Results in Increased Knowledge and Skills in Self-Monitoring Blood Pressure

world in 2013 but slightly lower than some other scale measurements performed on patients in Vietnam [8, 13, 33, 74].

The results of in-depth interviews with patients and doctors also help to explain the reasons for patients to abandon treatment, in which in the early stages of being diagnosed with chronic diseases, patients may receive more attention from those around them, but over time, this attention also decreases. This reality causes patients to gradually lose motivation to care and pursue treatment. At this time, if there is coordination from doctors in requiring patients to maintain monitoring and appropriate support tools to help patients assess the situation and record measured values regularly and can provide evidence during regular check-ups, it will motivate patients to regularly monitor, see the importance of monitoring the progression of the disease and the body's response in real conditions, thereby sticking to treatment more. At the same time, the physician can assess the patient's condition objectively based on the monitoring they provide, which helps avoid clinical inertia, instead of simply repeating the prescription, the physician will have to consider this more seriously in response to the patient's push for what they have self-monitored and reported. Combining this with a reasonable form of setting up a reasonable form for patients to receive long-term medication reminders will help increase adherence and compliance, reduce complications and improve treatment effectiveness. The above analysis supported the identification and design of the intervention content used in this study.

4.4. Discussion of intervention model

4.4.1 Conformity

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Identifying interventions that directly address gaps in hypertension prevention programs has led to an intervention model that breaks from the beaten path of current programs and has new and unique points in its approach.

The intervention model can be operated by the existing health system at the commune and district levels - that is, the grassroots health system, making the model sustainable and not requiring large funding; this approach is also in line with the orientation of the Ministry of Health, the World Health Organization, and the World Bank.

World Health Organization as well as national hypertension prevention programs.

The intervention model simultaneously applies the cultural characteristics of Vietnamese people, especially in rural areas, which are high sharing and connection, regular and rich community activities to introduce self-communication stimulation tools in the community and enhance the initiative and participation of patients.

The solution of directly consulting patients on the principles of drug use, on choosing drugs to minimize side effects, and on reasonable payment for middle-aged and elderly people in rural areas is a direct solution to help solve the fundamental problem of abandoning treatment in patients that many studies have shown, which is limited knowledge, patients do not know that they have to use drugs for a long time, are afraid of side effects, and have limited monthly payment for drugs. This solution is implemented by district-level doctors, which is very suitable because on average, each doctor at that level has less than 50 patients to see per day. Moreover, the solution also shows that patients only need to be consulted once at the beginning of treatment. However, the consultation must be specifically guided and the quality must be monitored through observation using a checklist with clear criteria.

4.4.2 Novelty

The solution to encourage patients to self-monitor their blood pressure using a blood pressure interpretation board and self-monitoring is a new research initiative. By providing patients in the community with a tool to interpret the meaning of their measured blood pressure values, know how to detect risks, and store monitoring information to effectively exchange feedback with physicians.

In addition, the interpretation board also supports patients to communicate more accurate knowledge about hypertension in the community, encouraging the community to pay attention to detection, treatment and participate in monitoring treatment results.

By providing such a tool, the solution has helped address many gaps in motivating patients to monitor their blood pressure regularly, engage more effectively in outpatient home management, increase the ability to detect complications, and enhance communication in the community.

Because it is a new approach, the development of a tool for use in intervention has required the implementation of a specialized research branch to ensure scientific validity and consensus of doctors with experience in managing and treating hypertension in all three regions of the North, Central and South. At the same time, ensuring the practicality of a product applied in research.

From implementing a component study with application purposes, the researcher also gains new research skills and experience, especially from implementing a Delphi study, which is a study to evaluate community acceptance of a new product that the study includes in the intervention.

The intervention solution using small groups to remind patients to regularly monitor blood pressure and take medication is the second new point of the model, which does not require funding, takes advantage of the community spirit of patients, especially in rural areas, and at the same time directly addresses the cause of patients not knowing the importance of taking medication regularly and the main cause of poor compliance is forgetting to take medication. Although the solution has many limitations if applied for a long time, it has a certain value for patients, especially in the early stages of treatment.

4.5. Discussion of the intervention implementation process

The rate of beneficiaries of the intervention solutions is quite high and consistent with the proposed solutions. With the solution of training people in blood pressure measurement skills, 100% of patients have been instructed and observed and corrected at least once in the first month of intervention. This is a great effort of the intervention monitoring team as well as the support of Tien Hai District General Hospital. This high rate is achieved due to the very good connection in the implementation of the intervention, the researcher invited the main collaborators, the group of doctors and nurses responsible for performing the examination and treatment of hypertension at the District General Hospital to participate in support. This is both suitable for professional tasks and reliable and inherited after the program, the patients in the intervention group of the study were all introduced to clinics and hospitals in the area that are suitable for the technical expertise and the place of insurance registration. Besides, it is also suitable for the context in Vietnam according to many assessments.

According to statistics, nearly 75% of hypertensive patients want to access treatment at the commune and district levels.

All patients were instructed on how to use the interpretation board and supported in self-monitoring of blood pressure at home. Patients were provided and exchanged with enough interpretation boards to use during the intervention period, closely monitored to guide the arising and record information, health fluctuations during the intervention period.

Regarding the package of solutions for counseling patients on medication use, similar to the training on blood pressure measurement, the researcher used collaborators who were doctors at the district hospital. The results showed that all patients were counseled on medication use to ensure avoiding side effects as well as being suitable for the affordability and disease characteristics of the individual. The results of monitoring counseling through a random checklist of over 10% of the total number of consultations also showed that all cases were counseled on at least 4/5 of the contents in the checklist as required in the intervention program.

The results of in-depth interviews show that each patient before entering the treatment process or having abandoned treatment needs to be carefully counseled and the reasons should be investigated to find ways to overcome and support them to pursue treatment. In outpatient clinics for hypertension, patients should be arranged in groups for convenient consultation and the consultation time should be arranged for about 10 patients/session/1 doctor. In addition, it is possible to train and use bachelors of public health or nursing to advise patients on treatment principles, learn to avoid drugs with a history of causing unwanted effects before the doctor prescribes. This will help patients feel secure in pursuing treatment. This approach is similar to the Australian model in 2011 when building small group counseling interventions based on direct discussion with patients, which is also considered effective. In addition, this conclusion is also consistent with Fletcher's opinion in a review of 20 studies [56, 58].

4.6. Discussion of intervention results

4.6.1. Results in improving knowledge and skills in self-monitoring blood pressure

The intervention has helped most patients benefit from the use of the Interpretation Board in self-monitoring of blood pressure at home, the monitoring process throughout the duration of treatment.

Interventions with a frequency of every 2 weeks and the application of the form of changing the interpretation table helped to monitor changes in patient condition well, at the same time collect rich data for research, increase patient commitment to participate in the research.

After the intervention, knowledge about the need to self-monitor blood pressure at home in the intervention group increased significantly, from only 68.2% of patients knowing the need to monitor blood pressure to 94.6%. In addition, the skill of measuring blood pressure correctly also improved when the rate of patients who knew how to measure themselves or had their family members measure for them increased from 66.9% to 80.8%.

This result shows that the intervention encourages patients to practice measuring blood pressure correctly and improves family members' participation in the patient support process. It helps reduce patients' dependence on medical staff and gives them more initiative in practicing self-monitoring. For chronic diseases requiring long-term treatment, this is also a benefit that needs attention because it helps to enhance patients' self-monitoring capacity in a more sustainable way.

Improvements in knowledge and skills in self-measurement of blood pressure will also promote increased rates of self-monitoring of blood pressure after intervention, and this has been confirmed through many studies.

On the other hand, although the intervention did not support blood pressure monitors, the rate of having a blood pressure monitor at home increased slightly compared to the initial assessment time. At the post-intervention period, 46.9% of patients in the intervention group had equipped themselves with a blood pressure monitor, while in the control group this rate remained almost unchanged.

4.6.2. Results in increasing the practice of self-monitoring of blood pressure

In the control group, the rate of good blood pressure monitoring only increased slightly from 36.4% to 39.7%, but in the intervention group it increased from 33.1% to 43%. In general, the rate of regular blood pressure monitoring, after 5 months, the rate of regular blood pressure monitoring in the intervention group increased by 37.4% (from 51% to 87.4%) while in the control group it only increased by 7.3%. And so indirectly, increasing the rate of regular self-monitoring of blood pressure will also be helpful in improving

The effectiveness of antihypertensive treatment has been confirmed by the authors through meta-analyses [116, 118].

4.6.3. Results in increasing the rate of antihypertensive drug use

From the group of solutions of group reminders and doctor's consultation with patients on the principles of using antihypertensive drugs, after the intervention, the rate of using antihypertensive drugs of patients in the intervention group increased from 48.3% to 77.5% while in the control group, the rate decreased slightly from 51.7% to 46.4%. That is, the absolute increase was 29.2% and the calculation of the intervention effectiveness coefficient increased the rate of using drugs to 70.7%.

Compared with the results in a review of 38 intervention studies with a total of 15,519 patients with a follow-up period of 2–5 months in Europe between 1975 and 2000, this absolute increase was higher than that of the “simplified treatment regimen” intervention model and also slightly higher than that of the motivational adherence strategy used in these studies. In particular, as the studies have shown, this is a different level of improvement compared with models that only applied communication [80].

The proportion of patients reminded by relatives or friends to take their medication improved before the intervention, although by the time of post-assessment, patients were no longer supported to maintain this pattern. From about 11% of patients being reminded by relatives before the intervention, this increased to 49.3% while in the control group, this rate decreased to 5.3%. The results showed that the intervention helped mobilize more participation from patients' relatives as well as the surrounding community to encourage patients to pursue treatment, at the same time, those relatives themselves will also be better aware of the importance of maintaining long-term medication use, a most notable point in the treatment of hypertension and stroke prevention.

4.6.4. Results in improving treatment compliance

The intervention increased the treatment adherence rate by 89.3%, thus this intervention model was effective in improving the medication adherence of hypertensive patients, the level of achievement was higher than the initial expectation given in the intervention target. Relatively speaking, this result is also higher than the improvements achieved in published intervention studies.

communication as well as applying simple solutions that affect service providers who are health workers but are different in target subjects because this study aims to improve the situation on people who have been diagnosed and treated at the district level, patient monitoring in a narrow range is easier than other large-scale studies, patients can be considered to have dropped out of treatment when changing treatment facilities [12, 18, 24].

The change achieved in the intervention was higher than the 15% achieved in a 2014 Canadian intervention study using pharmacist-led medication counseling and group management in outpatients [60].

The intervention model in this study developed and integrated the method applied by S Ross and colleagues in the UK in 2004, which was to use a patient self-diary intervention method called "belief and medication". At that time, his intervention also improved treatment compliance, although not much [104].

It is also understandable why the results after the intervention helped improve the rate of medication use and adherence so well. However, when compared with the randomized controlled trial by F Alhalaiqa et al. of the University of East Anglia, UK in 2011, it was reported that: After 11 weeks of intervention, the adherence rate in the intervention group conducted by this group of authors increased by 37% compared to the non-intervention group with the method of measuring by counting pills, the improvement in this study is similar. On the other hand, our study did not analyze to measure the level of blood pressure reduction of the patients as much as the study of this author, so it is also a limitation of the study that needs to be further developed [54].

Bivariate analysis comparing before and after with Khi Binh Phuong test suggested positive changes in patients' knowledge, self-monitoring of blood pressure practice as well as medication use and treatment compliance.

The results of the intervention effectiveness index calculation help to confirm more clearly the effect of applying the Interpretation Table in self-monitoring of blood pressure for out-of-hospital patients because it helped increase 35.3% of patients who knew they needed to monitor their blood pressure regularly, increased 58.1% of patients who practiced regular blood pressure measurement at home, and increased 137.6% of patients who recorded their blood pressure readings when they were measured.

This result shows that the applied intervention solutions have improved self-monitoring of blood pressure for out-of-hospital hypertensive patients although the intervention period was only 5 months, contributing to the implementation of CDC's recommendation that countries need to focus on level I prevention, encouraging patient participation in the process of monitoring and managing the disease.

Compared with other forms such as self-recording in personal notebooks, the rate of patients maintaining blood pressure monitoring in the study was much higher. Therefore, this is a new form with great potential in improving the status of self-monitoring of blood pressure of patients in the community.

In addition, the index calculation clearly shows that the intervention has helped increase the number of hypertensive patients reminded to take their medication by more than 3 times. This result achieved the intervention goal when increasing the number of patients taking antihypertensive medication by more than 15%, which was the target. At the same time, compared with other non-drug interventions, this is a good result.

Regarding medication status, both univariate and multivariate analyses confirmed the true results of the intervention model, helping to increase the proportion of patients taking antihypertensive medication by 70.8% and the proportion of patients adhering to treatment by 89.3%. The difference was statistically significant.

Compared with all the proposed objectives of the intervention, including increasing the number of patients practicing home blood pressure monitoring by 30%; increasing the rate of patients taking medication by 15% and increasing the rate of patients adhering to treatment, the intervention model achieved the proposed objectives. Although this is an initial result, it is very positive compared to simple communication interventions as well as some existing intervention models in Vietnam. However, it is also clear that a limitation of the study that makes it difficult to measure the results after the intervention period is due to the continuous interaction between the research team and the patients, which has caused the rate to increase without assessing the sustainability and real effectiveness of this intervention model.

However, the initial results of the intervention model also open up a new approach that needs to be expanded and strengthened, which is empowerment and the necessary tools.

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