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. 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.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.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.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.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.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.E-mail: [email protected] Access this article online Website: www.ijnmrjournal.net DOI: 10.4103/ijnmr.IJNMR_95_18 Quick Response Code: 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.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.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.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 |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.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.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.This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which 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.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.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.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.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.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.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.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.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.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.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.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.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.In Iranian societies, owing to its old traditions and cultures, elderly people are highly respected and thus their self-confidence is positively affected.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.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.The limitations of time and access to Gholamnejad, et al.: Self-care outcomes for hypertensive elderly Iranian Journal of Nursing and Midwifery Research |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.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.Gholamnejad, et al.: Self-care outcomes for hypertensive elderly 208 Iranian Journal of Nursing and Midwifery Research |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.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.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.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.It is notable that management and regulation of thoughts toward resisting internal and external stresses contribute to the self-actualization of the participants.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.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.Health professionals should be vigilant to encourage and promote education about the importance and advantages of self-care for elderlies.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.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.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.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.Active lifestyle This category is divided into three subcategories: having fun, keeping fit, and strengthening social interactions.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.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).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.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.Strengthening the social interactions and communicating with peers, as the third subcategory, presents the interest of the elderly for interacting with others.May-June 2019 211 maximum variance of participants from other cities may affect the generalizability of the results due to the cultural differences.Materials and Methods: This is a qualitative research with a conventional content analysis approach.Self-actualization of the elderly resulted in resisting against the destructive effects of internal and external stress and moving in the direction of growth.Materials and Methods This is a qualitative research with a conventional content analysis approach done in 2017.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.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.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.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.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.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.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.The participants consisting of 23 people were selected through purposive sampling.Data were collected through semi-structured interviews until data were saturated.These categories show the experience and outcomes of self-care behaviors among elderly patients with hypertension.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.The average duration of interviews was 40 min, and all interviews were conducted by the same interviewer.and from specialists and family members, What outcomes did you observe in hypertensive elderly taking good care of themselves?Thus, in the two last interviews, no novel idea or category was obtained.Next, the codes were placed under subcategories and categories based on their similarities and differences.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.Self-efficacy, active lifestyle, spirituality, and stress management are the main categories.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.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.In other studies, the majority of elderly were dissatisfied.[45,46] This difference can be related to the personality of the participants.Iran is one of the largest Islamic countries and a religious and Islamic culture dominates the society.Iranian J Nursing Midwifery Res 2019;24:206-12.Twenty-three participants were interviewed through purposive sampling.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 changes did you observe in the lifestyle of the hypertensive elderly taking care of themselves well?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.For illiterate participants, the consent form was read and they fingerprinted their consent forms.The demographic characteristics of the study participants are presented in Table 1.Recreational activities play an important role in improving one's understanding of health and life expectancy.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).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.It is not necessary for anyone to have all these qualities.[21] In this research, our participants have some characteristics of self-actualizing people.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.Such an issue can be attributed to the lack and scarcity of religious programs in these countries.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.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.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.The authors used MAXQDA11 software to manage the data.All study participants provided informed and written consents.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].More confidence in their ability to exercise self-care behaviors results in a greater endeavor to do them by the elderly.Stress management This category consists of three subcategories: to keep calm, to escape from tension, and to be patient when there are problems.In this study, self-actualization in the course of disease was extracted as the main outcome.Experiencing purpose in life was also described as being happy in everyday life and thinking positively in every situation.Keeping fit shows the willingness of the elderly to maintain their ideal weight.However, Barati et al. [53] concluded that stress management is very poor in old people.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.Subsequently, medical expenses will be reduced.The information was directly gathered from the participants.What are the outcomes of self-care in your lifestyle?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).For example, participants stated that, "My children insist on helping me, but I refuse. I want to be independent" (p. 2).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).Keeping fit The results showed that it is important to maintain a suitable physical appearance for most of the elderly.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.The results showed that our participants were people with high self-efficacy.Our participants showed that they have high self-esteem.In our study, participants have a high level of self-confidence, but in the mentioned study the self-concept of elderly is low.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.Health professionals should be aware that under the positive effects of self-care behaviors, the level of health will increase.Accepted: January, 2019.Volume 24 |What effect does disease control have on your beliefs?Volume 24 |For example, one of the participants said, "I love working with flowers. I am having fun with them" (p. 20)."I have some friends from the mosque. I sometimes speak with them. It makes me happy. All humans need to talk" (p. 14).They were trying to apply the necessary measures for the effective control and treatment of their illness.Praying is the most common form of benediction in our study.Volume 24 |Received: July, 2018.Issue 3 |Issue 3 |"We must accept the truth that in this busy world nobody can make time for you. You are responsible for your life" (p. 3).They often try to keep calm by not getting angry and anxious."My wife passed away last year. When I think about her, I feel sad. Therefore, I try to avoid thinking about her" (p. 11)."I always say this is life. I take life easy. If my disease cannot be treated, why am I making myself sad" (p. 4).Issue 3 |

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
Quick Response Code:
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
Attribution‑NonCommercial‑ShareAlike 4.0 License, which
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).
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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
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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
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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.