Types of Empowerments on Improving Hypertension among Elderly: A Systematic Review
Tri Nurhidayati1,2*, Ah Yusuf 1, Retno Indarwati1
1Faculty of Nursing, Airlangga University, Surabaya, PQJM+528, Mulyorejo, Surabaya, East Java 60115, Indonesia
2Faculty of Nursing and Health Sciences, Muhammadiyah University Semarang, Central Java 50273, Indonesia
*Corresponding Author’s Email: tri.nurhidayati-2022@fkp.unair.ac.id
ABSTRACT
Introduction: Hypertension is a cardiovascular disease, often referred to as the silent killer disease, that mostly affects the elderly. Changes in body condition and unhealthy lifestyles cause hypertension in the elderly. Hypertension is basically a cause of high mortality and impacts expensive care for the elderly. The caregiver's lack of ability is one of the triggers for the severity of hypertension. The caregiver plays a crucial role in helping elderly people with hypertension become independent. Research on the empowerment of caregivers of elderly hypertensives is very diverse, but research on the most effective empowerment for caregivers is limited. Objective: This study aims to investigate the type of empowerment that improves hypertension in the elderly. Methods: The online databases include Science Direct, ProQuest, PubMed, Sage, Ebscohost, and Google Scholar. Articles were reviewed from 2018 to 2022. Protocol and evaluation of literature review using the PRISMA checklist and the Joanna Briggs Institute Guidelines. Results: A total of 15 articles define the types of empowerments, comprising 6 types of such as family empowerment (4 articles), social support (4 articles), adaptation (2 articles), education (3 articles), dyadic partnership (1 article), and multidisciplinary (1 article). The development of a caregiver empowerment model is expected to increase the ability to care for the elderly and have an impact on the self-management of hypertension. Conclusions: Empowering caregivers for elderly people with hypertension is an important step in ensuring that elderly people receive optimal care and are able to better manage their hypertension condition. The most common were family empowerment and social support.
Keywords: Empowerment; Elderly; Hypertension
INTRODUCTION
In Southeast Asian countries, where the prevalence of hypertension is rapidly rising, there is a scarcity of studies examining how patients manage their self-care practices (Irwan et al., 2022). The highest non- communicable disease in Indonesia is hypertension (68.6%). The prevalence of hypertension in Indonesia was 658,201 people, while the elderly who suffered from hypertension were 63.5% (Riskesdas Kemenkes, 2018). Researchers find that caregivers struggle to provide adequate care for elderly people with hypertension (Boonyathee et al., 2021). The family has an important role in helping elderly people with hypertension become independent. Family involvement as a caregiver has a positive impact on handling elderly hypertension (Silva et al., 2021).
The caregiver has an important role in treating elderly people with hypertension to become independent (Raei et al., 2022; Elvira, 2018). A caregiver has a positive impact on handling the elderly. Caregiver support has the effect of increasing lifestyle and reducing stress (Wasmani et al., 2022). The caregiver plays a crucial role in ensuring medication adherence by monitoring the correct dosage, schedule, and method of medication administration (Kabia et al., 2022). Efforts aim to empower caregivers to enhance their caring abilities and family attitudes. While there is a wealth of research on how to empower caregivers of elderly
hypertensives, there is a dearth of research on the most effective forms of empowerment. The objective of this study is to explore the type of empowerment that improves hypertension in the elderly.
METHODOLOGY
This research design is a literature review and 15 articles using six databases: Science Direct, ProQuest, PubMed, Sage, Ebscohost, and Google Scholar. Articles were reviewed from 2018 to 2022. The process of evaluating this systematic review using the PRISMA checklist involved assessing an appropriate journal with keywords such as empowerment, hypertension, and the elderly.
Stage 1: Identifying The Research Topic or Questions
The exploration questions were made in light of the assumption that empowerment has a significant impact on the elderly with hypertension. The following question served as the basis for this analysis: what kind of empowerment is most common and effective for the elderly with hypertension?
Stage 2: Identifying Relevant Studies Search Scheme
The articles used six databases: Science Direct, ProQuest, PubMed, Sage, Ebscohost, and Google Scholar, from July to September 2023.
Search Terms
The search terms include empowerment, the elderly, and hypertension. The inclusion criteria minimized the number of articles.
Search Parameters
The articles that qualified include full-text articles in English from 2018 to 2022.
RESULTS
Stage 1: Study Selection
A total of 246 papers were discovered throughout the literature search. Twenty-three evaluations, after removing duplicates, abstracts, and interventions, finally included 15 research articles.
The identification of articles was done using PRISMA (See Figure 1).
Figure 1: PRISMA Flowchart for the Article Selection
Stage 2: Data Collection Quality Assessment of Articles
The quality assessment of the articles in this audit was finished in two ways: selecting studies based on the criteria established in this review and quality assessment with the Joanna Briggs Institute. Articles that met the criteria were chosen for further assessment.
Data Extraction and Charting
A charting design was made for this study. The chart included the following characteristics: author, year published, country, design, subjects, variables, instruments, analyses, and key findings.
Stage 3: Data Summary and Synthesis Article Characteristics
Fifteen articles met the inclusion criteria. Most of them are quantitative design and come from Asia (13 articles), Nigeria (1 article), and Albania (1 article). The empowerment intervention lasted from 12 weeks to 6 months. The following table explains the review results:
Table 1: Characteristics Studies
No | Title/Author/ Year/Country | Design/Subject/ Analysis | Variable/Instrument | Key Finding |
1 | Social support family / (Boonyathee et al., 2021)/Thailand | Design: Quasi experiment Subject: 286 elderly Analysis : ANOVA | Variables: Knowledge, self- efficacy, behavior, blood pressure, total cholesterol, HDL (elderly), Knowledge, self- efficacy, behavior (caregiver) Instruments: general demographics, knowledge-22, self- efficacy, health care behavior | The program underscores the significant job of parental figures in offering social help, expanding certainty, and taking part in care, observing and assisting the old with controlling |
2 | Family- centered Empowerment Model / (Hamedani, Salar & Kermansaravi, 2021)/Iran | Design: Clinical trial study Subject: 70 seniors and families Analysis: Independent sample t test, chi square, analysis of variance | Variables: Quality of Life Instruments: Quality of life in patients with hypertension-42 Shamsi | The results of the repeated measures analysis of variance revealed significant differences in the quality of life between the two groups at the second and third stages over time. |
3 | Knowledge and Behavior / (Seangpraw & Ong- Artborirak, 2020) /Thailand | Design: Cross- sectional study Subject: 402 caregivers Analysis : Multivariate linear regression | Variables: Knowledge, care behavior, quality of life Instruments: knowledge, care behavior, WHOQOL - BREF | Age, caregiver-patient relationship, knowledge, and attitudes toward health services in elderly patients with hypertension were found to be significantly associated with caregivers' quality of life in the multivariate linear regression test. |
4 | Family Empowerment Model/(Hidayat | Design: Pre experimental with one group of pre-test-posttest design | Variables: Compliance, Blood Pressure | The Paired T Test showed an increase in dietary adherence with a P value = 0.007 (p <0.05), while a decrease |
2020) /indonesia | Subject: 21 respondents Analysis : Pair t test | Instruments: Diet compliance-19 | in systolic blood pressure with a P value = 0.005 (p <0.05), and diastolic blood pressure with a P value = 0.023 (p < 0.05). | |
5 | Social Support / (Thuy et al., 2021) /Vietnam | Design: Crossectional study Subject: 220 seniors Analysis: The chi-square test and the Mann- Whitney test were performed as appropriate. Multivariate logistic and to bit regression models | Variables: Social support Instruments: age, gender, education, occupation, place of residence, smoking and alcohol drinking status, comorbidities, weight, height, body mass index, and quality of life. Short version 12 version 2 (SF-12v2) patient HRQoL instrument hypertension regarding physical components (PCS-12) and mental components (MCS- 12) | Social support and social networks are linked to controlling hypertension and adhering to recommended behaviors. Further mediations to further develop hypertension the board should address the likely impacts of informal community attributes |
6 | Family dyadic partnership program ( Zeng, Yang, & Chien, 2021)/China. | Design: RCT with pretest and post - test design. Subject: 44 family Analysis : ANOVA | Variables: Behavior, self-efficacy, relationship between patient and family Instruments: Chinese version of the Behavior and the Self- Efficacy Scale, Patient Health Questionnaire- 9 (PHQ-9), Generalized Anxiety Disorder Scale-7, f EuroQol five- dimensional five- level, Chinese version of Dyadic | Family dyadic partnership intervention is a viable and acceptable program with a high enrollment (81.5%) and fulfillment rate (95.5%) and positive reactions from members. Control Blood pressure was significant with P = 0.03. |
7 | Adaptation predictor / (Ifeagwazi, Egberi & | Design: correlational Subject: 226 patients | Variables: Emotional Reactions, Anxiety, blood pressure Instruments: 9-item Emotional Reactivity | Emotional reactivity was positively related to increased blood pressure. Anxiety is decidedly connected |
Chukwuorji, 2018)/ Nigeria | Analysis : regression | Scale (ERS), State- Trait Anxiety | with an expansion in circulatory strain. Emotional reactivity and elevated blood pressure are also partially mediated by anxiety. | |
8 | Knowledge predictors (Duygu Kes, 2019)/ Turkiye | Design: cross- sectional study Subject: 231 elderly Analysis: Kolmogorov- Smirnov test, multiple regression and, binary logistic regression analysis | Variables: predictors of blood pressure control and medication adherence Instruments: Description of Patient Medication Information and Compliance Form (MASES-SF) | Diet, physical activity, income level, employment status, and systolic and diastolic blood pressure all have a significant impact on medication adherence (p 0.05) when the significance test of the regression coefficient is taken into consideration. |
9 | Social and community (Pirkle et al., 2018)/Albania | Design : Description Subject: 393 elderly Analysis : STATA , multinomial logistic regression models (an extension of the binary logistic model | Variables: individual factor , interpersonal, community organization Instruments : social support and social network scale, Home And Community Environment (HACE) scale | This study illustrates the behavior of older patients and emphasizes the role of educating them to modify their behaviors, thereby preventing hypertension and other related issues. Additionally, another study has highlighted the importance of family caregivers in education, noting their role as intermediaries in transferring knowledge between themselves and the patients. |
10 | Family- centered empowerment model l/ (Someia et al., 2020)/ Iran | Design: RCT Subject: 60 elderly women Analysis: independent t- test, ANCOVA | Variables: HPLP, anthropometry, blood pressure Instruments: HPLP2, anthropometry, blood pressure | Family can further develop wellbeing advancing way of behaving/way of life and further develop serum digestion (cholesterol, urea, creatinine). The eighth week saw the greatest increase. Cholesterol, LDL-C, urea and creatinine diminished in both the control and |
treatment gatherings. Viable weight reduction at a half year after treatment. | ||||
11 | Family- centered empowerment model Multivariate Approach (Raei et al., 2022)/ Iran | Design: RCT Subject: 105 family Analysis: ANCOVA | Variables: Quality of Life, perceived stress, anxiety Instrument: HRQoL, PSQ-14, State trait anxiety | Family who were in the FCEM group had altogether higher normal degrees of seen pressure. In the meantime, further examination through the subsequent model uncovered that the mediation didn't altogether build all parts of QoL. FCEM has huge FCEM bis lessens side effects of uneasiness, stress. |
12 | Social support and family function (Zhang et al., 2020)/ China | Design: cross- sectional study Subject: 530 elderly Analysis: Wilcoxon rank- sum test and Kruskal–Wallis test, Spearman correlation analysis | Variables: social support, family functions Instruments: Hypertension Patients Self-Management Behavior Rating Scale (HPSMBRS) (Zhao & Liu, 2012), Social Support Rating Scale (SSRS), APGAR | Self-management behavior was independently associated with social support, family functioning, and well- being. |
13 | Multi- disciplinary active aging intervention (Chi, Wu & Liu, 2021)/ China | Design: experiment Subjects: 80 elderly people Analysis: model fit analysis, GEE analysis | Variables: healthy lifestyle, mental health, social participation, active elderly Instruments: Walker healthy living scale, Lee brief symptom rating scale, Zheng self-rated social and community participation scale, Lin self-rated active aging scale | The 19-week mediation resulted in enhancements in way of life, emotional wellness status, social support, and dynamic older people. The latent elements in this model are dynamic older, emotional well-being, and sound way of life. |
14 | Family caregiver empowerment program (Dharma et al., | Design: quasi experiment with a control group Subjects: 80 family | Variables: quality of life, functional capacity Instruments: SSQoL- 12, Barthel index | Six months after the intervention, CEP- BAM significantly improved the functional capacity of elderly |
2018) / Indonesia | Analysis: ANOVA | stroke survivors and their quality of life. Nine of the ten practical limit spaces further developed in the mediation after CEP- BAM, while two areas (eating and dressing) expanded fundamentally in the a half year after CEP BAM. |
A total of 15 articles defines the types of empowerments, comprising 6 types of such as family empowerment (4 articles), social support (4 articles), adaptation (2 articles), education (3 articles), dyadic partnership (1 article), and multidiscipline (1 article). The development of a caregiver empowerment model is expected to increase the ability to care for the elderly and have an impact on the self-management of hypertension.
DISCUSSION
This systematic review aims to discover the types of empowerment models that caregivers can use to increase their ability to care for elderly people with hypertension. Empowering caregivers for elderly people with hypertension is an important step in ensuring that elderly people receive optimal care and are able to better manage their hypertension condition. Hypertension, a non-communicable disease, currently poses a significant threat to global public health issues, particularly in Indonesia. Because hypertension ranks first among sufferers compared to other diseases, the Indonesian Ministry of Health has used various ways to deal with hypertension problems in society (Ministry of Health, 2018).
Thematic analysis identified for the articles was 6 types of empowerment, such as family empowerment (4 articles), social support (4 articles), adaptation (2 articles), education (3 articles), dyadic partnership (1 article), and multidisciplinary (1 article).
Family Empowerment. Family members are familiar with the behavioral patterns of older patients, and their role is to supplement their education to modify these behaviors as necessary to prevent hypertension and unexpected problems (Callaway, Connor, & Foley, 2018). Another study has demonstrated the importance of family guardians as supporters of training, as well as their ability to act as mediators, moving information between themselves and the patients (Boonyathee et al., 2021). Family caregivers need to understand the relevance of anthropometric and blood pressure measurements (Rosdiana, 2019).
Social Support. The elderly undoubtedly benefits greatly from social help and support, particularly when it comes to relaxing and participating in social activities within their families and local communities (Liu, Gou, & Zuo, 2016). The community centers' social network support assists with empowering the older people to go to social exercises (Pirkle et al., 2018).
Adaptation: Chronological age should not be the main criterion for adapting therapeutic strategies because of the large heterogeneity in the pace and consequences of the aging process among older adults(Benetos, Petrovic, & Strandberg, 2019). Establishment of support groups for caregivers to share experiences and get support from fellow caregivers and counseling services to help caregivers overcome stress and emotional exhaustion.
Education: Successful training and observing projects should be made to accomplish blood pressure control, and it is critical to realize the elements influencing pulse control so that such projects can be arranged in hypertension. (Duygu Kes, 2019). Education about hypertension by providing information about what hypertension is, risk factors, symptoms, and complications. Medical management involves training caregivers in medication management, blood pressure monitoring, and how to provide proper care. It imparts knowledge on the significance of maintaining a low-salt diet, engaging in physical activity, and managing stress. (Riskesdas Kemenkes, 2018). Monitoring programs prevent increasing hypertension as a result of weight management because nutritional status is associated with blood pressure. (Roy, Roy, & Ghosh, 2023). Stress management through relaxation techniques is critical for lowering blood pressure. (Rosdiana & Cahyati, 2019; Wijaya & Nurhidayati, 2020). The use of progressive muscle relaxation can reduce stress and blood pressure. (Rosdiana & Cahyati, 2019). Education and training, team-based care, consultation, and short message service reminders were the most common interventions. (Ye et al., 2024). Current evidence suggests that health coaching could reduce blood pressure, improve dietary behaviors, and increase self-efficacy among patients with hypertension, making it an effective and alternative method for managing hypertension (Meng et al., 2023). Meta-analyses found evidence for the positive effects of group-format interventions measuring empowerment, HbA1c, and self-efficacy. Some individual-format interventions also showed effects on empowerment. Stepanian et al., 2023 identified high levels of heterogeneity and variability among the conceptual frameworks. The meta-analysis showed that mean values of systolic blood pressure (SBP) and diastolic blood pressure (DBP) decreased significantly after strength training interventions (Correia et al., 2023). Lifestyle behavior modification plays an essential role in the management of hypertension. Education and counseling interventions and strategies to achieve lifestyle behavior modification are vital components (Bulto et al., 2024).
Dyadic Partnership: Spousal support for elderly people with hypertension can promote better management of their condition and help them enjoy a high quality of life. This support focuses not only on medical aspects but also on psychological ones, which are important for long-term management. The majority of elders whose spouses were still alive were really focused on by their mates and were commonly worried about one another (Perez-Sousa et al., 2020). They had to manage experiences collectively, and they considered interacting with each other as their duty. Investigations have discovered that guardians who are youngsters or grandkids can have preferable personal satisfaction over different gatherings (Seangpraw & Ong-Artborirak, 2020).
Multi Discipline: To ensure that seniors with hypertension receive comprehensive and holistic care, a multidisciplinary approach is essential (Durán-Vega et al., 2019). This approach involves various professionals from different disciplines working together to meet the physical, psychological, and social needs of older adults with hypertension (Shepperd et al., 2021). Doctors and nurses assist with treatment and blood pressure monitoring. The nutritionist provides a proper diet plan. Physiotherapists design safe exercise programs to improve heart health and reduce blood pressure. Psychologists provide support for dealing with stress. With a multidisciplinary approach, hypertensive elderly receives effective, efficient, holistic care that does not only focus on the disease but also improves overall quality of life (Sanclemente- Boli et al., 2019).
Limitations
The variability in definitions and implementations of empowerment in this article across the reviewed articles could introduce inconsistencies in the findings. The focus on diverse empowerment types without a standardized measure may affect the comparability of results, and the exclusion of non-English language studies may have led to a geographical bias. Finally, the study's scope did not include direct empirical data collection, relying solely on secondary sources, which may limit the applicability of the findings to real- world settings.
CONCLUSION
The results showed heterogeneous models of caregiver empowerment. Most of the results showed family empowerment and social support empowerment. Empowering caregivers for elderly people with hypertension is an important step in ensuring that elderly people receive optimal care and are able to better manage their hypertension condition. Improving the health of the elderly through better and more regular care. Caregiver stress and caregiver fatigue decrease due to proper support, and the quality of life of the elderly and caregivers improves. This raises the issue of how these needs can be focused on sustainable caregiver empowerment.
Future research should focus on developing and evaluating sustainable models of caregiver empowerment that integrate family support, social support, and other effective strategies identified in the study. It is crucial to investigate the specific training and resources required for caregivers to manage hypertension effectively and to develop standardized programs that can be widely implemented. Ensuring that these empowerment strategies are adaptable to diverse cultural and geographical contexts will enhance their applicability and effectiveness.
Conflict of Interest
The authors declare that they have no competing interests.
ACKNOWLEDGEMENT
The authors are thankful to Department of Nursing, Universitas Muhammadiyah Semarang (UNIMUS), Indonesia for providing funding.
REFERENCES
Benetos, A., Petrovic, M., & Strandberg, T. (2019). Hypertension management in older and frail older patients. Circulation Research, 124(7), 1045-1060. https://doi.org/10.1161/CIRCRESAHA.118.313236
Boonyathee, S., Seangpraw, K., Ong-Artborirak, P., Auttama, N., Tonchoy, P., Kantow, S., ... & Dokpuang, D. (2021). Effects of a social support family caregiver training program on changing blood pressure and lipid levels among elderly at risk of hypertension in a northern Thai community. PLoS One, 16(11), e0259697. https://doi.org/10.1371/journal.pone.0259697
Bulto, L. N., Roseleur, J., Noonan, S., Pinero de Plaza, M. A., Champion, S., Dafny, H. A., ... & Hendriks, J. M. (2024). Effectiveness of nurse-led interventions versus usual care to manage hypertension and lifestyle behaviour: a systematic review and meta-analysis. European Journal of Cardiovascular Nursing, 23(1), 21-32. https://doi.org/10.1093/eurjcn/zvad040
Callaway, M. V., Connor, S. R., & Foley, K. M. (2018). World Health Organization public health model: a roadmap for palliative care development. Journal of Pain and Symptom Management, 55(2), S6-S13. https://doi.org/10.1016/j.jpainsymman.2017.03.030
Chi, Y. C., Wu, C. L., & Liu, H. T. (2021). Effect of a multi-disciplinary active aging intervention among community elders. Medicine, 100(51), e28314. https://doi.org/10.1097/MD.0000000000028314
Correia, R. R., Veras, A. S. C., Tebar, W. R., Rufino, J. C., Batista, V. R. G., & Teixeira, G. R. (2023). Strength training for arterial hypertension treatment: a systematic review and meta-analysis of randomized clinical trials. Scientific Reports, 13(1), 201. https://doi.org/10.1038/s41598-022-26583-3
Dharma, K. K., Damhudi, D., Yardes, N., & Haeriyanto, S. (2018). Increase in the functional capacity and quality of life among stroke patients by family caregiver empowerment program based on adaptation model. International Journal of Nursing Sciences, 5(4), 357-364. https://doi.org/10.1016/j.ijnss.2018.09.002
Durán-Vega, L. A., Santana-Mancilla, P. C., Buenrostro-Mariscal, R., Contreras-Castillo, J., Anido-Rifón, L. E., García-Ruiz, M. A., ... & Estrada-González, F. (2019). An IoT system for remote health monitoring in elderly adults through a wearable device and mobile application. Geriatrics, 4(2), 34. https://doi.org/10.3390/geriatrics4020034
Duygu Kes, R. N. (2019). Predictors of blood pressure control and medication adherence among primary hypertensive patients. International Journal of Caring Sciences, 12(1), 483-491. https://www.internationaljournalofcaringsciences.org/docs/54_kes_12_1_1.pdf
Elvira, M. (2018). Influence of yoga on the blood pressure of elderly with hypertension. Malaysian Journal of Medical Research (MJMR), 2(3), 30-35.https://doi.org/10.31674/mjmr.2018.v02i03.004
Hamedani, M. A., Salar, A., & Kermansaravi, F. (2021). Effect of family-centered empowerment model on quality of life of patients with hypertension. Medical-Surgical Nursing Journal, 10(1), e117259. https://doi.org/10.5812/msnj.117259
Hidayat, A. A. A. (2020). The Increasing Obedience and Changes in Blood Pressure Through Family Empowerment Model in Elderly People with Hypertension. Indian Journal of Public Health Research & Development., 11(3). 1061–1064. https://doi.org/10.37506/ijphrd.v11i3.1533
Ifeagwazi, C. M., Egberi, H. E., & Chukwuorji, J. C. (2018). Emotional reactivity and blood pressure elevations: anxiety as a mediator. Psychology, Health & Medicine, 23(5), 585-592. https://doi.org/10.1080/13548506.2017.1400670
Irwan, A. M., Potempa, K., Abikusno, N., & Syahrul, S. (2022). Self-Care Management for Hypertension in Southeast Asia: A Scoping Review. Journal of Multidisciplinary Healthcare, 15, 2015–2032. https://doi.org/10.2147/JMDH.S367638
Kabia, F. M., El Fakiri, F., Heus, M., & Fassaert, T. (2022). Taking care of older caregivers who lose control: The association between mastery and psychopathology. Archives of Gerontology and Geriatrics, 101, 104687. https://doi.org/10.1016/j.archger.2022.104687
Kemenkes, R. I. (2018). Manajemen Program Pencegahan dan Pengendalian Hipertensi dan Perhitungan Pencapaian SPM Hipertensi. Subdit Penyakit Jantung Dan Pembuluh Darah Direktorat P2PTM Ditjen Pencegahan Dan Pengendalian Penyakit, April, 11, 17-20. [Ministry of Health. (2018). Management of Hypertension Prevention and Control Program and Calculation of Achievement of Hypertension SPM. Hypertension Prevention and Control Workshop, April,11,17-20.] http://p2ptm.kemkes.go.id/uploads/VHcrbkVobjRzUDN3UCs4eUJ0dVBndz09/2018/05/Manajemen_Pro gram_Hipertensi_2018_Subdit_PJPD_Ditjen_P2PTM.pdf
Liu, L., Gou, Z., & Zuo, J. (2016). Social support mediates loneliness and depression in elderly people. Journal of Health Psychology, 21(5), 750-758. https://doi.org/10.1177/1359105314536941
Meng, F., Jiang, Y., Yu, P., Song, Y., Zhou, L., Xu, Y., & Zhou, Y. (2023). Effect of health coaching on blood pressure control and behavioral modification among patients with hypertension: A systematic review and meta-analysis of randomized controlled trials. International Journal of Nursing Studies, 138, 104406. https://doi.org/https://doi.org/10.1016/j.ijnurstu.2022.104406
Ministry of Health, R. I. (2018). Hypertension Prevention and Control Program Management and Hypertension SPM Achievement Calculation. Cardiac and Vascular Diseases Subdit Directorate of P2PTM Directorate General of Disease Prevention and Control, April, 11, 17-20. http://p2ptm.kemkes.go.id/uploads/VHcrbkVobjRzUDN3UCs4eUJ0dVBndz09/2018/05/Manajemen_Pro gram_Hipertensi_2018_Subdit_PJPD_Ditjen_P2PTM.pdf
Perez-Sousa, M. A., Olivares, P. R., Gonzalez-Guerrero, J. L., & Gusi, N. (2020). Effects of an exercise program linked to primary care on depression in elderly: fitness as mediator of the improvement. Quality of Life Research, 29(5), 1239-1246. https://doi.org/10.1007/s11136-019-02406-3
Pirkle, C. M., Ylli, A., Burazeri, G., & Sentell, T. L. (2018). Social and community factors associated with hypertension awareness and control among older adults in Tirana, Albania. European Journal of Public Health, 28(6), 1163-1168. https://doi.org/10.1093/eurpub/cky036
Raei, M., Ghasemi, M., Hushmandi, K., Shirmohammadi-Khoram, N., Omolbanin Seyedrezaei, S., Rostami, H., & Vahedian-Azimi, A. (2022). Effectiveness of family-centered empowerment model on psychological improvement of patients with myocardial infarction: A Bayesian multivariate approach. Frontiers in Public Health, 10, 878259. https://doi.org/10.3389/fpubh.2022.878259
Riskesdas Kemenkes, R. I. (2018). Laporan Nasional Riset Kesehatan Dasar. Kementrian Kesehatan RI, 1-582. [Riskesdas Ministry of Health, R. I. (2018). National Report on Basic Health Research. Indonesian Ministry of Health, 1—582]. https://repository.badankebijakan.kemkes.go.id/id/eprint/3514/1/Laporan%20Riskesdas%202018%20Nas ional.pdf
Rosdiana, I., & Cahyati, Y. (2019). Effect of progressive muscle relaxation (PMR) on blood pressure among patients with hypertension. International Journal of Advancement in Life Sciences Research, 28-35. https://doi.org/10.31632/ijalsr.2019v02i01.005
Roy, S., Roy, J. G., & Ghosh, J. R. (2023). The Effect of Substance Abuse Associated with Nutritional Status and Blood Pressure in Santal Women. International Journal of Advancement in Life Sciences Research, 06(02), 15–24. https://doi.org/10.31632/ijalsr.2023.v06i02.002
Sanclemente-Boli, T., Ponce-Ruiz, S., Álvarez-Lorenzo, C., Zuriguel-Pérez, E., Tapia-Melenchon, R., Ramentol-Sintas, M., ... & Mestre-Torres, J. (2019). Effectiveness of a multidisciplinary educational intervention in patients with hip fracture: Sweet Home Study. Medicina Clínica (English Edition), 153(12), 446-453. https://doi.org/10.1016/j.medcli.2019.02.026
Seangpraw, K., & Ong-Artborirak, P. (2020). Knowledge and behaviors toward health care for elderly patients with hypertension, and quality of life among informal caregivers in Northern Thailand. Journal of Multidisciplinary Healthcare, 1771-1780. https://doi.org/10.2147/JMDH.S284886
Shepperd, S., Gonçalves-Bradley, D. C., Straus, S. E., & Wee, B. (2021). Hospital at home: home-based end-of-life care. The Cochrane Database of Systematic Reviews, 3(3), CD009231. https://doi.org/10.1002/14651858.CD009231.pub3
Silva, R., Bobrowicz-Campos, E., Santos-Costa, P., Gil, I., Neves, H., & Apóstolo, J. (2021). The Quality of Carer–Patient relationship scale: adaptation and validation into Portuguese. International Journal of Environmental Research and Public Health, 18(3), 1264. https://doi.org/10.3390/ijerph18031264
Someia, N. M., Atri, S. B., Areshtanab, H. N., Salehi-Pourmehr, H., & Farshbaf-Khalili, A. (2020). Effectiveness of education based on family-centered empowerment model on health-promoting behaviors and some metabolic biomarkers in elderly women: a stratified randomized clinical trial. Journal of Education and Health Promotion, 9 (1), 331. https://doi.org/10.4103/jehp.jehp_520_20
Stepanian, N., Larsen, M. H., Mendelsohn, J. B., Mariussen, K. L., & Heggdal, K. (2023). Empowerment interventions designed for persons living with chronic disease-a systematic review and meta-analysis of the components and efficacy of format on patient-reported outcomes. BMC Health Services Research, 23(1), 911. https://doi.org/10.1186/s12913-023-09895-6
Thuy, L. Q., Thanh, N. H., Trung, L. H., Tan, P. H., Nam, H. T. P., Diep, P. T., ... & Van Toan, N. (2021).Blood pressure control and associations with social support among hypertensive outpatients in a developing country. BioMed Research International, 2021(1), 7420985. https://doi.org/10.1155/2021/7420985
Wasmani, A., Rahnama, M., Abdollahimohammad, A., Badakhsh, M., & Hashemi, Z. (2022). The effect of family-centered education on the Care Burden of Family caregivers of the Elderly with Cancer: a quasi- experimental study. Asian Pacific Journal of Cancer Prevention: APJCP, 23(3), 1077. https://doi.org/10.31557/APJCP.2022.23.3.1077
Wijaya, E., & Nurhidayati, T. (2020). Penerapan Terapi Relaksasi Otot Progresif Dalam Menurunkan Skala Nyeri Sendi Lansia. Ners Muda, 1(2), 88. [Wijaya, E., & Nurhidayati, T. (2020). Application of Progressive Muscle Relaxation Therapy in Lowering the Scale of Joint Pain in the Elderly. Young Nurse, 1(2), 88.] https://doi.org/10.26714/nm.v1i2.5643
Ye, J., Sanuade, O. A., Hirschhorn, L. R., Walunas, T. L., Smith, J. D., Birkett, M. A., ... & Huffman, M. D. (2024). Interventions and contextual factors to improve retention in care for patients with hypertension in primary care: Hermeneutic systematic review. Preventive Medicine, 180,107880. https://doi.org/https://doi.org/10.1016/j.ypmed.2024.107880
Zeng, D., Yang, C., & Chien, W. T. (2021). Effects of a family dyadic partnership program for people with hypertension in a rural community: A pilot randomised controlled trial. Australian Journal of Rural Health, 29(3), 435-448. https://doi.org/10.1111/ajr.12712
Zhang, X., Zheng, Y., Qiu, C., Zhao, Y., & Zang, X. (2020). Well-being mediates the effects of social support and family function on self-management in elderly patients with hypertension. Psychology, Health and Medicine, 25(5), 559–571. https://doi.org/10.1080/13548506.2019.1687919