stages (Prochaska et al., 1992; DiClemente et al., 1993). Each process is a broad category encompassing multiple techniques, methods and interventions traditionally associated with disparate theoretical orientations. The 10 processes of change are: (1) consciousness raising, (2) counterconditioning, (3) dramatic relief, (4) environmental reevaluation, (5) helping relationships, (6) reinforcement management, (7) self-liberation, (8) self-reevaluation, (9) social liberation and (10) stimulus control. The definitions of processes of change are explained in Table 1, and are adopted from the publication of the Cancer Prevention Research Center (Cancer Prevention Research Center, 1991).
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The model was originally derived from studies conducted to compare smokers who successfully stopped smoking on their own with those involved in treatment programs. The stage-matched interventions have also successfully promoted a variety of health promotion and health protection behaviors, such as physical activity (Selby, 1990
; Marcus et al., 1998), condom use (Centers for Disease Control and Prevention, 1996), maintaining appropriate dietary fibre and fat intake (Campbell et al., 1994), reducing sun exposure (Rossi et al., 1997), mammography (Skinner et al., 1994; Rakowski et al., 1996) and reducing excessive alcohol use (Heather et al., 1996). |
METHODS |
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Study design
This project was a cross-sectional study and applied the transtheoretical model to assess six health behaviors of hypertensive adults by mail, telephone and face-to-face surveys. The six health behaviors were: a reduced fat diet, alcohol use, smoking, weight control, physical activity, and blood pressure check-ups. Different processes and stages of change for these six health behaviors were compared between the rural and urban study population. The processes of behavior change were then used as independent variables to determine the outcome: stages of behavior change.
In estimating the stage of physical activity, the physical activity guideline was to accumulate at least 30 min of moderate-intensity physical activity on all, or most, days of the week to obtain adequate health benefits (USDHHS, 1996).
Study population
The inclusion criteria for the Taiwanese study population were that subjects must be: (i) 20 years old; and (ii) classified as having ‘definite hypertension’, i.e. systolic blood pressure (SBP) 160 mmHg and/or diastolic blood pressure (DBP) 95 mmHg, or currently taking an anti-hypertensive medication (JNC, 1993). The exclusion criteria were difficulties in completing a self-administrated survey, telephone or faceto-face interview because of hearing and vision limitations. The study population was derived from two institutes: the National Taiwan University Hospital in Taipei urban area and the Jin-Shan Health Station in Taipei rural area.
Sample size
No study in the last 5 years was found to have examined hypertension-treated rate or hypertension-controlled rate in the Taiwan area, therefore studies of hypertension-treated rates in the US (55%) and Canada (39%) were referred to (Burt et al., 1995; Joffres et al., 1997). The treated rate of hypertension was assumed to be 60% in Taiwan urban areas and 40% in Taiwan rural areas. The treated rate in this study was interpreted as the percentage of hypertensive adults who engaged in the action and maintenance stages of behavioral change.
Furthermore, in estimating an appropriate sample size, 80% power, 0.05 probability level and other adjustments were used. The other adjustments included the design effect (1.3), the response rate of mailing or telephone survey (50%), and the expected proportion of eligible participants (80%) who have a telephone for contact. After using the adjustment procedures described above, the sample size was computed as 630 subjects.
Data collection
This survey was conducted from June 2000 to August 2000. Hypertensive adults, who were 20 years of age, were randomly selected from the patient medical records. A purposive sampling procedures were used to obtain sufficient sample sizes. Each study subject received an introductory letter and a self-administrated questionnaire via mail or a face-to-face interview. Those who failed to return the forms within 2 weeks were contacted by telephone. All participation in this study was voluntary and no incentives were offered to participants.
The hypertension control survey questionnaires were adapted from the psychological measures of General Health Survey Stage of Change assessment for 10 problem behaviors (CPRC, 1991). The questionnaire was translated into Chinese and evaluated by two primary physicians. A pre-test was also conducted to evaluate whether the wording and length of the questionnaire survey was acceptable.
The questionnaire was split into three parts. The first part was intended to assess the stages of change for six behaviors: diet, alcohol use, smoking, physical activity, weight control and blood pressure check-ups. The second was to assess the processes of change for three behaviors: diet, physical activity and blood pressure check-ups. The processes of change for smoking, alcohol use and weight control were not assessed in this study due to the complexity and measurement burden of these behaviors. The third part was used to examine the demographic variables such as age, gender, social class level and marital status.
To ascertain the reliability of the process of change scale, a Cronbach’s alpha coefficient was calculated. It yielded a value of 0.93 for processes of change of fat reduction diet, 0.95 for physical activity and 0.86 for regular blood pressure check-ups. The data were coded and entered in the Microsoft Excel program. Data analyses were directly executed by means of Statistical Analysis Software (SAS).
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RESULTS |
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For the step 1 analysis, the t-test was used to test for differences in means for age, SBP and DBP between rural and urban study populations. In addition, the chi-square test was used to compare different frequency distributions between the two study populations for demographic factors and place of routine blood pressure check-ups. The results showed that no significant difference was found between the two study populations for age, DBP, gender or marriage factors based on a criterion of probability <0.05. Mean age was 68 years and the average DBP value was close to 80 mmHg.
However, there were significant differences in the means for SBP (p = 0.029), and different frequency distributions for education level (p < 0.0001), income level (p < 0.0001), occupation (p < 0.0001) and place of routine blood pressure check-up (p < 0.0001) between urban and rural study populations. Slightly more than half (51.4%) of the rural sample never received any formal education experience, compared with 13.7% of the urban sample. In addition, 72.6% of the rural sample compared with 43.3% of the urban sample earned less than NT$20 000 (US$600) per month.
With respect to the place of routine blood pressure check-up, 53.9% of the urban sample used self-equipment at home, but only 10.3% of the rural sample had self-test equipment. In the rural area, most people (82.2%) accessed the Public Health Station for their routine blood pressure check-ups, compared with 36.3% of the urban sample.
On the step 2 analysis, the Pearson chi-square statistic was used to compare different distributions in the percentages of stages of change for six health behaviors between urban and rural areas. According to the results, there were statistically significant differences in the stage of change for smoking cessation (p = 0.0288) and physical activity (p = 0.0198). More than half (58.8%) of the urban study population successfully stayed in the maintenance stage for smoking cessation, compared with 35.9% of the rural study population. When the analysis was separated by gender, only males had significant differences (p = 0.0419). The pattern of differences was the same as that reported above.
For physical activities, the urban study population was more likely to change behavior than the rural study population. The percentage of rural study population in the pre-contemplation stage was twice that of the urban study population. When the analysis was separated by gender, the male population demonstrated a statistically significant difference (p = 0.0386); for example, in the pre-contemplation stage there were 20% of rural men compared with 8.14% of urban men, but there were no differences for women.
There were no statistically significant differences in the stages of change for other health behaviors, such as fat reduction diet, reducing alcohol, weight control and routine blood pressure check-up, between the rural and urban samples. With respect to diet, nearly 80% of hypertensive adults were maintained on a fat reduction diet. For blood pressure check-ups also, >80% of people had their blood pressure checked regularly.
For the step 3 analysis, logistic regression was used to compare differences in the processes of change for diet, physical activity and routine blood pressure check-up between urban and rural areas. The dependent variable was the process of change on a five-point scale (1 = never, 5 = always), and the independent variable was location (urban or rural). In Table 2, most processes of change for these health behaviors were associated with the location variable, with a p-value <0.05; however only one process—counterconditioning—was not different between the two areas for physical activity and routine blood pressure check-up.
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For the fat reduction diet, 10 processes of change were all statistically significant in relation to location, with a p-value <0.05. According to the odds ratio (OR) estimates, the proportions of the processes of change being used among the rural study population were much lower than among the urban study population (ORs = 0.32–0.66).
For physical activity, the results indicated that most processes of change were statistically significant with respect to location, but that the counterconditioning mechanism was not; both the rural and the urban study populations had similar intentions with respect to the counterconditioning mechanism, for example engaging in physical activity for relaxation rather than considering it as another task to accomplish. The ‘helping relationships’ process was particularly low, with an OR of 0.24, suggesting that the proportion of the rural study population depending on helping relationships was much lower than for the urban study population. Many elderly people live either alone or as couples in the Taiwan rural area because more young people move to urban settings to work or go to school and then do not visit their parents frequently.
For routine blood pressure check-ups, the OR range for these processes of change was 0.39–0.60. The rural study population had less intention than the urban population to use these behavioral mechanisms for routine blood pressure check-ups. Nevertheless, the counterconditioning process had the same likelihood for use among these two study populations, for which the OR was 1.103 (confidence interval 0.693–1.756).
On the step 4 analysis, the one-way analysis of variance (ANOVA) was the first method used to detect evidence of differences among the process means of difference stages. Secondly, the t-test was used for comparing means among different stages. When the sample size did not reach 30 people for one stage, the stage-combination method was used. Thirdly, logistic regression was applied to test the association of processes and stages of change for three behaviors.
For the fat reduction diet, significant differences were found among 10 processes of change across stages of change based on a level of significance <0.01. In Figure 1, comparing the differences between two stages, t-test analyses showed that the means of the pre-contemplation stage were significantly lower than those of the combination group, including contemplation, preparation and action stages for nine processes of change with a p-value <0.01. The ‘helping relationships’ process was the only process not significantly different for this comparison. Furthermore, when comparing the combination group with the maintenance group, t-test revealed that nine processes of change were significantly different with p-values <0.01, but not for the ‘social liberation’ process.
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For physical activity, the results of one-way ANOVA showed that all of the process variables differed significantly across the five stages for physical activity based on a level of significance <0.01. In Figure 2
, the t-test analyses indicated that the means were significantly increased from the pre-contemplation group to the combination group (contemplation, preparation and action stages) for 10 processes of change. In addition, in the comparison between the combination group and the maintenance group, the means significantly increased from the combination stage to the maintenance stage among eight processes, but not for dramatic relief and environmental reevaluation processes.
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For routine blood pressure check-ups, the ANOVA indicated that all means were significantly different among 10 processes across the stages of change with p-values <0.01. The sample sizes in the pre-contemplation, contemplation, preparation and action stages were all <30 people; therefore, they were combined together for comparison with the maintenance stage. In Figure 3
, the t-test revealed that the process of means in the maintenance stage were significantly greater than for the combination group.
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By logistic regression analysis, self-reevaluation, counterconditioning and social liberation were significantly associated with stages of change for a fat reduction diet. Secondly, dramatic relief, self-reevaluation, counterconditioning and stimulus control were significantly associated with stages of change for physical activity. Thirdly, helping relationships and counterconditioning were significantly associated with stages of change for routine blood pressure check-ups.
In brief, counterconditioning was the only process significantly related to stages of change for these three health behaviors. Also, counterconditioning was the most important process for routine blood pressure check-ups (p = 0.001). In the survey questionnaire, they were described as follows: ‘I think of blood pressure check-ups as a valued effort, rather than as a burden’; ‘Rather than viewing physical activity as a task to get out of the way, I try to use it as my time to relax’; and ‘When I’m tempted to eat high fat food, I try to distract myself by taking vegetable or fruits’.
In addition, self-reevaluation was the most important process in helping people to engage in physical activity. In the questionnaire, it was described as ‘I think that doing physical activity regularly will make me a healthier, and happier person’. Social liberation was the most important process for changing diet behavior (p = 0.0023). In the survey questionnaire, it was described as ‘I find that more people are cutting down on fat’.
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DISCUSSION |
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Based on the results of this study, the findings of demographic comparisons between rural and urban populations were similar to the studies conducted by Rogers and colleagues, and Lingg and coworkers in 1993 (Lingg et al., 1993
; Rogers et al., 1993); the rural population had lower education levels as well as lower incomes than the urban population in Taiwan. Furthermore, the findings showed that the rural population had more difficulties than the urban population in avoiding smoking and engaging in physical activity because the probabilities of processes of change being used by the rural population were significantly lower than the urban population. Also, many rural people considered their labor work as physical activity, therefore did not engage in other types of physical activity.
In this study, the findings showed that 51% of the urban study population compared with 20% of the rural study population had a history of being overweight. However, after hypertension diagnosis and treatment procedures, individuals in the urban area who valued processes of change would be more inclined to move from the pre-contemplation stage to the maintenance stage for high blood pressure control. These findings were similar to those of Perz and coworkers who found that individuals utilizing more experiential processes in the contemplation and preparation stages, and employing more behavioral processes in the action stage, were more likely to achieve abstinence from smoking than other individuals (Perz et al., 1992).
The generalizability of these findings is limited by the non-random sampling method used. With limitations due to both budget and the authority of the health institutes, only one rural public health station and one urban health institute were selected to participate in this study. In addition, most rural people had difficulty in completing the self-administered questionnaires, therefore most rural study participants were conveniently selected at the outpatient setting for conducting a face-to-face interview survey. These samples might have been biased toward performing health behaviors or readiness to perform health behaviors. Some populations in pre-contemplation, contemplation and preparation stages could be underrepresented. Thus, the sample sizes were not large enough to be analyzed by each stage. Even though the combination method was used, it had some limitations with respect to whether the processes of change did influence each stage of change.
Finally, due to the short period of time allocated for an office visit, it is not appropriate to hold a long interview at the clinic setting. Therefore, processes of change for alcohol use, avoidance of smoking, and weight control have yet to be assessed in this study. A future study may uncover more important relationships between stages of change and processes of change from these behaviors.
Implications for future research
Although research supports the constructs of the stages of change model, there is still a great deal to learn about the transitions between stages, and to understand about how relapses affect stage status. In this study, some study subjects could not be identified by the definition of stages of change because people were not certain whether they might change their behaviors in the following days. More research studies may target these subgroups to analyze their processes of behavior change.
For public health implications in Taiwan, the rural population should be targeted for specific health interventions to improve their smoking behavior and physical activity. An example is to increase the co-payment of health insurance from smoking individuals or to clarify the distinction between labor work and types of physical activities to obtain adequate health benefits. Furthermore, health organizations should focus on members of the urban population with a weight problem to prevent cardiovascular diseases. The work undertaken in this research has been an effort to contribute to the health promotion and intervention literature for hypertension control.
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ACKNOWLEDGEMENTS |
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We wish to acknowledge all hypertensive adults who consented to participate in this study in Taiwan. We also wish to thank Dr Yuan-Teh Lee (Superintendent, National Taiwan University Hospital) and Dr Lin Yi-Lien (Director of Jin-Shan Health Station) for patient enrolment and data collections.
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