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Health behaviors of people with hypertension: health belief model

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DOI: 10.15253/2175-6783.2014000300018

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 DOI: 10.15253/2175-6783.2014000300018 Original Article
www.revistarene.ufc.br

Health behaviors of people with hypertension: health belief model

Comportamentos de saúde de pessoas hipertensas: modelo de crenças em saúde

Conductas de salud de personas hipertensas: modelo de creencias en salud

Ariane Alves Barros1, Maria Vilaní Cavalcante Guedes1, Denizielle de Jesus Moreira Moura2, Luciana Catunda
Gomes de Menezes1, Letícia Lima Aguiar1, Gleudson Alves Xavier2

This study aimed to identify the lifestyle of hypertensive patients, focusing on their health behaviors in light of the Health
Belief Model. This is a descriptive cross-sectional study with a sample of 133 patients over 18 years old, with hypertension,
registered in the Clinical Management System for Hypertension and Diabetes Mellitus in Primary Care, and monitored in five
health centers in Fortaleza, CE, Brazil, chosen randomly and probabilistically. Data collection happened through a structured
interview that was designed based on the Health Belief Model, from March to December 2013. Participants perceived the
disease’s severity and felt susceptible to develop complications from hypertension. They reported receiving treatment
correctly; however, the values ​​of blood pressure, waist-hip ratio, and body mass index were high. Thus, it is necessary that
health professionals implement strategies that favor hypertensive patients who are undergoing treatment to have healthy
behavior.
Descriptors: Hypertension; Health Behavior; Nursing; Life Style. 

Objetivou-se conhecer o estilo de vida de hipertensos, com enfoque nos seus comportamentos de saúde à luz do Modelo
de Crenças em Saúde. Estudo transversal, descritivo, com amostra de 133 pacientes maiores de 18 anos, portadores de
hipertensão arterial, cadastrados no Sistema de Gestão Clínica de Hipertensão Arterial e Diabetes Mellitus da Atenção Básica,
e assistidos em cinco unidades de saúde de Fortaleza, CE, Brasil, escolhidas de forma aleatória e probabilística. Os dados
foram coletados por meio de entrevista estruturada elaborada com base no Modelo de Crenças em Saúde, entre março a
dezembro de 2013. Os participantes percebiam a severidade da doença e sentiam-se susceptíveis a desenvolver complicações
advindas da hipertensão arterial. Afirmaram realizar o tratamento corretamente, no entanto, os valores da pressão arterial,
relação cintura-quadril e índice de massa corporal encontravam-se elevados. Faz-se necessário que profissionais de saúde
implementem estratégias que favoreçam comportamentos saudáveis de hipertensos em tratamento.
Descritores: Hipertensão; Comportamentos Saudáveis; Enfermagem; Estilo de Vida.

El objetivo fue conocer el estilo de vida de hipertensos, centrándose en sus conductas de salud a la luz del Modelo de Creencias
en Salud. Estudio transversal, descriptivo, con 133 pacientes mayores de 18 años, registrados en Sistema de Gestión Clínica
de Hipertensión y Diabetes Mellitus en Atención Primaria y asistidos en cinco centros de salud de Fortaleza, CE, Brasil,
elegido en forma aleatoria y probabilística. Los datos fueron recolectados por medio de entrevista estructurada que se basa
en el Modelo de Creencias en Salud, de marzo a diciembre de 2013. Los participantes percibían la gravedad de la enfermedad
y se sentían propensos a desarrollar complicaciones de la hipertensión. Informaron que recibían tratamiento correctamente,
sin embargo, los valores de la presión arterial, índice cintura - cadera e índice de masa corporal fueron altos. Es necesario
que profesionales de la salud implementen estrategias de conductas de salud saludables de hipertensos en tratamiento.
Descriptores: Hipertensión; Conductas Saludables; Enfermería; Estilo de Vida. 

Universidade Estadual do Ceará. Fortaleza, CE, Brazil.

1

Faculdade Metropolitana de Fortaleza. Fortaleza, CE, Brazil.

2

Corresponding author: Ariane Alves Barros

Rua C, 85, Loteamento Expedicionários I, Itaperi. CEP: 60745-540. Fortaleza, CE, Brazil. E-mail: [email protected]

Received: May 13th 2014; Accepted: June 30th 2014. Rev Rene. 2014 May-June; 15(3):525-32. 525
 Barros AA, Guedes MVC, Moura DJM, Menezes LCG, Aguiar LL, Xavier GA

Introduction consequences; benefits, in which the subject believes

in the effectiveness of the action and correct use
Social, cultural and political changes that take of medicines, and its positive consequences; and
place in society affect directly the population’s health perceived barriers, which are the difficulties for not
status. After the 1960s, an increase in life expectancy following the recommended treatment(6-7).
and changes in the epidemiological profile were Given the above, one can see that systemic
identified, with a reduction of infectious diseases and hypertension worries health professionals and people
intensification of non-communicable chronic diseases affected by it due to the possibility of complications,
responsible for about 63% of global deaths in 2008(1). physical and psychological sequelae, or even death of
Among the infectious diseases, the systemic hypertensive patients.
hypertension is highlighted because of its relation to In this context, it was questioned: What are the
the onset of complications such as coronary artery health behaviors developed by hypertensive patients
disease, renal failure, stroke, heart failure, among assisted in primary health care? What are the beliefs
others. This disease is defined as a multifactorial related to the disease’s severity and susceptibility,
clinical condition characterized by high and sustained and the perceived benefits and barriers? Thus, it was
blood pressure levels(2). aimed to know the lifestyle of hypertensive patients,
The frequency of prior diagnosis of focusing on their health behaviors in light of the health
hypertension in the Brazilian population has a belief model.
prevalence of 22.7%(3). This is worrying and it alerts
health professionals, especially those in the primary Method
health care network, to investigate risks for the onset
of systemic hypertension, assisting individuals in the Cross-sectional study, conducted with a
adoption of healthy behaviors for the prevention of sample of 133 patients registered in the Clinical
this disease. Management System for Hypertension and Diabetes
Each person affected by hypertension is Mellitus in Primary Care, and assisted in five health
unique and adopts a lifestyle consistent with their facilities selected by a simple raffle in Fortaleza,
beliefs, perceptions and knowledge(4). Therefore, it Brazil. It was calculated from the formula developed
is imperative that nurses know how to recognize for finite studies, with estimated average prevalence
them, providing care guided by their needs, in order of hypertension in adults of 20% confidence level of
to facilitate adherence to the treatment and empower 95% and a sampling error of 5%.
individuals for self-care. In this context, the Health The individuals over 18 years old, who had
Belief Model can be used by health professionals as been accompanied at the clinic for at least one year,
a theoretical framework to explain human behavior were included. Those who reported having diabetes
related to the health-disease process. This model helps mellitus or other self-reported chronic disease were
understand changes and maintain patients’ behaviors, excluded.
enabling the investigation of the benefits and barriers Data were collected from March to December
of the adoption of preventive measures(5). 2013 with the help of a structured recorded interview,
The Health Belief Model is divided into four whose instrument was elaborated according to the
areas: perception of vulnerability or susceptibility, Health Belief Model. The interview was divided
which is the subjective perception of personal into four parts: information about socioeconomic
risk of contracting a disease; severity, when the characteristics, data related to physical examination
individual associates the disease with serious and treatment, identification of health behaviors and

526 Rev Rene. 2014 May-June; 15(3):525-32.

 Health behaviors of people with hypertension: health belief model

aspects related to the Health Belief Model. [State University of Ceará], according to Protocol
For this study, one had as variables of interest: number 177,060.
gender, age, occupation, marital status, education,
blood pressure, weight, height, waist and hip Results
circumference, diet, time of hypertension diagnosis
and treatment time. The analysis of the health behaviors of
Blood pressure, weight and height were hypertensive patients shows the need to know their
measured in the health units by trained professional socioeconomic and clinical characteristics, as shown
and registered on a follow-up card, used by health in Tables 1 and 2.
professionals during consultations. These data were
used as variables in the study. Table 1 - Description of sociodemographic
The measurement of waist and hip of the characteristics of 133 hypertensive patients of the
patients was performed by the researchers through sample
Variables n (%)
an inelastic tape, with divisions of 0.5 cm, in the
Age (years)
moment they were in the screening room. To measure 18-30 2 (1,5)
their waist circumference, participants were standing 31-45 12 (9.0)
upright with relaxed abdomen, legs parallel and 46-60 61 (45.9)
> 60 58 (43.6)
slightly apart, with the region of waist naked, and the
Sex
measurement was made in the pre-inspiring moment, Male 19 (14.3)
with the measuring tape directly on the patient’s skin Female 114 (85.7)
between the bottom edge of the last rib and the hip Occupation
Active worker 19 (14.3)
bone (iliac crest)(8).
Unemployed / Self Employed 92 (69.2)
And the hip circumference was measured under
Retired / Pensioner 22 (16.5)
a piece of thin clothes, with the participant standing Marital status
erect with arms away from the body and feet together, Married 69 (51.9)
with the tape allocated around the hip, on the area of Not married 64 (48.1)
Schooling (years)
larger diameter, without compressing the skin(9).
No schooling 10 (7.5)
Concerning the participants’ diet, information 1-6 53 (39.9)
was obtained from questions that made the instrument 7–9 41 (30.8)
10 – 12 23 (17.3)
of data collection, thus being characterized as self-
> 12 6 (4.5)
information. The diet was classified as low sodium
and low fat according to the responses of patients who
claimed not having a diet high in salt and lipids. Patients in the study were concentrated in the
People were invited and informed about the age group of adults and seniors, with 56.4 and 43.6%,
purpose of the study, how their participation would be, respectively, with an average of 59.70 years old,
the benefits and possible risks. Those who accepted standard deviation of 11.12 and a median of 58.5 years
the invitation, were given the Informed Consent Form old. One also identified a predominance of females
and their permission was required through their (85.7%), married (51.9%) and retired/unemployed
signature(10). (85.7%). In the study, patients with no education
The study was approved by the Research Ethics (7.5%) were identified, and the highest percentage of
Committee of the Universidade Estadual do Ceará the sample had up to nine years of study.

Rev Rene. 2014 May-June; 15(3):525-32. 527

 Barros AA, Guedes MVC, Moura DJM, Menezes LCG, Aguiar LL, Xavier GA

Table 2 - Description of the clinical characteristics of subjects with waist-hip ratio higher than expected
133 hypertensive patients (67.5%), with body mass index predominating
Variables n (%) between overweight (31.6%) and obesity (41.4%).
Time of diagnosis (years)
Regarding their lifestyle, it was found out that
0-5 55 (41.4)
5-10 32 (24.0) the majority had health behaviors related to non-
> 10 46 (34.6) pharmacological treatment of hypertension, in which
Treatment time (years)
70.6% reported eating fat diet, 83.4% reported low
0-5 55 (41.4)
5-10 35 (26.3) sodium diet, 83.4% did not consume alcohol and
> 10 43 (32.3) 91.7% were non-smokers. In contrast, only 34.5% of
Systolic Blood Pressure (mmHg
< 130 38 (28.6)
the patients underwent a type of physical activity such
131 - 139 33 (24.8) as walking and aerobics.
140 - 159 35 (26.3) By analyzing the behaviors of patients in light
160 - 179 19 (14.3)
≥ 180 8 (6.0) of the Health Belief Model, one identified divergent
Diastolic Blood Pressure (mmHg) discourses among patients when they responded
< 85 75 (56.4)
to the questions related to the susceptibility and
86 - 89 5 (3.8)
90 - 99 30 (22.6) severity of the disease: 69.2% felt susceptible, fearing
100 - 109 12 (9.0) complications of the disease, 94.7% believed they
≥ 110 11 (8.3)
lived well with the disease and 89.5% showed concern
Waist-hip ratio (n = 108)
<1.0 (men) and <0.8 in women 18 (13.5) to their keep blood pressure under control. Among
≥ 1 (men) and ≥ 0.8 (women) 90 (67.5) the complications that patients felt more susceptible
Body Mass Index (Kg/m²)
to, stood out acute myocardial infarction (91.7%),
18.5-24.9 36 (27.1)
stroke (93.2%), vision problems (72.2%) and kidney
25.0-29.9 42 (31.6)
≥ 30 55 (41.3) problems (64 , 7%), due to the disabling sequelae.
The disease’s severity was reported by 96.2%
Most patients had less than five years of and the possibility of bringing the patient to death
diagnosis (41.4%), with an average of 9.35 years was perceived by 97.0% of the patients. Participants
and a standard deviation of 7.93 years. This time is also believed that hypertension harms individuals,
consistent with the treatment time, ie, 41.4% had whether in their social activities (20.3%), family
treatment for less than five years, demonstrating life (22.6%), at work (27.8%) or financial situation
that hypertensive patients started drug treatment (24.1%). This condition led them to move away from
soon after the discovery of the disease. Out of the friends to avoid intake of alcoholic beverages and/
respondents, 23.30% of the sample reported having or smoking, and others got away from work to avoid
been hospitalized as a result of hypertension, the fatigue and stress, important allies in the elevation of
main reason was blood pressure peaks. blood pressure.
Systolic blood pressure was above the normal Among the perceived benefits, the highlights
range in 46.6% of participants and diastolic blood were the orientations given by healthcare
pressure remained in the normal level or threshold in professionals during the consultation, which 100%
60.2% of patients. These percentages were identified of patients reported to like. The taking of medications
by individual classification of systolic and diastolic was reported as a priority by 94.7% of participants;
pressures, showing a predominance of very common 91.7% reported having all medications, even with
isolated systolic hypertension in the elderly. financial difficulties, even when there were no drugs in
It was also identified high percentages of the pharmacy of basic health units and even in popular

528 Rev Rene. 2014 May-June; 15(3):525-32.

 Health behaviors of people with hypertension: health belief model

drugstores, so that they had to get the medicines in of the treatment(12).

private pharmacies with a higher cost . Low schooling affects people’s health, which
When considering family support to the may hinder the understanding of information and
patient’s adherence to health behaviors, 44.3% of the consequently hinder the adherence to the treatment,
respondents reported that their families did not always increasing their exposure to risk factors(13). One
support their treatment, making it difficult, especially identified low education in this study because patients
in the food question. Other barriers perceived by them had a maximum of nine years of study.
to adopt health behaviors were: not doing physical It was found that 65.4% of the patients had
activities (65.4%) and not being able to stop drinking diagnosis time of hypertension of less than 10 years,
(16.5%) and smoking (8.2%). getting closer to the findings of another study, in which
60.3% of the sample had up to 10 years of diagnosis(14).
Discussion The time that the patient has of hypertension diagnosis
may influence the development of complications,
This study highlights the prevalence of because the longer they have the disease, the higher
hypertension among older people, since there is a the chances to develop lesions in target organs such
direct and linear relationship between the increase in as the heart, the brain and kidneys.
blood pressure with age(2). Another consistent finding The time of treatment of systemic hypertension
was the predominance of female participants, pointing was consistent with the time of discovery of the
to the fact that women have better attendance to disease, in which only three patients reported taking
health services. A study conducted in Fortaleza-Ceará some time to start the treatment after the discovery
presents a percentage of women (≥ 18 years old) who of the disease. This fact allows us to verify patient’s
reported medical diagnosis of hypertension of 20% adherence to the pharmacological treatment.
and men of 14%(3). The process of adherence to the treatment of
Women attend more assiduously health chronic diseases is complex and it usually requires a
services, recognizing the changes that occur in their sudden adaptation to a new lifestyle and the adoption
bodies, identifying each new sign that appears, of healthy behaviors. This process is permeated
then, they know more quickly how to diagnose their by the individual’s family, social, economic and
illnesses. However, health professionals should pay cultural context. Therefore, dialogue between health
attention to the male population for which they are professionals and patients is important, aiming to
responsible, and health services should reach them, understand this subject in its entirety(15).
even though actions to do so require more dedication. The study participants were also interested
In this study, a minority of the participants in maintaining a low sodium and low fat diet. Excess
declared themselves as active workers corroborating sodium in a diet is a risk factor and it can raise blood
with another research that showed that these patients pressure, low-fat diet contributes to the maintenance
probably come from families that do not have a good of body weight, preventing obesity. Daily intake
quality of life due to low incomes, observing thus a of sodium should be about 100 mEq/day, which
higher frequency of hypertension in low economic is equivalent to six grams of salt or a teaspoon.
classes(11). Regarding marital status, the percentage Concerning weight control, for every 10 kg of weight
between married and unmarried remained close, reduced, there is a reduction from 5 to 20 mmHg in
however, it is known that the family plays an important systolic blood pressure(2,16).
role in providing and maintaining the patient’s However, body mass index isolated is not able to
wellbeing, supervising and assisting in the completion detect systemic changes that come from overweight.

Rev Rene. 2014 May-June; 15(3):525-32. 529

 Barros AA, Guedes MVC, Moura DJM, Menezes LCG, Aguiar LL, Xavier GA

Therefore, it is also used the measure of waist/hip able to keep blood pressure under control, besides
ratio, as a way to supplement the data obtained. And the importance of following the treatment correctly,
in this study it was identified a high percentage of regardless of the number of medicines. They also
subjects with altered waist/hip ratio (67.5%). believed that the guidance provided by the health
The body mass index and waist/hip ratio are professionals should always be followed to prevent
indicators of fat, both body and abdominal, and are complications and improve their health.
strongly associated with systemic hypertension. This Knowledge about the disease’s severity and the
fact was also confirmed in a study conducted with perceived susceptibility may motivate individuals to
2,143 elderly in São Paulo, where it was found that act, and if they are not able to generate such an act,
excess fat, regardless of the anthropometric indicator there must be greater incentive to change, after all,
used, is one of the main risk factors for arterial these two factors together will make patients realize
hypertension(17). their proximity to other health problems resulting
When considering the health behaviors of from the underlying disease, causing them to act in a
patients in the study, it was noticed that the discourse more appropriate way(20).
of patients were contradictory with the observed The perceived benefit is also essential
reality. After all, they reported that they followed the for patients. It is in this moment that there is a
recommended diet during consultations, restricting predominance of beliefs about the importance of
salt and lipids, however, the body mass index and health treatment and trust in the professionals(7).
waist-hip ratio showed the opposite. However, some patients fail to observe the benefits
The consumption of alcohol and smoking were clearly, especially when they start to affect their social
observed in a smaller proportion among patients in and family life.
the study. Ethanol, if consumed in large amounts, can The barriers are perceived and interpreted
increase blood pressure and the risk of cardiovascular in a particular way by each patient, depending on
morbidity and mortality. The dose of ethanol to be how they are present in their lives. However, one
consumed by men should not exceed 30g a day and by must consider that the personal difficulties, such as
women this value should not exceed 15g a day(2). eliminating a risky lifestyle, controlling their diet and
The practice of physical exercise, in turn, had taking the indicated medicine require high investment
low adherence among the study participants. Thus, by patients(7).
one highlights the need for educational activities
that encourage this practice. The practice of regular Conclusion
exercise can reduce morbidity and mortality, lowering
blood pressure and associated risk factors(18). It can be seen by this study that hypertensive
A fact mentioned by patients, mostly in relation patients’ lifestyles are able to directly influence blood
to diet, was the difficulty to perform the recommended pressure values. It is also responsible for defining
dietary prescription, because of family and social patients’ health behaviors, indicating therefore their
eating habits. Then, family and social support quality of life.
contributes to a successful treatment, which will make One found as a relevant result and related to
the restrictions only one stage to be surpassed. The lifestyle, the concern in performing a healthy diet
family is an indispensable point for proper completion with low fat and low sodium, demonstrating that
of the treatment, providing emotional support to the participants have knowledge about the disease and
patient(19). their susceptibility to complications.
The survey participants reported they are The study also showed how the Health Belief

530 Rev Rene. 2014 May-June; 15(3):525-32.

 Health behaviors of people with hypertension: health belief model

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