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Practice guidelines advocate combining pharmacotherapy with lifestyle counseling for patients with hypertension. To allow for appropriate tailoring of interventions to meet individual patient needs, a comprehensive understanding of baseline patient characteristics is essential. However, few studies have empirically assessed behavioral profiles of hypertensive patients in Web-based lifestyle counseling programs.
The objectives of this study were to (1) specify baseline psychobehavioral profiles of patients with hypertension who were enrolled in a Web-based lifestyle counseling trial, and (2) examine mean differences among the identified profile groups in demographics, psychological distress, self-reported self-care behaviors, physiological outcomes, and program engagement to determine prognostic implications.
Participants (N=264; mean age 57.5 years; 154/264, 58.3% female; 193/264, 73.1% white) were recruited into a longitudinal, double-blind, randomized controlled trial, designed to evaluate an online lifestyle intervention for hypertensive patients. A series of latent profile analyses identified psychobehavioral profiles, indicated by baseline measures of mood, motivation, and health behaviors. Mean differences between profile groups were then explored.
A 2-class solution provided the best model fit (the Bayesian information criterion (BIC) is 10,133.11; sample-size adjusted BIC is 10,006.54; Lo-Mendell-Rubin likelihood ratio test is 65.56, P=.001). The 2 profile groups were (1) adaptive adjustment, marked by low distress, high motivation, and somewhat satisfactory engagement in health behaviors and (2) affectively distressed, marked by clinically significant distress. At baseline, on average, affectively distressed patients had lower income, higher body mass index, and endorsed higher stress compared with their adaptive adjustment counterparts. At 12-months post intervention, treatment effects were sustained for systolic blood pressure and Framingham risk index in the adaptive adjustment group, and those in the adaptive adjustment group were 2.4 times more likely to complete the 12-month intervention study, compared with their affectively distressed counterparts.
Interventions for patients who are adaptively adjusted may differ in focus from those designed for the affectively distressed patients. As such, this study underscores the importance of identifying psychobehavioral profiles, as they allow for evidence-based tailoring of lifestyle counseling programs for patients with hypertension.
ClinicalTrials.gov NCT01541540; https://clinicaltrials.gov/ct2/show/NCT01541540 (Archived by WebCite at http://www.webcitation.org/6yzZYZcWF)
Elevated systolic blood pressure (SBP) places individuals at increased risk of cardiovascular disease (CVD), stroke, coronary heart disease, heart failure, and CVD mortality [
As the feasibility and clinical utility of large-scale motivational interviewing and cognitive behavioral therapy-based lifestyle counseling programs continue to be established and further disseminated for patients with hypertension [
The goals of this study were to (1) assess and specify baseline psychobehavioral profiles of patients with hypertension who were enrolled in a Web-based lifestyle counseling trial, (2) examine mean baseline differences among the identified profile groups in demographics, psychological distress, and self-reported self-care behaviors, and (3) assess differences in physiological outcomes (SBP; diastolic blood pressure, DBP; pulse pressure, PP; and Framingham risk index, FRI) and program engagement across these profile groups over 12 months to determine prognostic implications.
This is a substudy of the Reducing risk with E-based support for Adherence to lifestyle Change in Hypertension (REACH) trial [
Both the control and e-counseling arms of REACH were organized by sessions that included a URL that linked participants to their session content. For controls, each session included content representative of the e-based support provided by heart health organizations at the inception of the study [
As a part of the parent study, all participants were asked to complete in-person study assessments at baseline, 4-month, and 12-month follow-up. All in-person study assessments were conducted by a trained nurse or research assistant and included the collection of both questionnaire and physiological data.
This study included 263 participants (mean age 57.5 years; 154/264, 58.3% female; 193/264, 73.1% white), who completed the baseline assessment. Inclusion criteria for the larger longitudinal study included the following: age: 35-74 years, hypertension diagnosis, baseline blood pressure measured at baseline study session: ≥140/90 (if no meds); ≥130/85 (if on meds); if on medications, an unchanged prescription for ≥2 months, and comprehension of written and oral English [
Four well-established self-reported measures of psychological distress were used in this study. The Patient Health Questionnaire-9 (PHQ-9) [
Baseline measures of physical activity and dietary behaviors were used in this study. Physical activity was measured by calculating the 4-day number of steps recorded on a triaxial pedometer (4-day step count, LifeSource/A&D XL-18CN Activity Monitor, China) [
Dietary behaviors were monitored by a 24-hour urinary sodium analysis (mmol/day) and the National Institute of Health/National Cancer Institute Dietary Health Questionnaire, a self-reported measure of fruit and vegetable intake, which has established validity and has been successfully adapted for a Canadian population [
Prochaska transtheoretical algorithm [
SBP, DBP, and PP, as well as the FRI for 10-year absolute risk of CVD [
Study completion was used as a measure of participant engagement in their assigned treatment programs. Study completion was coded as a binary measure such that 0=Incomplete, assigned to participants who did not complete the in-person 12-month study assessment, and 1=Complete, assigned to participants who completed the in-person 12-month study assessment.
A series of latent profile analyses (LPA) were conducted within a structural equation modeling framework to obtain psychobehavioral profiles of patients with hypertension. Psychobehavioral profiles were indicated by baseline measures of mood (PHQ-9), motivation (readiness to change: exercise and diet), and health behaviors (4-day Step Count and Urinary Sodium, see
Once psychobehavioral profile groups were established, a series of
Theoretical model of latent psychobehavioral profiles of patients with hypertension.
A series of models with sequentially increasing number of psychobehavioral profiles of patients with hypertension were tested for overall model fit. First, indicators of psychobehavioral profiles (eg, baseline measures of mood, motivation, and health behaviors) were assessed in a 1-class LPA (BIC=10,166.92; ABIC=10,119.36). Second, a 2-class LPA using indicators of psychobehavioral profiles was tested (BIC=10,133.11; ABIC=10,006.54; LMR=65.56;
The 2-class solution revealed 2 main psychobehavioral profiles of hypertensive patients. Most patients (228/263, 86.7%) were found to be adaptively adjusting to their hypertension diagnosis. The psychobehavioral profile of the adaptive adjustment group was marked by symptoms of depression in the minimal range of clinical severity (meanPHQ 3.69, SD 0.23), relatively high motivation to adhere to guidelines for both diet and exercise (meanreadiness diet 3.98, SD 0.05; meanreadiness exercise 3.98, SD 0.07, both approaching action stage), and somewhat active engagement in physical activity (meansteps 7900.38, SD 222.25). Nevertheless, on average, the adaptive adjustment group showed very poor adherence to a low-sodium diet as indicated by 24-hour urinary sodium (meansodium 130.81, SD 4.47;
A minority of patients (13.3%, 35/263) were classified in the second psychobehavioral profile group, which was marked by moderately elevated levels of depression, indicative of clinically significant distress (meanPHQ 13.39, SD 0.83). This affectively distressed group also demonstrated relatively lower levels of motivation to exercise (meanreadiness exercise 3.34, SD 0.25, preparation stage) and physical activity (meansteps 7165.43, SD 562.44, low active). Although this group indicated motivation to change dietary behavior indicative of individuals approaching the action stage (meanreadiness diet 3.85, SD 0.13), adherence to sodium intake guidelines was poor (meansodium 121.44, SD 9.74;
The
The
The
Two psychobehavioral profiles of patients with hypertension. PHQ: Patient Health Questionnaire.
The
In keeping with the therapeutic changes at 12 months reported for the REACH trial [
ANCOVA analyses were not conducted for the affectively distressed group because of the small number of participants assigned to each group (ncontrol=16, ntreatment=4) and the wide variability in change in SBP, PP, and FRI, from baseline to 12-month follow-up (
Logistic regression found a significant positive effect of profile group on program engagement, as assessed by completion of the in-person 12-month study assessment (beta=0.88, SE=0.386,
Assessing baseline outcome mean differences between profile groups. BMI: body mass index; BP: blood pressure; HADS: Hospital Anxiety and Depression Scale.
Outcome variable | Profiles | ||||
Adaptive adjustment (n=228) | Affectively distressed (n=35) | ||||
Females, n | 131 | 23 | N/Aa | N/A | |
Age, mean (SD) | 57.88 (9.53) | 55.51 (9.32) | −1.37 (261) | .17 | |
Incomeb, mean (SD) | 7.46 (2.80) | 5.47 (2.86) | −3.73 (237) | <.001 | |
Education, mean (SD) | 16.22 (2.62) | 15.28 (3.01) | 2.03 (250) | .06 | |
Systolic BP | 141.02 (11.46) | 140.17 (11.45) | −0.41 (261) | .69 | |
Diastolic BP | 87.26 (8.67) | 87.26 (8.34) | −0.001 (261) | .99 | |
Pulse pressure | 53.76 (12.51) | 52.91 (12.53) | −0.37 (261) | .71 | |
Framingham risk index | 16.24 (10.71) | 15.11 (12.03) | −0.56 (257) | .58 | |
BMI | 30.63 (6.10) | 33.97 (7.14) | 2.95 (261) | .003 | |
Patient Health Questionnaire | 3.69 (.23) | 13.39 (.83) | N/A | N/A | |
HADS: Anxiety | 5.40 (3.43) | 10.59 (3.74) | 8.1 (249) | <.001 | |
HADS: Depression | 2.96 (2.64) | 8.53 (3.13) | 11.15 (251) | <.001 | |
Perceived stress | 14.75 (5.04) | 20.97 (4.70) | 6.66 (247) | <.001 | |
4-day step count | 7900.38 (222.25) | 7165.43 (562.44) | N/A | N/A | |
24-hour urinary sodiumc | 130.81 (4.47) | 121.44 (9.74) | N/A | N/A | |
Fruit and vegetable intake | 8.36 (5.55) | 6.43 (4.16) | –1.89 (241) | .06 | |
Exercise | 3.98 (0.05) | 3.34 (0.25) | N/A | N/A | |
Diet | 3.98 (0.07) | 3.85 (0.13) | N/A | N/A |
aN/A: not applicable.
bSelf-reported income per family (Can $), 1=≤$19,000, 10≥$100,000.
c89.4% (236/264) of all participants completed the baseline 24-hour urinary sodium assessment.
Change in main outcomes at 12 months in adaptive adjustment group by treatment allocation. DBP: diastolic blood pressure; FRI: Framingham risk index; PP: pulse pressure; SBP: systolic blood pressure.
Adaptive adjustment | Treatment group | |||
e-Counseling (n=96), mean (SD) | Control (n=80), mean (SD) | |||
ΔSBP | −10.51 (1.31) | −5.81 (1.44) | 5.80 (1) | .02 |
ΔDBP | −5.15 (0.78) | −3.40 (0.86) | 2.28 (1) | .13 |
ΔPP | −5.40 (0.90) | −2.63 (0.99) | 4.27 (1) | .04 |
ΔFRI | −2.24 (0.64) | −0.02 (0.70) | 5.39 (1) | .02 |
Change in main outcomes at 12 months in affectively distressed group. DBP: diastolic blood pressure; FRI: Framingham risk index; PP: pulse pressure; SBP: systolic blood pressure.
Affectively distresseda | Treatment group | |
e-Counseling (n=4), mean (SD) | Control (n=16), mean (SD) | |
ΔSBP | −12.00 (8.25) | −6.63 (15.01) |
ΔDBP | −11.00 (8.29) | −4.25 (8.51) |
ΔPP | −1.00 (15.94) | −2.37 (11.10) |
ΔFRI | −2.04 (1.34) | −0.93 (6.05) |
aANCOVA analyses were not conducted for the affectively distressed group because of small sample size; however, raw means and standard deviation are reported.
This study identified 2 baseline psychobehavioral profiles for hypertensive patients: adaptive adjustment and affectively distressed. The affectively distressed group had significantly lower income and significantly elevated baseline BMI and levels of distress (eg, anxiety, depression, and perceived stress) and engaged in the Web-based counseling program less than their adaptively adjusted counterparts. Moreover, treatment effects on SBP, PP, and FRI were statistically significant in the adaptive adjustment group but failed to reach statistical significance for DBP. These findings indicate that a large majority of patients with hypertension are likely to benefit greatly from interventions designed to provide practical support regarding adherence to lifestyle recommendations for the management of hypertension. Nevertheless, a minority of patients may also benefit from additional support to help manage psychological symptoms and associated stressors that may interfere with a patient’s ability to adhere to Web-based interventions and suggested lifestyle changes.
Most participants (86.7%, 228/263) in this study were found to be psychologically well-adjusted to their diagnosis and indicated relatively high motivation to engage in both healthy diet and exercise behaviors. Participants categorized in the adaptive adjustment group reported levels of motivation and physical activity within expected ranges for a cohort of patients seeking help in lifestyle behavior changes to manage their blood pressure. For example, the mean readiness for change in exercise and the somewhat active range of physical activity found in the adaptive adjustment group was comparable to a previous report of both motivation to increase physical activity and engagement in physical activity in a large sample of individuals diagnosed with CVD and/or diabetes or who were at high risk of CVD [
A small proportion of the participants in this study (13.3%, 35/263) was identified as being affectively distressed, as their profile was marked by clinically significant elevations in depressive symptoms. The rate of clinically elevated depressive symptoms is comparable to rates of diagnosis of anxiety or depression previously reported in a large sample of hypertensive patients [
Examination of baseline differences between the profile groups worked to further validate the 2 psychobehavioral groups identified in this study. As would be expected, the 2 profile groups differed significantly in their baseline endorsement of psychological distress. On average, the affectively distressed group was more anxious, depressed, and stressed compared with their adaptive adjustment counterparts. The affectively distressed group also reported, on average, a lower household income compared with their adaptively adjusted counterparts. These results indicate that patients who are classified in the affectively distressed group may not only experience clinically elevated symptoms of depression but also the elevated symptoms of a wide range of other psychological symptoms and associated stressors that are also important to acknowledge and address when planning interventions for this subgroup of patients with hypertension.
Although there were no significant differences between these groups on baseline measures of SBP, DBP, or PP, the 2 groups did differ in baseline BMI. The affectively distressed group had significantly higher mean BMI than the adaptive adjustment group. The strong reciprocal association between depressive symptoms and obesity has been well established, and it has been hypothesized that multiple biological, psychosocial, and behavioral pathways likely account for this association [
Analysis of 12-month outcomes within the adaptive adjustment group indicated that the e-counseling program effectively reduced SBP, PP, and FRI for this profile group. Although there was no treatment effect for DBP overall, these outcomes are similar to those found in the primary outcomes paper for the larger study (unpublished data, 2018, [
This study also found that the adaptively adjusted participants were 2.4 times more likely than the affectively distressed participants to complete both baseline and 12-month follow-up assessments. This finding is important, as it highlights a potentially significant difference in program engagement between profile groups. This finding is consistent with other studies that have found that psychological symptom severity is an important predictor of adherence to Web-based interventions [
As noted previously, psychobehavioral profiles identified in this study are important to consider from a clinical perspective when looking to implement large-scale Web-based lifestyle intervention programs for hypertensive patients, such as the program tested in the parent REACH study [
Nevertheless, this study also identified a minority of patients who indicated that they experienced clinically significant elevations in low mood. Identification of these distressed patients is likely critical. Previous studies have indicated that patient distress or depression impairs their ability to adhere to self-care behavior and to engage in programs focused on promoting therapeutic change in lifestyle [
Although this study provides a promising new way to tailor Web-based health behavior counseling interventions for patients with hypertension, there are limitations with regard to these results. First, it is important to consider limits to the generalizability of these findings. This study sample represents a cohort of patients with hypertension who actively sought information regarding a Web-based program for self-care adherence. The relatively high levels of motivation and moderate levels of engagement in physical exercise seen in the sample may be a reflection of sampling bias introduced in the recruitment strategy. Our sample comprised health information seekers who had initially landed on the website of a public heart health organization and responded to our invitation about participating in a research project [
Future studies may aim to identify psychobehavioral profiles across a wider range of patients with hypertension to get a more accurate estimate of whether the 2 profiles reported here are replicable. Furthermore, it would be important to examine whether individuals with varying profiles respond differently to interventions aimed at promoting self-care adherence. Future randomized controlled trials may aim to oversample patients who are particularly distressed at baseline to directly examine how treatment effects may differ across varying psychobehavioral profiles. Moreover, future studies would benefit from working to eliminate in-person assessments and collecting detailed information regarding the degree to which participants engage in online programs to better define and tailor such interventions for a heterogeneous population of patients. Nevertheless, this study underscores the importance of identifying and understanding psychobehavioral profiles, as they allow for efficient evidence-based tailoring of lifestyle counseling programs for patients with hypertension.
This study identified 2 latent psychobehavioral profiles for hypertensive patients based on an analysis of baseline characteristics: adaptive adjustment (86.7%, 228/263) and affectively distressed (13.3%, 35/263). Those in the affectively distressed group had significantly lower self-reported household income, elevated BMI, higher levels of distress (eg, anxiety, depression, and perceived stress) and significantly lower program adherence compared with their adaptively adjusted counterparts. The adaptively adjusted patients enrolled in an e-counseling intervention also showed significant improvements in SBP, PP, and FRI compared with their control counterparts. Accordingly, a large majority of patients with hypertension are likely to respond well to Web-based interventions designed to provide practical support regarding adherence to lifestyle recommendations for the management of hypertension. It also indicates that a minority of patients may require additional support to help manage psychological symptoms and associated stressors that may interfere with their ability to implement and adhere to suggested changes. The establishment of such psychobehavioral profiles provides an evidence-based strategy to understand the variability in patients with hypertension interested in enrolling in a Web-based intervention for lifestyle change. Such information is imperative in the development of effective person-centered Web-based interventions for a broad sample of patients with hypertension.
Background Characteristics, Health Behavior and Cardiovascular Risk Factors for Total Sample at Baseline.
sample-size adjusted Bayesian information criterion
analysis of covariance
Bayesian information criterion
body mass index
Canadian Hypertension Education Program
cardiovascular disease
diastolic blood pressure
Framingham risk index
Hospital Anxiety and Depression Scale
Lo-Mendell-Rubin likelihood ratio test
latent profile analysis
Patient Health Questionnaire
pulse pressure
Reducing risk with E-based support for Adherence to lifestyle Change in Hypertension
systolic blood pressure
The REACH study was funded by the Canadian Institutes of Health Research, Grant #FRN111242. The authors would like to thank the participants for their contribution to the study.
None declared.