Introduction
Hypertension is a major risk factor for cardiovascular disease and premature death. The World Health Organization estimates that hypertension affects more than one billion individuals worldwide and accounts for 13.5% of total deaths per year [
1]. Serious concerns about hypertension in people with disabilities have been regularly reported in national studies. In South Korea, 56.4% of the population living with a physical disability was affected by hypertension in 2017, which was twice as high as the population without a disability [
2]. People with disabilities have been shown to are at 2.3-fold high risk of developing hypertension and five times higher mortality rates due to hypertension than the general population [
3,
4]. Statistical reports have consistently identified people with disabilities as experiencing poorer health outcomes, resulting in a higher mortality rate than their peers in the general population. Unfortunately, to date, most studies have focused mainly on hypertension in the general population, whereas the subpopulation that experiences disabilities has largely been neglected.
Engagement in self-management behaviour is indispensable for the management of hypertension. The 2018 Korean Society of Hypertension Guidelines provide self-management recommendations essential for the control of high blood pressure including abstaining from smoking, limiting alcohol consumption, eating a diet rich in fruits and vegetables, taking part in regular physical activity, and maintaining a healthy weight [
5]. Adherence to such self-management behaviours significantly reduces blood pressure, resulting in more cost-effective use of healthcare resources [
6]. The main causes of mortality in hypertensive patients are linked to unhealthy behaviours such as physical inactivity, tobacco smoking, poor diet, obesity, and excessive alcohol consumption [
7,
8]. Overwhelming substantive evidence supports the significant role of self-management behaviour on blood pressure [
9].
Despite the clear benefits of self-management behaviours, many hypertensive patients do not comply with the suggested recommendations, thereby failing to regulate their blood pressure. Self-management may be even more challenging for those with physical disabilities due to their complex needs, such as physical restrictions and co-morbid health conditions, thus highlighting the need for extra support and appropriate accommodations [
10]. Providing safe, appropriate, and accessible options for people with disabilities requires support across many sectors to help them engage more easily in essential healthy behaviours [
11]. However, there is a lack of scientific evidence that supports addressing priority health needs and the identification of key determinants of health behaviours in people with physical disabilities.
A diverse array of characteristics and physical needs has been demonstrated among people with physical disabilities [
12]. Thus, it is critical to take special consideration of the unique needs of individuals with physical disabilities in relation to self-management behaviours. Exploration of person-centred typologies could contribute to understanding the heterogeneity of self-management behaviours. Thus far, however, it remains unclear how the different aspects of hypertension management regimes appear in behavioural patterns among people with physical disabilities. To date, the majority of studies have focused only on hypertension management behaviour as a single concept, and the level of practice was evaluated by a total score of unidimensional measure [
7]. This traditional variable-level method has limitations as it has led to reduced appreciation of the diversity of patient challenges and specific needs, which has then fostered misleading and overgeneralised conclusions with study findings representing the overall sample [
13]. This methodological limitation of traditional variable-centred methods may be avoided by utilising a latent class analysis (LCA) approach. LCA is a person-centred method, suitable for discrete and dichotomous variables; it also enables the identification of distinct configurations of heterogeneity within a given population sample [
13]. Hence, LCA has been described as a more logical and informative approach for exploring health behaviours [
7,
13].
Therefore, this study aimed to identify the typology of hypertension self-management behaviours to improve understanding of self-management patterns using LCA on the basis of the clustering of five hypertensive management recommendations: abstaining from smoking, limiting alcohol consumption, adequate physical activity, balanced diet, and weight control. We also aimed to explore the factors associated with these behaviours and how these classes differ with respect to various health measures to identify potential unobserved, at-risk groups among hypertensive adults with physical disabilities living in South Korea.
Discussion
The present study has identified three mutually exclusive subgroups of hypertension self-management behaviours: a high self-management group, a harmful habitual behaviour group, and an inactive behaviour group, based on five self-management behaviours: smoking, alcohol intake, physical activity, diet, and weight control. Only 40.8% of our respondents showed adherence to the 2018 Hypertension Guidelines in their self-management of hypertension Therefore, our results extend the existing literature observations that a large proportion of patients with hypertension do not perform self-management behaviours well [
7,
10,
17]. On the other hand, contrary to prior studies of people without disabilities using LCA [
7,
10] a clear distinction in the self-management behaviours among groups was evident in our study. In particular, the classes exhibited stark differences with respect to physical activity (high self-management group; 100.0% vs. inactive behaviour group; 0%), although the overall probability of physical activity was not particularly different compared to previous studies [
7,
10]. Since inadequate physical activity is a well-known challenge for people with physical disabilities [
18], it is important to define the characteristics and health measures among the groups.
Use of tobacco and alcohol, which are strongly correlated, are known to be common health-risk behaviours that negatively impact control of high blood pressure. Within the present analysis, the harmful habitual behaviour group exhibited the lowest percentages of people avoiding smoking or excessive alcohol intake; young, single males were most likely to belong to this group. This result was in agreement with a previous study that reported frequent substance use, such as cigarettes and alcohol, is often amplified among those who are young, male, and single [
19]. Young men display a greater tendency toward substance use when coping with their problems [
10] and prioritise other goals before taking care of their health [
20]. Conversely, female sex predicted membership in the inactive behaviour group, whose members satisfactorily complied with avoiding harmful habitual behaviours, such as tobacco and alcohol use. Such findings built on previous literature reporting that women are likely to have a lower prevalence of tobacco and alcohol use [
10,
21], likely because of social and cultural factors that might discourage women from smoking and alcohol intake [
19]. Accordingly, targeted policy and individual level interventions that simultaneously address tobacco use and excessive alcohol drinking could arguably be most effective when targeting addressing unhealthy behaviours in young, single males.
Regarding employment status, Rimmer [
18] argued that unemployment or underemployment is related to reduced physical activity in people with disabilities. By contrast, our results indicated that being employed was associated with those in the inactive behaviour group who were physically inactive. The reasons for the inconsistency in results are uncertain, but can likely be attributed to the type of jobs that members of the disabled population tend to hold. Compared to people with other types of disabilities, those who have physical disability are more likely to have a sedentary job that requires no physical exertion. As a prior study [
22] proposed that sedentary jobs can contribute to inadequate physical activity; the participants categorised in this group are highly likely to have sedentary jobs due to their physical limitations. Still, further research is warranted to explore the underlying mechanisms between health behaviours and employment among people with physical disabilities.
Dissatisfaction with friendships was another variable associated with belonging to the inactive behaviour group. Studies have provided evidence that social relationships influence health behaviours. Umberson and Karas [
23] highlight that social relationships can instil a sense of responsibility and concern for others that then lead individuals to engage in positive self-care behaviours. Similarly, s
ocial isolation is associated with less favourable lifestyle choices [
24]. Notably, people who have poor functional status tend to experience a lower quality of social relationships, resulting in social isolation [
25]. Coordinated programmes thereby should identify socially isolated adults with physical disabilities and mobilise local resources to offer instrumental and social support to these individuals.
Many researchers have raised concerns about the high prevalence of low-quality diet in people with disabilities [
26]. This corresponds to our findings that the vast majority of the participants across the whole sample reported having an unhealthy diet, which is of high prevalence compared to the similar studies of people without disabilities [
17,
27]. The low probability of achieving adequate nutrient intake was more apparent in the participants belonging to the inactive behaviour group which was associated with severe disability and ADL dependency. Among people with physical disabilities, those who are more dependent in terms of ADL may have additional functional limitations other than physical disability, such as trouble seeing or hearing, resulting in an increased risk of having a diet that may interfere with disease management protocols [
28]. Thus, it is of paramount importance to identify the at-risk individuals who have poor functional abilities and urgent need for policy interventions aiming to improve diet quality among people with disabilities.
Achieving the recommended level of physical activity can be challenging for people with severe physical disabilities, particularly among those who have difficulty walking due to pain or imbalance, or those who are unable to walk due to paralysis [
18]. A distinctive feature noted from the behavioural patterns in the inactive behaviour group was that none of the members engaged in regular physical activity. It can be expected the participants belonging to this group may experience substantial challenges to overcoming insufficient physical activity as they were likely to have a severe degree of physical disability [
18]. Since functional level is strongly associated with physical activity, co-occurring health conditions and level of independence should be considered as important determinants of physical activity in those with physical disabilities [
29]. Thus, policy and infrastructure changes to promote the inclusion of people with diverse forms and degrees of physical disabilities in physical activity initiatives are a high priority to promote physical activity and to reduce health disparity within the population with disability.
Our study further attempted to identify and differentiate previously unidentified, at-risk groups within the population of individuals with physical disabilities by comparing the health measures between the subgroups. The inactive behaviour group displayed the poorest HRQOL and subjective health and had the highest prevalence of depression and unmet medical needs. This phenomenon implies that the inactive behaviour group represents the most-at-risk population among the three groups. Accumulated evidence has demonstrated that these health measures are largely determined by various health-promoting behaviours. In particular, physical activity is emphasised as a critical behaviour that significantly impacts both immediate and long-term health [
30]. Extant studies indicate that engaging in physical activity is associated with a better HRQOL and subjective health in hypertensive patients and is also effective for the treatment of depression [
31‐
34]. Considering the fact that none of the participants in the inactive behaviour group performed physical activity, it is worth presuming that the self-management behaviour pattern in this group may have led them be at greater risk of hypertension. In other words, they exhibited a tendency to only practice certain self-management behaviours that do not require any physical capability to carry out. These findings imply that functional limitations may have acted as barriers to health-promoting activities that require physical capability, as the degree of disability and ADL dependence are closely interrelated and may have had a negative impact on their health measures.
Unmet medical needs are considered to be key determinants of health status in vulnerable populations living with disabilities and can potentially threaten the viability of community living [
35]. Our results indicate that the rate of unmet medical needs in the inactive behaviour group was 23.7%, which is roughly twice as high as the 11.6% found in a previous study on Korean adults without disabilities [
36]. It appears from the literature that those with the greatest need are also the least likely to have those needs met by the healthcare system [
35]. Those who experience unmet medical needs are likely to practice unhealthy behaviours and experience deteriorating health conditions; this conclusion is supported by previous studies that demonstrated correlations between unmet medical needs and various proxy indicators, such as health status and death [
37].
What we can conclude, as indicated in the behavioural patterns in the inactive behaviour group, is that avoiding certain harmful habitual behaviours, such as cigarette smoking and alcohol intake, alone may be insufficient to address the issues of increasing poor health risks. AlHadlq et al. [
22] highlights that the cycle of good practice of self-management behaviours is interrelated and each behaviour will not work well without the other; thus, ideally these positive health behaviours should occur simultaneously. Policy makers and healthcare professionals should take into account that various components of health-promoting behaviours should be practiced in harmony. Moreover, healthcare intervention in the inactive behaviour group should be prioritised and, more importantly, it should focus on providing appropriate assistance to enhance participants’ engagement in health-promoting behaviours, especially those which require physical capability such as physical activity.
Our study has several limitations, the most severe being insufficient information to assess specific dietary patterns and obesity due to data constraints caused by using the secondary data. First, we were only able to use a single-item measure of patient-reported balanced diet adherence. Although the optimal means of assessing diet is unclear, our use of a single-item diet measure remains a limitation in that it could not capture specific dietary patterns regarding food groups and serving sizes. Future studies should use questionnaires which measure extensive diet patterns such as a food frequency questionnaire to evaluate dietary approaches to stop hypertension diet scores. Similarly, using BMI to indicate obesity was another limitation in this study. Although BMI has been used globally as a simple indicator of obesity, it is not an optimal measure of obesity in people with physical disabilities. Height and weight may not be accurate, and standard cut-offs underestimate obesity in people with physical disabilities. Thus, it is recommended that alternative anthropometric measures, such as waist circumference, which is a simple, more sensitive alternative to BMI in population with disabilities, be used instead [
38]. Furthermore, due to limited information availability, we were unable to consider other variables that may be associated with hypertension management adherence such as residential area, religion, time since diagnosis of hypertension, or health literacy. The present study could not determine causal relationships due to the cross-sectional study design. Another limitation was the potential bias caused by the self-report measurement. Although the National Survey of Disabled Persons ensures the representativeness of the population with disabilities, potential threats to measurement validity cannot be adjusted. Furthermore, self-reported items such dietary assessment, are at risk of misinterpretation. Lastly, in as our analysis, the sample population had an average age of 65 or older; it remains unknown whether the same patterns occur in younger age groups.
Conclusions
This study demonstrated the typology of hypertension self-management behavioural patterns including abstaining from tobacco use, limiting alcohol consumption, engaging in regular physical activity, eating a balanced diet, and maintaining weight control, which are essential health behaviours for the management of hypertension, as evidenced using large-scale data. The present study considers the subgrouping of hypertensive adults with physical disabilities sample into three classes: a high self-management group, a harmful habitual behaviour group, and an inactive behaviour group. Our study also identifies factors associated with hypertension self-management such as age, gender, marital status, employment, degree of physical and functional disability, and satisfaction with social relationships; it also provides important insights into how health-promotion strategies for hypertensive patients with physical disabilities might be targeted differently in each group. As such, a special consideration should be given by health professionals considering the self-management behaviours that appeared to be deficit in each group, such as avoiding habitual health-risk activities (i.e., harmful habitual behaviour group) or practicing regular physical activity (i.e., inactive behaviour group). More importantly, the at-risk population, such as the inactive behaviour group identified in our study, should be prioritised in receiving assistance with hypertension self-management behaviours that require physical capability. These observations and their implications contribute to a better understanding of this heterogeneous, underserved population and provide evidence for healthcare teams to design strategies for supporting self-management and to develop a health-promoting service model for the population with physical disabilities.
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