Lakhasly

Introduction
Currently, developing countries such as
Chile, China, Russia, and Iran are more
likely to face the phenomenon of aging
population growth.[1] Iran, with 9.27%
of the elderly population, has passed the
first phase of aging.[2] Hypertension is the
most common disease reported around
the world.[3] The overall prevalence of
hypertension in the elderly has been
reported about 40.5%.[4]
Hypertension is the most important and
most common modifiable risk factor
for cardiovascular disease (CVD), also
the leading cause of mortality among
adults worldwide.[5] Management and
effective self‑care of hypertension have
a vital role in prevention and reduction
of complications such as the number of
strokes (by 30%–40%),[6] renal failure,
heart cardiovascular complications
(by 20%–25%),[6,7] and improving the
health of the elderly or people with
hypertension.[8] Self‑care programs in CVDs
result in a decrease in the impact of risk
factors such as cholesterol level, obesity,[9]
Address for correspondence:
Dr. Ali Darvishpoor‑Kakhki,
Vali‑Asr Avenue, Cross
of Vali‑Asr and Hashemi
Rafsanjani Highway, Opposite
to Rajaee Heart Hospital,
P. O. Box: 1996835119, Tehran,
Iran.
E‑mail: [email protected]
Access this article online
Website: www.ijnmrjournal.net
DOI: 10.4103/ijnmr.IJNMR_95_18
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Abstract
Background: This study aims to analyze the experiences of older patients with hypertension to realize
the outcomes of their self‑care behaviors for controlling hypertension. Materials and Methods: This
is a qualitative research with a conventional content analysis approach. The participants consisting
of 23 people were selected through purposive sampling. Data were collected through semi‑structured
interviews until data were saturated. Granheim and Lundman’s conventional content analysis
was applied to analyze the data. Results: After data analysis, four main categories including
self‑efficacy, active lifestyle, spirituality, and stress management were obtained. These categories
show the experience and outcomes of self‑care behaviors among elderly patients with hypertension.
Conclusions: Awareness of the elderly of their potentials and role in disease control in addition
to relying on the power of spirituality provides positive results in hypertension management.
Self‑actualization of the elderly resulted in resisting against the destructive effects of internal and
external stress and moving in the direction of growth. Health professionals should be vigilant to
encourage and promote education about the importance and advantages of self‑care for elderlies.
Keywords: Achievement, aged, hypertension, Iran, self‑care
Self‑Actualization: Self‑Care Outcomes among Elderly Patients with
Hypertension
Original Article
Hanieh
Gholamnejad1
,
Ali DarvishpoorKakhki2
,
Fazlollah Ahmadi3
,
Camelia Rohani4
1
Student Research Committee,
School of Nursing and
Midwifery, Shahid Beheshti
University of Medical Sciences,
Tehran, Iran, 2
Department of
Medical-Surgical Nursing,
School of Nursing and
Midwifery, Shahid Beheshti
University of Medical Sciences,
Tehran, Iran, 3
Department of
Nursing, Faculty of Medical
Sciences, Tarbiat Modares
University, Tehran, Iran,
4
Department of Community
Health Nursing, School of
Nursing and Midwifery, Shahid
Beheshti University of Medical
Sciences, Tehran, Iran
How to cite this article: Gholamnejad H,
Darvishpoor‑Kakhki A, Ahmadi F, Rohani C.
Self‑actualization: Self‑care outcomes among
elderly patients with hypertension. Iranian J Nursing
Midwifery Res 2019;24:206-12.
Received: July, 2018. Accepted: January, 2019.
This is an open access journal, and articles are
distributed under the terms of the Creative Commons
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allows others to remix, tweak, and build upon the work
non‑commercially, as long as appropriate credit is given and the
new creations are licensed under the identical terms.
For reprints contact: [email protected]
and an increase in the quality of life.[10] In
addition, they are associated with increased
self‑esteem among elderly.[11] Self‑care can
empower individuals and allow them to have
more control over their health independently
from their health specialists.[12] Self‑care
strategies concentrate on the different
individual needs to achieve a sense of
wholeness and health, including spirituality
and creativity.[13] Self‑care refers to the
activities done by people to promote their
health, prevent diseases, limit illness, and
maintain their health.[14] Self‑care is one of
the keys to self‑actualization. Individual
creativity, quest for spiritual enlightenment,
pursuit of knowledge, and the desire
to give to and/or positively transform
society.[15] Autonomy, sense of humor,
and being socially compassionate[16] are
examples of self‑actualization. Recognition
of these factors from the perspective of
patients and based on their experiences
will lead to more precise understanding of
the outcomes which can lead to production
of knowledge in this field. Accordingly,
qualitative studies can be conducted for
a true understanding of the behaviors,
lifestyles, knowledge, attitudes, feelings,
Gholamnejad, et al.: Self‑care outcomes for hypertensive elderly
Iranian Journal of Nursing and Midwifery Research ¦ Volume 24 ¦ Issue 3 ¦ May-June 2019 207
beliefs, values, and experiences of these patients.[17] Given
the importance of self‑care in improving and promoting
the health of the elderly and prevention of long‑term
complications of hypertension, this study was conducted to
explain the experiences of older patients with hypertension
from different geographic regions of Tehran to realize the
advantages of their self‑care behaviors for controlling
hypertension.
Materials and Methods
This is a qualitative research with a conventional content
analysis approach done in 2017. The information was
directly gathered from the participants. According to the
participants’ point of view, codes, subcategories, and
categories were created using an inductive process.[18]
Semi‑structured interviews were used to collect the required
data. Twenty‑three participants were interviewed through
purposive sampling. Inclusion criteria were age more than
60 years, history of diagnosed hypertension for at least
6 months and confirmed by cardiologist or nephrologist,
taking administered antihypertensive drugs, and the ability
to communicate with a researcher. Subjects suffering from
debilitating diseases such as cancer or cognitive disorders
were excluded. All interviews were conducted in a quiet and
private room in the clinics or participants’ houses for the
older people and families or in the office of the therapeutic
team members by prearrangement. The average duration of
interviews was 40 min, and all interviews were conducted
by the same interviewer. To achieve the maximum variance,
the samples were selected from different age groups, with
different levels of education and work experience, and from
different geographic regions of Tehran. The main questions
of interviews from elderlies included the following: What
changes have you observed in your life after getting your
disease under control? What are the outcomes of self‑care
in your lifestyle? What effect does disease control have on
your beliefs? and from specialists and family members,
What outcomes did you observe in hypertensive elderly
taking good care of themselves? What changes did you
observe in the lifestyle of the hypertensive elderly taking
care of themselves well? Moreover, specific questions
were asked based on the answers of interviewees during
the interviews (Can you explain it more?). Interviews
were continued until data saturation. Thus, in the two last
interviews, no novel idea or category was obtained. The
interviews were recorded and then typed in Microsoft
Word by the first author immediately after the interviews,
and then studied several times to obtain a general
understanding. The authors used MAXQDA11 software to
manage the data. Granheim and Lundman’s conventional
content analysis was applied to analyze the data.[19] The
texts of the interviews were divided into semantic units
and the primary codes were determined. Next, the codes
were placed under subcategories and categories based
on their similarities and differences. Finally, the themes
representing the hidden content of the interviews were
created.[19] Four Guba and Lincoln’s criteria including
credibility, transferability, dependability, and conformability
were used to evaluate accuracy of the findings from
this research.[20] To ensure the validity of the data, in
addition to providing sufficient time for data collection,
long‑term involvement with data, and immersion in them,
we tried to apply conflation of data collection method,
semi‑structured interviews, integration into data sources,
integration of research sites, sampling in health clinics,
mosques, physicians’ offices, and observing maximum
diversity in sampling, which means interviewing people
from different geographical areas of the city with different
levels of education and in various specialties and different
job positions. To increase the credibility and dependability
of the data, member checks with four older people with
hypertension and peer checks with two PhD students were
used. In addition, sufficient time was allocated to collect
the data (9 months, October 2016–June 2017) and manage
it over a long period of time, as well as being immersed in
the data.
Ethical consideration
The present qualitative research was approved by the Ethics
Committee of Shahid Beheshti University of Medical
Sciences under the code of IRSBMU.PHNM1395‑675. All
study participants provided informed and written consents.
For illiterate participants, the consent form was read and
they fingerprinted their consent forms.
Results
This study evaluates the experiences and perceptions of the
elderly and key participants in the self‑care concept and
its outcomes in the elderly hypertension. The demographic
characteristics of the study participants are presented in
Table 1.
In this study, self‑actualization in the course of disease was
extracted as the main outcome. It includes 4 categories and
12 subcategories [Table 2]. Self‑efficacy, active lifestyle,
spirituality, and stress management are the main categories.
Self‑efficacy
This category is composed of three subcategories of
self‑esteem, attempt to preserve the independence, and
purposeful life.
Self‑esteem
This subcategory suggests that most of the elderly are not
stressed after being informed of hypertension and they
believe in their ability to dominate and control the disease.
More confidence in their ability to exercise self‑care
behaviors results in a greater endeavor to do them by the
elderly. One of the participants said, “When I was first
informed about my hypertension, I was not scared at all.
I had faith in myself and I knew I would be able to control
the disease” (p. 4).
Gholamnejad, et al.: Self‑care outcomes for hypertensive elderly
208 Iranian Journal of Nursing and Midwifery Research ¦ Volume 24 ¦ Issue 3 ¦ May-June 2019
Attempt to preserve their independence
This subcategory shows that the elderly rely on their own
ability, insist on doing their own personal and daily tasks
independently to escape from dependence, and prevent
homestay due to the illness. For example, participants
stated that, “My children insist on helping me, but I refuse.
I want to be independent” (p. 2).
“We must accept the truth that in this busy world nobody
can make time for you. You are responsible for your
life” (p. 3).
Having a purposeful life
The elderly said that a daily schedule prevents them from
monotony and depression and increases their motivation
to continue their life, to feel useful, and to be more
self‑interested. For example, one of the participants stated
that, “I have a plan for my days. If I have a problem that is
important to me, I do not wait until tomorrow; I solve it as
soon as possible” (p. 7).
“I solve puzzles every day. I do not want to get
Alzheimer’s” (p. 1).
Active lifestyle
This category is divided into three subcategories: having
fun, keeping fit, and strengthening social interactions.
These subcategories are described as follows:
Having fun
According to the results of this study, elderly entertainment
is composed of spending time with favorite things, walking
around, and going outdoors. Recreational activities play an
important role in improving one’s understanding of health
and life expectancy. For example, one of the participants
said, “I love working with flowers. I am having fun with
them” (p. 20).
Keeping fit
The results showed that it is important to maintain a
suitable physical appearance for most of the elderly. Most
of the elderly are interested in maintaining a suitable weight
and keeping fit to avoid the negative effects of obesity on
disease control. One of the participants stated that, “After
retirement, I gained weight. I decided not to eat dinner.
After some months, I lost my extra weight” (p. 1).
Strengthening social interactions
Walking with friends or spending time in companionship
with peers and friends, meeting friends daily, hiking with
friends, and chatting with them are among the issues
mentioned by participants for strengthening their social
interactions. “I have some friends from the mosque.
I sometimes speak with them. It makes me happy. All
humans need to talk” (p. 14).
Spirituality
“Trust in God,” “satisfaction,” and “benediction” are the
introduced subcategories, which are explained in detail
along with quotes in this section:
Trust in God
Connecting to a greater power like God and trusting him,
and passing the affairs of life, children, and problems to
God were cases referred by the participants. This solution
is used by most of the elderly of this research, “I do
not worry about my disease, I put everything in God’s
hands” (p. 9).
Table 2: Categories and subcategories of
self‑actualization
Subcategory Category Theme
Self‑esteem Self‑efficacy Self‑
Attempt to preserve the independence actualization
Having a purposeful life
Having fun Active lifestyle
Keeping fit
Strengthening social interactions
Trust in God Spirituality
Satisfaction
Benediction
To keep calm Stress
To escape from tension management
To be patient during the problems
Table 1: Demographic and clinical characteristics of
participants
No. Age
(years)
Sex Education Duration of diagnosed
HBP (years)
1 71 F College 15
2 68 F elementary 12
3 65 F High school 16
4 77 F Master’s degree 18
5 33 F Nurse PhD student ‑
6 38 F Bachelor of nursing ‑
7 75 F College 15
8 41 F Bachelor of nursing ‑
9 60 F Illiterate 1
10 66 M High school 15
11 62 F Middle school 10
12 54 F Cardiologist ‑
13 40 F Cardiologist ‑
14 77 F Illiterate 10
15 61 M Illiterate 17
16 42 F Gerontologist ‑
17 62 F Elementary 7
18 69 F Illiterate 6
19 68 M Elementary 30
20 68 F Elementary 18
21 40 F Diploma ‑
22 24 M Diploma ‑
23 42 F Diploma ‑
HBP: 130 or higher, 80 or higher
Gholamnejad, et al.: Self‑care outcomes for hypertensive elderly
Iranian Journal of Nursing and Midwifery Research ¦ Volume 24 ¦ Issue 3 ¦ May-June 2019 209
Satisfaction
When the participants believed in God, they felt good
and expressed their satisfaction with the present situation.
Praying and being satisfied with God’s commands were
the strategies used by the participants, “I am proud of
myself because I accept everything in my life even my son’s
passing. I think praying helps me to remain calm” (p. 15).
Benediction
The participants said that benediction reduces the
fears and stress and creates a sense of security through
religious practices such as praying and praising God. The
elderly subjects mention their experiences in this field as,
“Sometimes, when I feel anxious, I take my rosary and
utter the Salavat. It helps me feel relaxed. I speak with God
and feel calm” (p. 17).
Stress management
This category consists of three subcategories: to keep calm,
to escape from tension, and to be patient when there are
problems.
To keep calm
Most of the elderly try to choose a calm lifestyle away
from tension to avoid recurrence of attacks and relapses
of the disease. They often try to keep calm by not getting
angry and anxious. Some participants said, “I never let
anything make me anxious. I don’t feel stressed” (p. 10).
To escape from tension
Having a life without stress is the second category of this
analysis. Actions like avoiding stressful environments,
negative thoughts, remembering bitter memories of the
past, and ignoring sad issues are some strategies used by
most of the elderly in this study. “My wife passed away
last year. When I think about her, I feel sad. Therefore, I try
to avoid thinking about her” (p. 11).
Patience during difficulties
Patience when facing disease and problems, not
exaggerating the issues, and taking life easy were the most
common strategies used by elderly. “I always say this is
life. I take life easy. If my disease cannot be treated, why
am I making myself sad” (p. 4).
Discussion
The aim of this research was to analyze the experiences of
the elderly with hypertension to understand the outcomes
of self‑care and its aspects in Tehran. In this study,
self‑actualization in the course of disease was extracted
as the main outcome. Self‑actualization, according to
Maslow, represents growth of an individual toward
fulfillment of the highest needs; those for meaning in life,
in particular.[16] Individual creativity, quest for spiritual
enlightenment, pursuit of knowledge, being realistic,
acceptance, problem centering,[15] autonomy, sense of
humor, and interpersonal relations[16] are characteristics of
self‑actualizing people. It is not necessary for anyone to
have all these qualities.[21] In this research, our participants
have some characteristics of self‑actualizing people.
The results showed that our participants were people with
high self‑efficacy. Being realistic, acceptance, and problem
centering were the characteristics of our participants that is
in line with other studies.[15,22] Receiving the diagnosis and
adapting one’s life to disease requires strength, willpower,
and determination of the patient. Our participants showed
that they have high self‑esteem. They were trying to
apply the necessary measures for the effective control
and treatment of their illness. But most of the Ecuadorian
elderly have low self‑esteem and self‑confidence,[23]
which might be due to the cultural differences in different
countries. In Iranian societies, owing to its old traditions
and cultures, elderly people are highly respected and thus
their self‑confidence is positively affected. Elderlies with
a high self‑confidence level are more engaged in self‑care
activities.[24] One study showed the positive and direct
effects of self‑care behaviors on the elderly’s self‑esteem.[22]
Receiving the diagnosis and adapting one’s life to disease
requires strength, willpower, and determination of the
patient. Resilience is key to better management of disease
and its consequences.[25] Self‑esteem will contribute to
psychosocial strengths and enhance their quality of life.[26]
The elderly with high self‑confidence believe that they
can create some changes toward improving their illness
and increase their health level and vice versa,[27] and
therefore, self‑esteem is among the main components in
therapeutic compliance and performing self‑care issues. To
attempt to preserve the independence is the other extracted
subcategory which similar to other study results shows
that 70% of elderly were completely independent.[26] But
in Japan the proportion of dependency at an advanced
age group was too high.[28] Positive feelings of being
independent when growing old were seen in relation to
earlier experiences of life.[29] Autonomy is one of the traits
of self‑actualized persons.[16] The elderly expect to continue
the management and authority they have gained so far in
the rest of their life. Those who live in their homes keep
their health status by employing various self‑care measures,
doing their daily chores, and trying to live independently
as much as possible. The elderly prefer to keep their
autonomy and emphasize on independently doing their
expected indoor and outdoor functions.[30] Having a
purposeful life is the last subcategory. In our study, the
elderly prevent monotony and depression by planning and
creating different goals and motivations such as planning
to solve the problems and managing life. Experiencing
purpose in life was also described as being happy in
everyday life and thinking positively in every situation.
In one study, having enjoyable hobbies, managing the
household, and maintaining friendships were mentioned acontributing to experiences of purpose in life.[29] Having a
goal and planning to achieve it gives the person a sense of
life and puts him on the path of movement.
Active lifestyle is the second category extracted in this
work. Having fun improves the sleep pattern, makes
people calm, heals their pains, and helps them escape
from loneliness. Entertaining themselves with interests
such as plants/gardening, walking around, going
outdoors, and making relations with younger individuals
are of the common forms of having fun among the
participants that is in line with the result of another
study.[31] But in India photography, birdwatching, and
card playing are the most common recreational activities
for seniors,[32] and the Swedish elderly tend to participate
in travel tours, communities, studying, and athletic
activities.[33] Considering the relatively low economic status
of the Iranian elderly, they tend to have activities that are
low cost and require no specific facility. Keeping fit shows
the willingness of the elderly to maintain their ideal weight.
Weight loss of about 5%–10% has remarkable effects on
their hypertension level.[34] This finding is inconsistent with
the results of Findlow and Seymour[35] who reported that
only one‑third of overweight elderly make some effort to
deal with this problem. Other studies also found that only
40% of the elderly suffering from hypertension cared about
their weight loss and keeping fit.[36,37] Since this study
was conducted in Tehran, which has considerable cultural
differences with other cities, the difference between the
results of this work and those of our study, which was
done in a smaller city with a high cultural difference
compared with Tehran, can be justified. Strengthening
the social interactions and communicating with peers, as
the third subcategory, presents the interest of the elderly
for interacting with others. having interpersonal relations
is one of the characteristics of self‑actualized persons.[16]
The results of this study showed that our results for this
subcategory contradict those of Robert and Dunbar[38] who
reported that the elderly have less tendency to create
friendly relations since keeping such communications
requires investing and making further effort. However,
in Canada activities with family or friends were the most
common.[39] When elderlies are asked to describe their close
friendships, they express their common interests, sense of
belonging, and opportunities to exchange their secrets, all
of which become stronger with the passage of time.[40]
Spirituality is the third category extracted in this work.
Spirituality is mentioned as one of the characteristics
of self‑actualization.[16] Based on age, religion, culture,
and health status, spirituality in human life is reflected in
different forms.[41] Spirituality causes calm, vitality, and
compatibility with chronic disease in the elderly.[42] In our
study, trust in God was a way to deal with hypertension
that is line with the result of one other study,[43] but
another research[44] showed reliance on God’s help was
not generally associated with health‑related quality of
life. Faith is conceptualized as the individual’s strength
of belief in a higher power.[22] Satisfaction is the second
subcategory that showed participants accept their diseases
and condition. In other studies, the majority of elderly
were dissatisfied.[45,46] This difference can be related to the
personality of the participants. In our study, participants
have a high level of self‑confidence, but in the mentioned
study the self‑concept of elderly is low. Praying is the
most common form of benediction in our study. In one
study, 45% of participants were introduced to the religious
community and participated in religious activities in the
process of chronic disease management.[26] The elderly
people spent most of their time praying.[46,47] Considering
the many religious activities conducted by Iranian elderly
compared with the Swedish ones, and the findings of
the study by Rocha and Ciosak[25] conducted in Brazil, it
is observed that many of the elderly did not view faith
and religious beliefs as a positive mechanism for dealing
with illnesses and did not consider any positive benefits
for them. Such an issue can be attributed to the lack and
scarcity of religious programs in these countries. Iran is one
of the largest Islamic countries and a religious and Islamic
culture dominates the society. Thus, it is not surprising that
the participants of this study perform religious practices
such as praying to reduce their anxieties and stress and to
provide mental peace.
Participants used strategies such as avoiding stressful places
and negative thoughts as well as having patience toward the
illness and life problems and not exaggerating them as some
stress management strategies. Stress management is one
of the health behaviors in the elderly.[48] There is a direct
relationship between self‑esteem and stress management.[49]
The results of Izadirad et al.[49] also showed that the elderly
prefer peaceful activities to keep calm. Other studies have
shown that elderly used abdominal breathing, massage
therapy, progressive muscle relaxation, music therapy,[50]
look and focus on good things,[51] and Tai Chi[52] as stress
management techniques. However, Barati et al.
[53] concluded
that stress management is very poor in old people. Lack
of required knowledge about stress control skills and not
applying such skills are of the main reasons of poor stress
management in these participants. Barati et al.
[53] carried
out a study in subsidiary villages of a remote city, and
according to the conditions in Iran, the lack of educational
resources and specific advice on stress management and
control, problem‑solving, and improvement of life skills for
the elderly in the villages and, on the other hand, the low
level of elderly literacy in rural areas and the inability to
study and learn skills may justify the low level of stress
management among participants in this stud. Considering
the fact that this study was carried out in a large city of
a religious country, the probability of generalization of the
results to other elderlies is low. The results of the study can
be used to help the elderly to increase their motivation for
self‑care behaviors. The limitations of time and access to
Gholamnejad, et al.: Self‑care outcomes for hypertensive elderly
Iranian Journal of Nursing and Midwifery Research ¦ Volume 24 ¦ Issue 3 ¦ May-June 2019 211
maximum variance of participants from other cities may
affect the generalizability of the results due to the cultural
differences.
Conclusion
The findings of this study could draw a clear image of
the self‑care experiences of the elderly suffering from
hypertension and their consequences. These elderly maintain
hope in the struggle with their illness, effectively control
their thoughts and actions, and pass and enjoy this period
with a sense of capability, hope, joy, and spirituality. The
self‑actualized elderly resist against the damaging effects of
internal and external stresses (as the inseparable component
of their lives) and take necessary steps toward their
flourishing. It is notable that management and regulation
of thoughts toward resisting internal and external stresses
contribute to the self‑actualization of the participants. At
the end, it is recommended to develop care plans or design
educational programs to institutionalize a culture of fun
for the elderly to teach positive psychology to prevent the
occurrence and deepening of the elderly problems. Health
professionals should be aware that under the positive effects
of self‑care behaviors, the level of health will increase.
Subsequently, medical expenses will be reduced.