Hypertension patients in Singapore demonstrate high levels of self-care

Self-care appears to be central to hypertension management among patients in Singapore (SG), with a recent study showing that they have better scores across the behaviour, motivation, and self-efficacy metrics compared with their counterparts in Malaysia (MY).

“The higher total Hypertension Self-Care Profiles (HTN-SCP) scores in SG patients may be partly due to its healthcare system and policy. It is designed to enable the population to take on higher responsibility to manage their health through co-share healthcare financing, comprehensive individual and community empowerment, and self-management programmes,” the investigators explained. [PLoS One 2019;14:e0216303-e03; BMC Health Serv Res 2019;19:177-177; Int J Equity Health 2019;18:1]

Despite all that, the implementation of the said programmes is still hampered by the inability to reach out to all patients, such as those with lower health literacy and motivation, the investigators added.

The present study involved 1,123 hypertensive patients seen in primary care clinics in MY (n=702; mean age 60.4 years) and SG (n=421; mean age 63.6 years). Demographically, the SG cohort were more likely to be aged ≥60 years (63.4 percent vs 54.6 percent) and educated up to tertiary level (22.3 percent vs 13 percent), but less likely to be married (67 percent vs 81.6 percent). Diabetes mellitus, as a comorbidity, was more common in the MY cohort (65.8 percent vs 46.8 percent; p<0.001). [BMJ Open 2021;11:e044192]

Close to half of the patients in both cohorts were on at least one blood pressure (BP)-lowering medication, but a much higher proportion in the MY cohort were taking three or more than four medications (20.9 percent vs 14.3 percent; p=0.023). In terms of BP control, significantly more patients in the SG cohort attained their target (74.6 percent vs 33.8 percent; p<0.001) based on the Joint National Committee Eighth (JNC 8) guidelines. [JAMA 2014;311:507-520]

The mean total score of HTN-SCP was markedly higher in the SG vs MY cohort (190 vs 184; p<0.001). This was true for all subscores, namely motivation (67 vs 65), self-efficacy (65 vs 62), and behaviour (58 vs 56).

Ethnicity, education, age factor in

In both MY and SG cohorts, Indian ethnicity and tertiary education positively influenced HTN-SCP behaviour, motivation, and self-efficacy scores. The HTN-SCP behaviour score was additionally associated with age ≥60 years.

“We also found that Malay ethnicity in MY’s study population had better self-care scores in all HPT-SCP domains than SG’s study population. These findings may be related to ethnicity and medium of language used by healthcare staff in the primary care setting,” the investigators noted.

“The majority of Malaysian healthcare staff are of Malay ethnicity [and use] Malay language as the primary medium of communication. The similar medium of language used may have eased the access and understanding of health education across all aspect of self-care provided by the system,” they added. [Musculoskelet Sci Pract 2018;38:120-127]

The factors associated with high self-care profile, particularly higher education levels, make sense, given that being more educated allows patients to access and understand health information and resources to better manage their health, according to the investigators. Older patients, meanwhile, tend to be more conscientious about monitoring their BP and maintaining their weight. Also, they may have had hypertension for a longer duration, which helped improve their coping skills. [PLoS One 2019;14:e0224649; Ethiop J Health Sci 2019;29:421-430; Int J Hypertens 2013;2013:1-8; PLoS One 2019;14:e0218947]

Additionally, the investigators called for further exploration to look at other factors, such as the role of genetics in cardiovascular outcomes, to explain the favourable outcomes among patients of Indian ethnicity.

“It has been shown that monitoring BP alone is not enough to improve cardiovascular outcomes. Self-care is not just about an individual responsibility to care for their health. Based on this study, self-care may be supported by the education policy and the healthcare system through better access to education and reducing gaps in health inequalities, that is, ethnicity and gender,” the investigators noted.

“Holistic management of hypertension is multi-faceted, including behaviour change approach and raising the motivation level. Enhancing self-efficacy to actualize self-care is one prerequisite for cost-effective and optimal long-term control of an individual’s BP,” they added.

Therefore, interventions targeted to improve self-care in the management of hypertension should be tailored to the patient’s behaviour, motivation, and self-efficacy levels, the investigators said.