Research Article Effectiveness of A Stroke Risk Self-Management Intervention For Adults With Prehypertension

Research Article Effectiveness of a Stroke Risk Self-Management Intervention for Adults
with Prehypertension
Hee-Young Song, RN, PhD, 1 Kyoung A Nam, RN, PhD 2, *
1
Department of Nursing, Wonju College of Medicine, Yonsei University, Wonju, South Korea 2 Division of Nursing, College of
Medicine, Hallym University, Chuncheon, South Korea
a r t i c l e i n f o
Article history: Received 8 December 2014 Received in revised form 26 April 2015 Accepted 16 September 2015
Key words: prehypertension primary prevention risk self-care stroke
s u m m a r y
Purpose: The aim of this study was to evaluate the effectiveness of a community-based intervention for prehypertensive adults, to
enhance stroke risk awareness and to adopt a preventive lifestyle for primary stroke prevention. Methods: This was a
single-blinded, repeated measures quasi-experimental study with 47 participants (23 in the experimental group and 24 in the
control group) recruited through convenience sampling from two urban areas. The stroke risk self-management intervention
consisted of three weekly, 2-hour, face-to-face sessions and two booster telephone sessions, utilizing strategies to enhance
motivation for behavioral changes based on the Self-Determination Theory. All participants completed a pretest, a 1- month and a
3-month post test of stroke risk awareness and preventive lifestyle including blood pressure self-monitoring, healthy diet, and
regular physical activity. Data were analyzed using descriptive statistics, chi-square test, two sample t test, repeated measures
analysis of variance, and Friedman test with PASW Statistics 18.0. Results: After the intervention, significant improvements
were found in the experimental group for stroke risk awareness, blood pressure self-monitoring and regular physical activity, and
were sustained over time. Conclusions: Our preliminary results indicate that the stroke risk self-management intervention is
feasible and associated with improvement in self-management of stroke risk factors for primary stroke prevention among a
prehypertensive population.
Copyright © 2015, Korean Society of Nursing Science. Published by Elsevier. All rights reserved.
Introduction
Stroke is the second most common cause of death and a major cause of disability worldwide [1,2]; the condition imposes sub-
stantial health, economic and social costs on individuals, families and health systems. In 2008, the total annual cost related to
stroke care was estimated at $65.5 billion in the US and V27 billion in the European Union [1]. In Korea, annual costs for
patients hospitalized with stroke increased by 42.8% between 2005 and 2010 [3].
In spite of the serious and pervasive impacts of stoke, stroke can be prevented by identifying and modifying risk factors
including hypertension, hyperlipidemia, atrial fibrillation, physical inactivity, obesity, and smoking [4,5]. Elevated blood pressure
(BP) is a
powerful and prevalent determinant of increased risk for both ischemic and hemorrhagic stroke [6], which suggests the impor-
tance of BP control for primary stroke prevention.
Recently, individuals with prehypertension (characterized as a systolic BP of 120e139 mmHg and/or diastolic BP of 80e89
mmHg) have been targeted for primary stroke prevention because prehypertension has been associated with increased risk of
hypertension and stroke relative to normal BP [7e9] across races and ethnicities [10]. In addition, findings from various national
and international samples suggest that individuals with prehypertension are likely to have multiple risk factors for stroke such as
hypercholesterolemia, diabetes, overweight/obesity [8,11], lack of physical activity and a high-fat diet [12,13]. These findings
war- rant the need for interventions to detect and control multiple risk factors aforementioned, along with BP, in prehypertensive
adults in the community. * Correspondence to: Kyoung A Nam, RN, PhD, Division of Nursing, College of Medicine, Hallym
University, 1 Hallimdaehak-gil, Chuncheon-si, Gangwon-do, 24252, South Korea.
E-mail address: namka@hallym.ac.kr
However, previous research findings on prehypertension have primarily focused on epidemiology, and, until now,
intervention studies for stroke prevention in this population [14e17] have been
Asian Nursing Research 9 (2015) 328e335
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http://dx.doi.org/10.1016/j.anr.2015.10.002 p1976-1317 e2093-7482/Copyright © 2015, Korean Society of Nursing Science.
Published by Elsevier. All rights reserved.

insufficient. In many intervention studies, the study sample was composed of people with hypertension as well as
prehypertension and few explicit theoretical models have been used to develop interventions and evaluate the independent
contribution of specific variables [18]. In other words, the effect or theoretical base of intervention strategies for prehypertension
in free-living condi- tions remains unclear; thus, it is difficult to identify evidence based on these interventions and apply it to real
practice.
In addition, individuals with prehypertension who do not have any other current medical diagnosis mostly consider
themselves healthy and are unlikely to seek expert help to manage their health [19,20]. Resources and expertise in the
community, which can be used for preventive intervention, are also very limited. In this regard, further studies are warranted to
develop effective interventions that are based on a sound theoretical base and feasible for this population. These interventions
should focus on enhancing awareness of stroke risk and lifestyle changes that can be modified to control stroke risk.
Given these circumstances which require feasible as well as efficacious interventions for community populations, an
alternative option highlighted recently is a self-management approach. For this approach, it has been suggested that people who
involve themselves in hypertension management have been shown to have better BP control [21]. A number of studies
investigated the effectiveness of the self-management approach to enhance stroke preventive behaviors in a community
population, including home BP self-monitoring [22], self-examination of pulse for cardiovascular disease prevention [23], and
BP self-monitoring among stroke survivors to prevent recurrent stroke [24].
Self-management emphasizes the responsibility for self-care in response to an increased risk of developing disease, and
individual motivation is critical for success [25e27] as motivation is the reason or incentive for performing and maintaining
behaviors [5]. One of the theoretical perspectives that examines motivation, the Self-Determination Theory (SDT), is a
well-established theory of human motivation and behavior [28]. It focuses on autonomous motivation, not controlled autonomy,
which refers to acting with a sense of volition and the experience of willingness [29]. According to SDT, autonomously
motivated people take on changing a particular behavior or goal and are more whole-heartedly engaged, persistent, and
efficacious than individuals that have controlled motivations [29,30].
In this regard, elements of SDT are likely applicable to self- management strategies and existing findings have indicated that
self-management intervention based on SDT theory were effective in community populations for behavioral changes [29,30].
How- ever, few studies have developed and tested the effectiveness of SDT-based self-management intervention and targeted
prehyper- stensive populations.
Therefore, this study incorporated strategies based on a theoretical approach of SDT into an intervention to enhance stroke
risk self-management (SRSM) among adults with prehypertension living in the community. The hypothesis was that intervention
for SRSM would result in greater awareness of stroke risk and adoption of a preventive lifestyle, that is, BP self-monitoring, a
healthy diet, and regular physical activity.
Methods
Design
A single-blinded, repeated measures quasi-experimental design was used with data collection at three time points
(preintervention and, 1 month and 3 months postintervention).
H. Song, K.A. Nam / Asian Nursing Research 9 (2015) 328e335 329
Participant sampling
The sample of 56 participants (28 experimental; 28 control) was recruited from community cultural centers and private groups
in one church in two urban areas within G Province, South Korea. Convenience sampling was used. The inclusion criteria were
(a) Joint National Committee (JNC) 7 stage prehypertension (i.e., systolic BP 120e139 mmHg or diastolic BP 80e89 mmHg)
[7], (b) age between 40 years and 64 years, (c) community dwelling, (d) no activity restrictions or impairments in the ability to
perform daily living activities and (e) no use of antihypertensive medication.
The sample size was calculated by G*power 2.0, to determine what was necessary to use repeated measure analysis with a
significance level of a at .05, power of 0.8 and effect size of 0.35, which resulted in 23 participants for each group. Effect size
of 0.35 was calculated based on an estimated effect size d from a previous finding on the effectiveness of an educational
intervention among community-living adults [31].
The dropout rate was considered and 56 participants were recruited. The actual attrition rate was 16.1%, including five par-
ticipants in the experimental group and four participants in the control group. These nine people were excluded from data
analysis because of the following reasons in both groups: In the experimental group, three withdrew voluntarily before the end
of the intervention and two did not complete the postintervention measurements. In the control group, two withdrew voluntarily
before the end of the intervention, and two did not complete the postintervention measurements (Figure 1). No significant
differences existed in the demographic characteristics between the completers (n 1⁄4 47) and the dropouts (n 1⁄4 9).
Ethical consideration
To protect the human rights of the participants, the study was reviewed and approved by the Yonsei University Institutional
Re- view Board (IRB-2010-48). All participants provided informed consent prior to data collection, after being informed about
the nature of the study, the voluntary nature of participation, the right to refuse to participate in the study and to withdraw consent
at any time without reprisal, the anticipated benefits and potential risks of the study, and the confidentiality of responses.
Data collection
To recruit participants, the investigator contacted a represen- tative of each group, and explained the goals and the procedure
of the study. The flyers to solicit the potential participants were posted on the bulletin boards at the churches and centers. The
contact numbers of the representatives and research assistants were also posted to let potential participants voluntarily contact
and express interest in participation. Then the research assistants attended those meetings or gatherings, explained the study,
identified and contacted potential participants who had expressed interest in participating.
To identify subjects who met the inclusion criteria among those who wished to participate, BP was measured twice and the
mean value of the two measurements was used. BP was measured by research assistants on the right arm of participants, using an
appropriately sized cuff and a standard mercury sphygmoma- nometer, after participants had been seated for 15 minutes, with
feet on the floor and arm supported.
The primary investigator decided on participants who met the inclusion criteria of the study. These individuals who met the
inclusion criteria provided informed consents prior to data collection,

and were randomly allocated to the experimental or control groups by flipping a coin.
The SRSM intervention for the experimental group was deliv- ered by two nurse interventionists selected on the basis of their
previous experience in community healthcare. They received 10 hours of training to ensure the consistency in implementing the
intervention.
Participants in the control group received a 60-minute session on stroke prevention using a supplemental pamphlet which con-
tained information from the Korean Stroke Society web links [32]. After data collection was completed, participants in the
control group were provided with the materials used for the experimental group and invited to participate in the intervention.
Trained research assistants conducted a pretest prior to the intervention and 1-month and 3-month post test after the last
intervention session. The 1-month and 3-month postintervention assessments were conducted by telephone at the participants'
convenience. Data collection was conducted between January and October, 2011.
SRSM Intervention
The SRSM intervention consisted of three weekly, two-hour, face-to-face sessions and two booster telephone sessions. The
principal aim of the intervention was to increase stroke risk awareness and motivation for behavioral change to maintain self-
management for stroke risk factors they already had. SRSM was guided by SDT, which emphasizes the satisfaction of
psychological needs of autonomy, competence and relatedness as essential nu- trients that are required for autonomic motivation
[29] and focused on fostering participants' self-managemant skills, such as decision making, taking actions and partnership with
healthcare providers [26]. The main strategies included increasing knowledge, skill training, guided goal setting and action plans,
and offering autonomy supportive climate by giving the participants control and respect and helping them chart a pathway of
engagement in their
Figure 1. Flow diagram of the study.
own care that they could both endorse and apply. Table 1 lists the summary of the intervention.
The first session focused on providing information regarding the association between stroke and risk factors that can be
controlled by individuals, highlighting relatively increased personal stroke risk due to prehypertension and other concomitant
risk factors such as high body mass index, inactivity, and un- healthy eating. Information on individualized stroke risk was
formulated based on the existing Korean Stroke Society risk score profile [32], which weighs systolic BP, particularly with
advancing age. During the individual counseling, the participants were given relevant information about health risks and the
relationship between their behaviors and possible health consequences, which is likely to allow them to make their own
informed choices about how to behave.
The second and third session incorporated methods to learn necessary skills and to prompt motivation to perform the
necessary behavior for self-management of stroke risk, including training BP self-measurement with guided goal setting and
action plans to change behaviors, and supportive small group. For skill training, participants had the opportunity to practice the
necessary skills for BP self-monitoring, measuring BP using a digital wrist BP manometer (OMRON
®
7 SeriesTM Wrist Blood Pressure Monitor, Omron Healthcare, Inc., Tokyo, Japan) that was given to
each participant and to read the results.
For guided goal setting and action planning, participants were instructed to develop and establish formal goal statements and
action plans for adopting a preventive life style with the interventionist as well as other participants. Actual action plans were
developed according to their goals, which guided participants to prepare strategies for how they would make their chosen behav-
ioral changes for stroke risk self-management. The components of preventive lifestyle, that is, BP self-monitoring, healthy diet,
and regular physical activity were selected based on established effectiveness from existing recommendations [32] and literature
for Korean populations [31].

In the subsequent small group meetings, participants were encouraged to share what they experienced and how they attained their
goals. During these sessions, feedback was also available from interventionists and group members. At the end of the face-to-face
sessions, participants were empowered to continue and build upon their healthy diet and physical activity according to their own
goals, and were instructed to keep the calendar on which they checked and recorded the frequency of BP self-measuring on a
regular basis as a way to track goal achievement, and to mail the calendars back using return envelopes.
Booster phone calls were made at both 6 weeks and 10 weeks after the last face-to-face intervention. Interventions by phone
calls have been widely used in several previous studies for community- living adults with obesity, hypertension, and chronic
obstructive pulmonary disease [25,33e35]. In addition, to maximize treatment fidelity and consistency, a trained interventionist
made each phone call with a standardized protocol which outlined the interview during the phone call as following: beginning
with an open-ended question, sharing experience regarding keeping BP self-monitoring and healthy lifestyle, verifying the status
of meeting individualized short-term goals and commitment to the necessary self- management behavior of stroke risk, and
encouraging individuals' exertion regardless of goal achievement.
Outcome variables and instruments
An interviewer-administered questionnaire consisting of 34 items was used to measure stroke awareness and preventive life-
style (BP self-monitoring, healthy diet, regular physical activity) including demographic data and the stroke risk factors of
participants.
For the current study, the questionnaire's content validity was established using experts selected to ensure the validity of
aspects
Table 1 Summary of the Intervention.
Session (Duration)
Weekly session topics Objectives Description
Session 1 (2 hours)
Stroke facts and prevention of stroke - Stroke warning symptoms - Stroke sequel and complications - Stroke prevention What is
my stroke risk? - What is stroke risk? - How about my stroke risks? - How about my BP and lifestyle?
To incite motivation and prompt autonomous
informed decision-making for behavioral change
Education on general information to increase knowledge of stroke and stroke prevention Individual counseling to give
personally
relevant information (e.g. individualized 10- year stroke risk) and to connect stroke risk factors with personal risks in everyday
life
Session 2 (2 hours)
Stroke prevention on my own! - Practicing measuring BP - Adopting a healthy lifestyle - Establishing self-care strategies to
modify life style
To learn necessary skills and strategies for
self-management of stroke risk factors To facilitate motivation and the feeling of
competence to take preventive behaviors To provide relatedness and support
Training to give instruction to practice BP
measurement skills repeatedly until they feel competent Guided goal setting and action planning to
prompt behavioral change, barrier identification, and building ways to perform the necessary behavior for self-management of
stroke risk Supportive small group meetings to foster
social interaction with supportive nonjudgmental peer groups and to increase participants' self-esteem, to provide positive
feedback Session 3 (2 hours)
Put thoughts into action and Stick to it! - What has been changed? - How can I go through with this? - Applaud myself!
To confirm the skills and intention for BP self-
monitoring and preventive lifestyle To prompt self-monitoring of behavior To provide appropriate feedback
Individual counseling to consolidate the goals
and action plan for stroke prevention Supportive small group meeting for sharing personal insights and commitment to BP
self-monitoring, supporting behavioral change and celebrating their individual achievement Individualized booster sessions
Follow-up sessions for progress review and support
To acknowledge participants' exertion of
behavioral change To support personal choices and progress
Individual phone-based counseling in a nonjudgmental, neutral and supportive manner regardless of goal achievement
of stroke care, community-based intervention research, and intervention for health behavior and self-management. To establish
reliability of the questionnaire for this study, a survey was conducted with a sample of 40 people with prehypertension who
were recruited according to the selection criteria of the current study but who were not included in the overall study. Cronbach a
for each of the instruments was acceptable.
General characteristics and stroke risk factors
General characteristics and lifestyle risk factors were assessed at baseline with 11 custom-designed questions. Physiological
risk factors were measured by anthropometric and BP measurements (Table 2).
Stroke risk awareness
Stroke risk awareness, defined as the participants' knowledge about stroke and recognition of their own stroke risk, was
measured with 17 items. Stroke knowledge was examined using a scale of 15 items regarding person's knowledge of stroke risk
factors, warning symptoms, treatment, and prevention. This scale was modified by the investigator based on items suggested by
a previous study that investigated stroke knowledge among a community population [36] and was validated by a study
conducted with Korean community-dwelling adults [31].
Participant recognition of personal stroke risk was measured using two items on a dichotomous scale regarding knowledge of
BP and body weight within normal limits, that is whether they knew the normal limits of BP and body weight. These two
indicators have been suggested to be key indicators for major illnesses, which can predispose an individual to stroke [27]. Correct
answers from the stroke knowledge scale and affirmative answers to questions on the recognition of stroke risk were scored and
summed to give a total stroke awareness score that ranged from 0 to 17. A higher score

indicated greater awareness of stroke. The Cronbach a of the scale in the pilot and the current study were .79 and .78,
respectively.
Preventive lifestyle
The preventive lifestyle was defined as the degree to which participants adopted stroke risk self-management behaviors to
control stroke risk factors, which included BP self-monitoring, healthy diet, and regular physical activity.
BP self-monitoring was assessed based on the average frequency of BP self-measurement for a month, which was recorded on
individual calendars by participants.
Healthy diet was measured using four items, and was originally developed and validated by Koffmann et al [37] in a study to
enhance regular physical activity among women who lived in communities in the US [37] and validated in a previous study in
Korea [31]. This questionnaire was developed to determine dietary behaviors associated with the reduced fat and salt intake and
eating plenty of fruit and vegetables. Each item was scored on a 4-point scale ranging from 1 (never)to4(always). A higher score
indicated a better adherence to a healthy diet. The Cronbacha of the scale in the pilot and the current study were .73 and .76,
respectively.
Regular physical activity was measured with one item which asked the participants about the stage of change in regular
physical activity, which was originally developed and validated by Koffman et al [37] and was validated in a previous study in
Korea [31]. This item assessed the participants' stage of change by asking about intent to perform or maintain regular physical
activity. The following question and responses were used: “Do you do regular physical activity for 30 minutes at a time more
than 5 days in a week?”“No, and I do not intend to in the next 6 months” (precontemplation); “No, but I intend to in the next 6
months” (contemplation); “No, but I intend to in the next few days” (preparation); “Yes, I have been doing it for less than 6
months” (action); “Yes, I have been doing it for more than 6 months” (maintenance).
Table 2 Comparison of General Characteristics and Stroke Risk Factors of Participants (N 1⁄4 47).
Variables Categories Experimental (n 1⁄4 23) Control (n 1⁄4 24) t (p) or c2
(p)
n (%) or M (SD) n (%) or M (SD)
Age 46.52 (8.00) 48.23 (8.16) 0.56 (.580) Sex Male 9 (39.1) 10 (41.7) 1.56 (.667)
Female 14 (60.9) 14 (58.3) Education High school 9 (39.1) 10 (41.7) 1.50 (.134)
! College 14 (60.9) 14 (58.3) Marital status Married 22 (95.7) 21 (87.5) 1.57 (.666)
Unmarried 1 (4.3) 3 (12.5) Economic status Low 1 (4.3) 3 (12.5)
Middle 18 (78.3) 17 (70.8) 0.69 (.709) High 4 (17.4) 4 (16.7) Religion Christian 7 (30.4) 5 (20.8)
Catholic 3 (13.1) 3 (12.5) 0.65 (.886) Buddhism 4 (17.4) 6 (25.0) None 9 (39.1) 10 (41.7) Lifestyle risk factors
Current smoker Yes 2 (8.7) 5 (20.8) 2.99 (.393)
No 21 (91.3) 19 (79.2) Immoderate alcohol consumption
a
Yes 12 (52.2) 17 (70.8) 3.08 (.214) No 11 (47.8) 7 (29.2) Physiological risk factors
BP (mmHg) Systolic 122.80 (12.09) 125.68 (13.06) À1.68 (.102) Diastolic 73.77 (8.30) 77.03 (7.04) À1.20 (.239) BMI (kg/m
2
) Underweight (<18.5) 1 (4.4) 1 (4.2)
Normal (18.5e22.9) 10 (43.5) 9 (37.5) 2.70 (.260) Overweight (23.0e24.9) 9 (39.1) 10 (41.6) Obese (> 25.0) 3 (13.0) 4 (16.7)
Note. BMI 1⁄4 body mass index; BP 1⁄4 blood pressure.
a
Drinking more than seven glasses of alcoholic drinks such as Korean jin, beer, wine, etc. for men and four glasses for women
at one time. Korean Centers for Disease Control and Prevention. Korea Health Statistics 2010: Korea National Health and
Nutrition Examination Survey (KNHANES V-1). Seoul: 2011. p.24e25.
Statistical analysis
Using PASW 18.0 Statistics (SPSS Inc., Chicago, IL, USA), descriptive statistics, chi-square test, Fisher's exact test, and two
sample t test were used to compare baseline variables between the experimental and control groups.
To test the effectiveness of the intervention, repeated measures analysis of variance was used to analyze changes in stroke risk
awareness, BP self-monitoring, and healthy diet over time. The Friedman test was performed to analyze the change of stage of
regular physical activity with the post hoc test by Wilcoxon sign rank test. A p value less than .05 was considered significant.
Results
General characteristics and stroke risk factors
As indicated in Table 2, the final sample of completers was predominantly middle-aged, married, female, and most had
completed high school. More than half of the participants were religious and reported immoderate alcohol consumption. Mean
systolic BPs of the experimental group and the control group were 122.80 mmHg (SD 1⁄4 12.09 mmHg) and 125.68 mmHg (SD
1⁄4 13.06 mmHg), respectively. Prevalence of overweight and obesity in the experimental group were 39.1% and 13.0%, and that
in the control group were 41.6% and 16.7%, respectively. There were no significant differences in these variables between the
groups.
Comparison of study variables between groups at baseline
Table 3 showed the scores of stroke risk awareness and preventive lifestyle and comparison of these variables between the
groups before the intervention, as well.

pretest Table 3 Comparison of Study Variables between Groups at Baseline (N 1⁄4 47).
and 1-month post test as well as pretest and 3-month post
Variables Experimental
(n 1⁄4 23)
test (p < .05).
The stage of change in regular physical activity analyzed by the Friedman test showed significant change only in the
experimental group (c2
1⁄4 10.47, p 1⁄4 .005), and Wilcoxon signed rank test indicated differences between pretest and 3 months post test (p
< .05). However, there were no significant differences in healthy diet between the groups, changes over time, or interactions
between groups and times (Table 4).
Discussion
The present study was the first to evaluate the effectiveness of an intervention to enhance self-management of stroke risk
factors for community-dwelling adults with prehypertension in Korea by incorporating strategies based on SDT. Results of this
study are potentially very useful and provide preliminary evidence about an effective and feasible intervention to prevent stroke
for adults that have a high risk for developing stroke due to elevated BP compared with adults who have an optimal BP.
In the current study, more than half of the participants (52.1% in the experimental group and 58.3% in the control group) were
overweight or obese and more than 80.0% of them did not do regular physical activity. These results are comparable with the
existing finding that suggests association between higher prevalence of overweight, obesity, and low physical activity and pre-
hypertension when compared to persons with normal BP [8].
One of the main findings in the present study is that the SRSM intervention improved stroke risk awareness in the
experimental group, and it was maintained for 3 months. Of significance is this finding that increased awareness about stroke risk
is likely to enhance participants' motivation to make decision for behavioral change with their own informed choices about how
to behave.
In particular, providing relevant and individualized stroke risk information through one-on-one counseling in the first SRSM
session may have given a clear rationale for behavioral change to participants and prompted them to reflect on their own
situation,
Table 4 Changes in Stroke Risk Awareness and Preventive Lifestyle over Time (N 1⁄4 47).
Variables Baseline 1-month 3-month Group Time Group Â Time
n (%) or M (SD) n (%) or M (SD) n (%) or M (SD) F (p) or c2
(p)
Stroke risk awareness (range: 0e17)
Experimental (n 1⁄4 23) 9.95 (2.71)b,c 14.00 (4.95)a 13.56 (5.68)a 7.24 (.001) 9.25 (< .001) 4.28 (.020) Control (n 1⁄4 24) 10.55
(5.25) 9.86 (5.88) 9.24 (5.37) Preventive lifestyle
BP self-monitoring (times/month)
Experimental (n 1⁄4 23) 1.26 (1.08)b,c 12.27 (4.56)a 12.09 (5.94)a 11.10 (< .001) 4.57 (.041) 3.85 (.027) Control (n 1⁄4 24) 1.60
(1.06) 2.29 (2.14) 2.48 (1.78) Healthy diet (range: 4e16)
Experimental (n 1⁄4 23) 9.52 (3.12) 12.11 (1.34) 12.40 (1.57) 2.15 (.153) 0.09 (.765) 1.18 (.207) Control (n 1⁄4 24) 9.35 (2.53)
9.34 (1.31) 9.40 (1.24) Stage of change in regular physical activity
t (p) or c2
(p)
n (%) or M (SD)
Control (n 1⁄4 24)
n (%) or M (SD)
Stroke risk awareness
(range: 0e17)
9.95 (2.71) 10.55 (5.25) À1.65 (.109)
Preventive lifestyle
BP self-monitoring (times/month)
1.26 (1.08) 1.60 (1.06) À1.43 (.163)
Healthy diet (Range: 4e16) 9.52 (3.12) 9.35 (2.53) 0.16 (.872) Stage of change in regular physical activity
Precontemplation 6 (26.1) 2 (8.3) Contemplation 6 (26.1) 10 (41.7) 3.36 (.500) Preparation 8 (34.8) 8 (33.4) Action 1 (4.3) 2
(8.3) Maintenance 2 (8.7) 2 (8.3)
Participants in the experimental and control groups reported that they performed BP measurement by themselves 1.26 (SD 1⁄4
1.08) and 1.60 (SD 1⁄4 1.06) times in a month, respectively.
Among participants, 87.0% in the experimental group and 83.4% in the control group claimed that they had not been doing
any regular physical activity at that moment. There was no significant difference in stroke risk awareness and preventive lifestyle
between the groups before the intervention.
Effects of intervention
Repeated measures analysis of variance revealed significantly different changes between the groups in stroke risk awareness
(F 1⁄4 7.24, p 1⁄4 .001) and BP self-monitoring (F 1⁄4 11.10, p < .001) and statistically significant differences over time (stroke
risk awareness: F 1⁄4 9.25, p < .001; BP self-monitoring: F 1⁄4 4.57, p 1⁄4 .041). There were significant group and time
interactions in stroke risk awareness (F 1⁄4 4.28, p 1⁄4 .020) and BP self-monitoring (F 1⁄4 3.85, p 1⁄4 .027). A post hoc test
showed significant differences between
*
Experimental (n 1⁄4 23)
Precontemplation 6 (26.1) 1 (4.3) 1 (4.3) Contemplation 6 (26.1) 2 (8.7) 1 (4.3) 10.47 (.005) Preparation 8 (34.8) 12 (52.2) 4
(17.4) Post hoc
d
: pretest < 3-month post test Action
1 (4.3) 4 (17.4) 10 (43.5) Maintenance 2 (8.7) 4 (17.4) 7 (30.5) Control (n 1⁄4 24)
Precontemplation 2 (8.3) 5 (20.6) 2 (8.3) Contemplation 10 (41.7) 6 (25.0) 8 (33.3) Preparation 8 (33.4) 8 (33.3) 8 (33.3) 2.14
(.343) Action 2 (8.3) 4 (16.8) 4 (16.8) Maintenance 2 (8.3) 1 (4.3) 2 (8.3)
Note. BP 1⁄4 blood pressure;
c
3-month post test; superscripts a, b, and c indicate that differences among
measurements were significant at p < .05 by Bonferroni test.
a
Pretest,
b
1-month post test, d
Post hoc tests were performed using Wilcoxon signed rank test. *p < .05 using the Friedman test.

gain insight on the extent to which they are predisposed to stroke and assess their susceptibility.
Accordingly, participants may have been motivated to make decisions to carry out preventive behaviors to reduce stroke risk
and, as a result, to be reinforced to the progression to actual improvement of preventive behavior, which is BP self-monitoring
and regular physical activity. This explanation can also be validated by findings of significant improvements in BP
self-monitoring and the stage of regular physical activity in the current study.
The significant improvement of BP self-monitoring in the experimental group is partly comparable with previous findings
suggesting the benefits of educational intervention on positive changes in adopting BP self-monitoring practice among
individuals with minor stroke [24], in practicing pulse self-examination among community population [23], in voluntary
care-seeking behavior for stroke risk screening among community adults [25], and in compliance of behavior for
self-management among patients in a stroke rehabilitation facility [38].
It is worthwhile noting that the improvement of BP self- monitoring was sustained for 3 months, which may have been due to
supervised hands-on practice with detailed instruction during educational session, followed by self-practice at home. Also the
participants were encouraged to set their personal short-term goals for planning and implementing BP self-monitoring, for
example, when and how often to measure BP at home. In- terventionists helped participants identify barriers and practical ways
to perform the necessary behaviors, giving positive feedback in a nonjudgmental way.
All these approaches were likely to contribute to enhancing participants' perceived competence in behavioral change and
achievement of the desired outcome which is the key to actual behavioral change according to SDT [30], and subsequent actual
improvement of BP self-monitoring and regular physical activity.
In addition, throughout the sessions, interventionists tried to establish a partnership with participants to enhance autonomous
supportive climate, assuring participants of their choices, providing participants relevant feedback in a nonjudgmental way and
supporting the participants' decisions and efforts to cope with the consequences of their choices regardless of goal attainment
[29]. Supportive small group meetings were also utilized to foster social interaction with supportive nonjudgmental peer groups,
to increase participants' self-esteem, and to provide positive feedback.
In particular, strategies for partnership have been recently focused as core skills of self-management in contemporary health
care environment where seeking health care before getting ill is more emphasized and valued [26]. In this regard, the strategies to
enhance the participants' partnership with health care providers in the current study may have significant practical implications
for the community dwelling population who are unlikely to seek expert help to manage their health.
Unlike the improvements in BP self-monitoring and stage of regular physical activity, there was no significant sustained
improvement in healthy diet in the experimental group. Possible explanations for this result are likely related to cultural aspects
of food intake and dietary habit. In Korea, it is common that meals are served with shared dishes among a group of people, either
with the family, friends, or colleagues. Furthermore, possible gender differences in eating behavior should be considered; about
half of the participants were men whose traditional gender role in our country does not encourage active participation in shopping
for food or meal preparation. Therefore, it might be difficult for these individuals to make dietary changes, even if they wanted
to adapt healthy eating practices. In addition, the measurement of healthy diet in this study may not have captured eating/diet
behavioral changes specific to stroke prevention among the participants, who
were mostly in their 40s, which may highlight the need for a more relevant measurement of eating behaviors in this population.
A couple of practical considerations are suggested by the current findings. In the current study, the withdrawal rate (16.1%)
was relatively low compared to rates of 22.0% and 30.0% seen in studies by Sit et al [24] and Munschauer et al [23],
respectively, studies in which the effectiveness of interventions using the self- management approach in community-based
populations had been previously examined. This result could be attributable to the persistence of the interventionist, which
allowed participants to make choices independently by considering personal life context, and factors such as time, personal
preference, and affordability, which were strategies based on the SDT to enhance autonomic motivation [29]. For example, the
face-to-face sessions were ar- ranged at the participant's convenience, and goal setting and action plans were initiated by
participants.
In addition, booster phone calls in the current study likely contributed to sustaining the effect until 3 months after the inter-
vention, which corresponds to existing findings reporting the effectiveness of individualized phone calls on successful health
behavioral change [25,33e35]. All these results from the current study are inspiring for their practical applicability, considering
the efficacy, the limited involvement of professionals and an intervention based on SDT.
In this regard, the authors cautiously suggest that this intervention can be applied for populations in the work environments or in
younger populations such as college students in the community who may be at high risk but are unlikely to have the resources
such as time and cost, or the expertise to utilize to manage stroke risk factors. Some limitations of the study should be taken into
account with several suggestions for future research. First, given the small sample size and short follow-up time, findings of this
study should be interpreted with caution and viewed as preliminary results. Further studies are warranted to validate these
findings with a larger sample size. Also, facilitating autonomous motivation seems vitally important to maintaining long-term
behavioral change [39]. Therefore, further studies are needed to clarify the long-term effectiveness of self-management
intervention in prehypertensive populations, with a follow-up period that is greater than 6 months. Secondly, self-reporting was
used to evaluate the adoption of a preventive lifestyle and BP self-monitoring, which is a less objective validation to these
changes among participants. It is also unclear whether increased stroke risk awareness in the participants enabled the participants
to modify physiological risk factors such as BP, which were not assessed in the current study. Therefore, to address these
limitations, future studies are needed to confirm the physiological changes after the intervention.
Lastly, we did not conduct an evaluation of the intervention from the participants' perspectives. This should be also
considered for future studies, regarding participants' evaluation of the intervention would have given practical and insightful
information on refining the intervention and research in the future.
Conclusion
The findings of this study suggest an empirical, feasible and retainable intervention based on a well-established theory, SDT,
to improve self-management skills for stroke prevention for middle- aged community-living adults with prehypertension whose
risk of stroke has been known to be relatively high.
Regarding the recent consensus, the most effective approach for primary prevention of stroke is to combine a
population-based strategy with focused interventions in those found to be at high risk. Thus, targeting community-living adults
with prehypertension in the current study has timely significant implications.

Given the overlap in risk factors between stroke and cardiovascular diseases, the findings of this study suggest the possibility of
applying SRSM intervention to the management and prevention of cardiovascular diseases. Future studies to verify the
effectiveness of the intervention are warranted to examine the applicability of SRSM for extended target populations with various
risk factors.
Conflicts of interest
The authors have no conflicts of interest to declare.
Acknowledgments
The authors would like to thank all of the study participants. This research was supported by the Basic Science Research
Program through the National Research Foundation of Korea funded by the Ministry of Education (NRF-2014R1A1A2060027),
and a research grant from Yonsei University Wonju College of Medicine (YUWCM 2010-7-0485).
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