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Self-Care Management for Hypertension in Southeast Asia: A Scoping Review

Background Self-care practices such as lifestyle modifications in diet, exercise, and stress management are effective in reducing the incidence of and enhancing better management of hypertension. However, little is known about the self-care management practices of people with hypertension in Southeast Asia (SEA) countries where the prevalence of hypertension is sharply increasing. Methods A scoping review of research and grey literature (2006–2021) was performed using Scoping Review Frameworks by Arkey and O’Malley. For the research literature, ten databases were searched followed by a manual search of the reference lists of relevant topical papers. Criteria for inclusion included both qualitative and quantitative primary data studies, focused on adult (18 years and over) hypertensive patients, self-care management methods, conducted in SEA. The study protocol has been registered at Open Science Framework (https://osf.io/s4nvk/). Results Out of 1667 studies examined, there were 57 studies that met criteria and were included in this review. Results indicate a paucity of relevant literature. Moreover, most studies reviewed showed an incident rate of 50% or more incidence of behavioural risk factors in people diagnosed with hypertension, including overweight/obesity, poor physical exercise, poor/low-quality dietary intake, and not adhering to medication. Few studies indicated adequate traditional self-care practice among SEA hypertension populations. Use of a non-prescription herbal as the medication is identified in some studies. Several reviewed articles indicated that there is individual variation in the facilitators and barriers to implementing self-care practices and we put it into a working framework. The facilitators and barriers are relevant to personal choice (internal factors) or to the environment or context (external factors). Conclusion Enhancing self-care management of hypertension in SEA may require a multi-focused approach including targeting personal choice as well as external factors such as cultural relevance, environment, and resources.


Introduction
To reduce the incidence of and to provide better management of hypertension, several self-care activities are recommended by the 8th Joint National Commission including medication adherence, bodyweight management, dietary intake, alcohol consumption, tobacco cessation, and physical exercise. 4,5 Modification of lifestyle risk factors addressed through healthy self-care management activities is now a fundamental part of treatment recommendations, as people who implement such self-care strategies have shown a decrease in blood pressure, increase adherence to antihypertensive medications, reductions in complications and in overall mortality rate associated with hypertension. 6 Numerous reviews of self-care management for hypertension have been done regarding the experimental approach to lifestyle intervention provided through the research protocol. [7][8][9] While important to understand the efficacy of the intervention, these studies do not address the self-care management initiated and sustained by people in their naturalistic settings. Few studies address potential facilitating and inhibiting factors in practicing self-care management for hypertension. In addition, the majority of studies reviewed were conducted in Western countries. [7][8][9] Different cultures, lifestyles, and food preferences in SEA countries will affect the use and success of self-care management of hypertension.
In SEA countries, the prevalence of hypertension has been sharply increasing for the past two decades. 10 In a recent study, there was a reported increase of one-third of the adult population with hypertension in SEA annually. 11 SEA countries are currently experiencing rapid modernization and fast-changing lifestyle, conditions contributing to the high prevalence of hypertension. 10 However, little is known about the self-care management practices of these populations. The previous review by Nawi et al focused on the prevalence and risk factors of hypertension in the urban area without emphasizing current selfcare management for hypertension. 11 Understanding the self-care management of people with hypertension is crucial to determine gaps and potential points of intervention to strengthen their use and effectiveness. Therefore, we conducted a scoping review to explore and map the current state of self-care and lifestyle management activities among people with hypertension in SEA countries. Secondarily, we reviewed the retrieved articles for facilitating and inhibiting factors to the reported self-care management practices. The anticipated outcome of such a scoping review is to better understand the current state of self-care practices for hypertension management in SEA. This information will be useful in designing future studies.

Methods
The Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews (PRISMA-SCR) was utilized to optimize reporting and increase fidelity (Supplementary File 1). The review was conducted using the guidelines of Scoping Review Frameworks. 12 In addition, The Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews (PRISMA-SCR) was utilized to optimize reporting and increase fidelity. 13 The study protocol has been registered at Open Science Framework (https://osf.io/s4nvk/). We utilized the five stages of Scoping Review Frameworks as indicated below.

Stage 1: Research Question
key words and phrases used in the search. In addition, references in the Google Scholar search engine were sought for additional articles that may have been missed in the previous database searches.

Stage 3: Study Selection
Study Extraction from Databases Figure 1 illustrates the process, screening results, and criteria for manuscript extraction once the initial search was completed based on the study inclusion and exclusion criteria. To summarize, from the 10 databases, 1667 relevant abstracts were collected and 41 additional manuscripts were identified through Google Scholar. After the removal of duplication of articles, 1668 articles remained. Furthermore, titles were screened for their relevance resulting in 167 articles for further screening. Of these, 125 articles were categorized as directly related to the research question,

2018
Irwan et al Dovepress followed by full article reading and study abstraction. Third-stage searching was also conducted by screening reference list from the articles selected by reading full text resulting in an additional 20 articles. Articles were then excluded that were not relevant to the hypertension, not self-care management, not in SEA, or were an intervention, a study protocol, or were a literature review. This selection process resulted in the final inclusion of 57 primary research studies in the analysis.

Reliability of Study Extraction
All abstracts identified from the article search were downloaded to Mendeley software reference manager and exported following de-duplication into the Rayyan software program. 18 To ensure inter-rater reliability of articles screened using exclusion and inclusion criteria was established by two reviewer random samples of 25 articles in English language (AMI and KP) for sampling of titles, abstracts, and full texts using JBI Manual methods. 17 There was disagreement in 5% of articles which was resolved in reviewer discussion to reach 100% agreement at each sampling stage.

Stage 4: The Data
Data were extracted to include important information, encompassing the study site, study design, aim, sample, and main findings. Variable measured are listed in Tables 3 and 4.

Stage 5: Thematic Summary and Key Findings
Inductive thematic analysis, informed by the work of Braun and Clarke 19 across studies, was used to identify emerging key themes. This entails familiarization with each research finding and generating initial codes. These codes were then refined to arrive at the final themes reported in the paper.

Ethical Considerations
This study was exempt from review by the Institutional Review Board for Human Subjects (IRB) because only deidentifiable data is revealed in the articles reviewed.

Study Characteristics
Across the 57 included studies, more than half (thirty studies) were conducted in Indonesia, seven in Thailand, six in Malaysia, four in Myanmar, three for each in Vietnam and in Singapore, one in the Philippines, one in Laos, and two combined across SEA countries. There are three countries of SEA which have no included articles: Brunei, Cambodia, and East Timor. The design of the studies was varied. Forty-five were cross-sectional studies, 20-64 ten were qualitative, 65-74 one case control, 75 and one mixed-method design. 76 The findings of quantitative and mixed-method studies are displayed in Table 3 and qualitative studies in  75 and two studies in multiple settings. 30,35 For quantitative studies, four of them were conducted in urban settings, 66,67,70,71 five were in the rural area 65,69,[72][73][74] and one study could not be specified. 68 Overall, thirteen 22,[26][27][28][29]32,42,45,[57][58][59][60]64 studies have the mean age of older people as the participants (60 years old and above), whereas the rest of the studies were adults 18 years and older.

Self-Care and Lifestyle Management
In the quantitative and mixed-method studies, body weight management (

Urban area
Inhibiting and barrier of self-care. See Table 2 Traditional Social and physical environments of hypertensive older patients. See Table 2 Traditional: Culturally diet intake, physical exercise, medication adherence
In the qualitative studies, the majority explored reasons for not adhering to self-care management mainly on medication adherence which we will explain in detail in the next section. Overall, a few studies 28,70,73 identified the usage of herbal as medication for hypertension.

Facilitating and Inhibiting Factors
In the review of the retrieved articles, we identified facilitating and inhibiting factors of self-care management for hypertension. These factors are described in the article texts as examples from the statements of participants found in the studies and are described in Table 5. We further divided these examples into internal and external associated factors. Internal sources are those that are under individual's control or influence and external sources or associated factors are those that are influenced by others in the household or by the community or environment in which the participant lives. Statements described in the articles text such as "Put reminder not to forget" and "motivation to avoid progression" are considered as internal facilitating factors to practice self-care management. Having "discussion with partners related to medication problems and organized activities by the health center" to improve health, are examples of external facilitating associated factors. Whereas statements in the text such as "Perceived self-care practice not as a priority", 'side effects', "feeling tired of medication", "having no signs and symptoms" of hypertension, as well as "time and financial barrier" were classified as internal inhibitory sources which inhibit self-care practice among hypertensive subjects in SEA. Whereas hypertension diet "not adjusted to the culture", "distance barrier" to the health center, "lack of family support", and "lack of knowledge" related to hypertension and its management were considered as external sources.

Discussion
The primary aim of this review was to examine and map the state of the science of self-care management of hypertensive people living in SEA countries. The evidence presented indicates that there is a high rate of overweight/obese, poor physical exercise, poor/low-quality dietary intake, and not adhering to medication in hypertensive people in the SEA region. As a consequence of economic development, significant changes in diet, mainly the increased consumption of high fat and sugar, combined with physical exercise reduction occurred in many Asian countries. 77,78 Other economically developed or developing countries show similar trends. In the USA, diet adherence and body weight management are only 18% and 39%, respectively, among hypertensive patients. 80 Poor body weight management (53.2%) and poor physical exercise (69%) were reported among hypertensive patients in Ethiopia. 79 In Iran, among hypertensive patients, only 24.5% adhered to performing physical exercise and 39.2% managed their body weight. 80 Lifestyle has been a critical factor contributing to the rise in incidence of hypertension globally, and lifestyle risk factors remain poorly managed by many populations including SEA. A focus on lifestyle risk reduction in hypertensive people is a clear implication of our findings.
Another finding of our review is the use of herbal as hypertension medication. Similarly, previous studies have shown that using a herbal as self-medication is not only found with older age, but also among young people in SEA. Fear of adverse reactions in prescribed medicine, the effectiveness of herbal medicine, and easier access were reasons for choosing herbal. [83][84][85] However, consuming herbals as self-medication poses a health risk as dosing is unreliable, efficacy for short-and long-term use is understudied, and harmful interaction effects with polypharmacy may occur. [84][85][86] Therefore, it is important to assess the knowledge of patients in using herbal and to what extent herbal medicine is used to manage hypertension.
We report various internal and external factors described across studies influencing poor self-care management. Because this is a secondary finding of our review, further research into the scope and complexity of factors influencing self-care management is warranted.   70 Tan et al 71 I keep it in a plastic bag. I will write or record in a book when taking medicine to avoid forgetting because I am a stroke patient; 70 p.4).
Hypertensive study participants described unique challenges across studies we examined. However, some patterns emerged. We found that motivation to avoid the progress of hypertension, having discussion partners, and various health activities conducted by health centers were facilitating factors in the practice of self-care management. Others have reported that the motivation to avoid the progress of hypertension increases when patients have sufficient knowledge of the disease process. Knowledge of hypertension was positively related to self-care management of hypertension. 81,82 By sharing with others, patients have a chance to exchange information, share their problems and increase their willingness to manage their hypertension. 81,83,84 Therefore, assessing knowledge of hypertension, ensuring the availability of partner to support hypertension management, and creative program offered by community health centers are important to consider in future research.
Another consideration of self-care management for hypertensive patients in SEA countries is family structure, where most are extended families. 85,86 People living under the same roof will affect self-care management as indicated in our findings. Lack of family support is one of the inhibiting factors in implementing high-quality dietary intake. In one study, low family support also correlated with the low score of hypertension self-care among hypertensive patients. 87 Therefore, involving family while working with hypertensive patients to strengthen their self-care management need to be considered in future research.
We identified some cultural aspects as inhibiting factors to implement self-care practice as in Figure 2. Food intake in SEA countries is still closely affected by the culture in terms of salty, oily, and cooked with coconut milk. 81 Things that should be reduced in self-care management. Approach that aptly adopts culture could increase the successfulness of intervention. 14 Another inhibiting factor is the financial status of the individual and family. Insufficient response of health-care systems in low-income/middle-income countries in many SEA nations left the burden of medical cost to the patients, 88 including the patient with chronic diseases such as hypertension who need lifelong treatment. The cost of medication was a major reason for non-compliance in self-care management. 89,90 Better understanding of the particular issues confronting hypertensive individuals will allow for a better-adjusted response to address the need of particular patients and for particular environments and contexts. 95 Personalized approaches that consider both personal attributes and external circumstances in self-management of hypertensive populations were found to be important in this scoping review and should be rigorously studied in future research. Nurses working in the community have an important role to help manage the self-care practice and should consider individual and cultural aspect in helping hypertensive patients to manage their self-care. In addition, health service agencies must consider issues of access and cost of hypertension treatment which is prevalent among the adult populations of SEA and requires lifetime treatment.
The limitations of the review are only English and Bahasa material were included in the analysis.

Conclusions
Our review is the first to explore hypertension self-care management in SEA countries in naturalistic setting. Our findings indicate a high prevalence of obesity, low physical exercise, poor quality dietary intake and poor adherence to prescribed medications in many of the studies reviewed. Use of herbals as the anti-hypertensive medication is also identified in some of the reviewed studies. Our review indicates a range of challenges for individuals in practicing hypertensive self-care. Further prospective research on the challenges to self-care management of hypertension needs to be done to better understand individual and contextual influences. Personalized approaches to manage these challenges will require rigorous study.