The Effect of Nursing Interventions Based on Protection Motivation Theory on Drug Adherence and Healthy Lifestyle Behaviors in Patients With Hypertension: A Randomized Controlled Study
Phase: NA
Conditions: Hypertension, Public Health; Nursing Staff
Sponsor: Necmettin Erbakan University

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THE EFFECT OF NURSİNG INTERVENTİONS BASED ON CONSERVATİON 
MOTİVATİON THEORY ON DRUG ADHERENCE AND HEALTHY LİFESTYLE 
BEHAVİORS İN PATİENTS WİTH HYPERTENSİON: A RANDOMİZED 
CONTROLLED STUDY 
 
 
 
 
 
 
NCT05995977 
 
 
 
 
 
 
 
Document Date: 1 August 2023 
 
 
 
 

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ABSTRACT 
Hypertension is a major global public health problem. For success in the prevention and 
management of hypertension, it is necessary to ensure that patients receive timely and accurate 
diagnosis, acquire healthy lifestyle habits, start antihypertensive drug treatment on time, and 
ensure compliance with treatment. The study was conducted in a pre-test-post-test parallel 
group randomized controlled design in order to determine the effects of nursing interventions 
consisting of hypertension education and sending short messages, created by utilizing Rogers' 
Protective Motivation Theory (CMT), on medication compliance and healthy lifestyle 
behaviors for hypertensive individuals. The study was conducted at Family Health Center No. 
7 in the center of Karaman province between November 2023 and May 2024. The study group 
included individuals between the ages of 40 and 59, who had low compliance with treatment, 
had no communication problems in terms of hearing, vision, and understanding, used a mobile 
phone to receive the short message to be sent by the researcher, and were diagnosed with 
primary hypertension. The study was conducted with 78 hypertensive individuals, 39 in the 
intervention group and 39 in the control group, calculated with 95% power. Ethics committee, 
institution, scale use permission and written consent of the participants were obtained before 
the study. Data were collected at the beginning (T₀), at the end of the third month (T₁) and at 
the end of the sixth month (T₂) using the Personal Information Form, Antihypertensive Drug 
Treatment Adherence Scale, Healthy Lifestyle Behaviors Scale, Blood Pressure Monitoring 
Form. Multiple nursing interventions consisting of hypertension education, brochure and short 
message created by using Rogers' KMT were applied by the researcher for 14 weeks. The 
control group was expected to continue their routine treatment for six months and no 
intervention was applied. Pre-test, interim and post-test measurements were collected by the 
researcher using the face-to-face interview method. Blindness was applied in terms of statistics 
expert and reporting. In the analysis of data, t test, chi-square test (Pearson chi-square/Fisher 
exact test) were used in independent groups, mixed order analysis of variance (ANOVA) was 
used in comparing variables according to follow-up times in groups, and Bonferroni correction 
was used in comparing main effects in the analyses. After the applied nursing interventions, a 
significant difference was found between the total mean scores of Antihypertensive Drug 
Treatment Adherence Scale, Healthy Lifestyle Behaviors Scale and systolic blood pressure and 
diastolic blood pressure values of the intervention and control groups (p<0.05). After the 
nursing interventions, the total mean scores of Antihypertensive Drug Treatment Adherence 
Scale and systolic blood pressure and diastolic blood pressure values of hypertensive 

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individuals in the intervention group were significantly lower compared to the control group, 
and the total scores of Healthy Lifestyle Behaviors Scale were significantly higher (p<0.05). 
Based on the results of this study, feasible, economical interventions combining health 
education and technology can be recommended as an important tool in health services to reduce 
the burden of hypertension in society.  
Keywords: Nursing, Hypertension, Medication adherence, Protective motivation 
theory, Healthy lifestyle behavior.  
1. MATERIALS AND METHODS  
1.1. Type of Research  
This study was conducted in a randomized, pre-test, post-test controlled experimental 
parallel design. The research was reported according to CONSORT 2022 (Junqueira et al., 
2023).  
1.2. Location and Characteristics of the Research 
The research was conducted at Family Health Center No. 7 (ASM) affiliated with the 
Karaman Provincial Health Directorate. The center serves a total of 9,150 people. Three family 
physicians, three family health workers and one assistant staff work at this center. The ASM 
provides service between 08:30 and 17:30 on weekdays. The ASM has a laboratory, injection-
dressing-emergency room and an examination room for patients. Polyclinic services are 
provided at all three polyclinics. Regarding hypertension, cardiovascular risk assessment, 
screening, follow-up and result procedures are performed for individuals registered in the 
family medicine unit for hypertension. In terms of the duties of the nurse, the nurse measures 
the blood pressure of hypertensive patients who apply to the center when deemed necessary and 
directed by the physician, and provides education and counseling services on the disease, 
medication use and health lifestyle behaviors. There is no planned education or telephone 
follow-up for patients with hypertension at the center.  
1.3. Universe of the Research and Study Group 
Universe: The research population consists of 407 individuals with primary 
hypertension between the ages of 40-59, registered in Family Health Center No. 7.  
Working group: In this study, the sample size was calculated before the data collection 
stage at a 95% confidence level using the "G. Power-3.1.9.2" program to determine the study 
group. Özpancar's (2013) study, which examined the effect of education given by nurses on 

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treatment compliance in patients with hypertension, was used for the calculation. According to 
the data obtained from the study in question, the sample number required for the study was 
determined as 35 for each group (35 people for the control group + 35 people for the 
experimental group; 70 people in total) by taking the alpha value of 0.05 for the Mann Whitney 
U test, the effect size of 0.90, and the theoretical power as 95%. The 10% loss rate in previous 
studies (Zahr et al., 2019; Dağıstan Aköz, 2022) was taken into account and it was decided to 
include a total of 78 participants, 39 in each group.  
 
1.4. Inclusion and Exclusion Criteria for Participants in the Study  
In this study, the characteristics in Table 3.1 regarding the inclusion and exclusion 
criteria in the study group were taken into consideration. 
 
Table 1. Participant inclusion and exclusion criteria 
Inclusion 
Exclusion 
• 
Participants diagnosed with primary 
hypertension (at least one year) 
• 
Between the ages of 40 and 59 * 
• 
Those who use a mobile phone to receive 
the SMS to be sent by the researcher 
• 
Those who are at least literate and can speak 
Turkish 
• 
Those who have no communication 
problems in terms of hearing, seeing and 
understanding 
• 
Those who use antihypertensive medication 
and who score “8 and above” on the 
compliance scale, and who are defined as 
non-compliant with treatment, were decided 
to be included in the study  
• 
Those with a second chronic disease 
• 
Those with a mental or communication 
problem 
• 
Those with secondary hypertension 
(Addison's disease, Renal artery stenosis, 
Hypo/hyperthyroidism, Parenchymal kidney 
disease, Cushing's disease) 
• 
Those who are pregnant or breastfeeding, 
 
* It is known that hypertension increases with age (Turkish Society of Endocrinology and Metabolism, 2022). At 
the same time, according to the socio-demographic data obtained from the ASM where the study was planned to 
be conducted, the age of the hypertensive individuals who will participate in the study is similar in terms of age, 
40 and above, so the lower age limit was determined as 40 in our study. In addition, according to TÜİK data, the 
upper age limit was determined as 59 years due to the decrease in the rate of internet and mobile phone use in 
people over 60 years of age in our country (TÜİK, 2022).  
1.5. Exclusion Criteria from the Study  
1. Wanting to leave the study 
2. Moving to another city during the follow-up period 
3. Death during the follow-up period 
4. Having acute health problems that require hospital monitoring and treatment during the 
follow-up period  

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1.6. Randomization  
The socio-demographic data (age, gender, education level and income level) of 
hypertensive patients from the 7th Family Health Center where the study was to be conducted 
were obtained as a list and found to be similar. Therefore, no stratification was applied in the 
study while determining the sample of the study. In the first stage of the study, the individuals 
registered in the 7th Family Health Center and continuing antihypertensive drug treatment were 
used to determine the hypertensive individuals defined as non-adherent to the treatment (scoring 
“8 and above”) using the antihypertensive drug treatment compliance scale. This process was 
continued until the specified sample size (n: 78) was reached. Each individual to whom the 
scale was applied was given a number from one to 78 according to the application order and a 
list of orders was created. In the second stage, the participants were assigned to the intervention 
and control groups from the web page (https://www.random.org/) according to the simple 
randomization method based on the order in the list created. In this assignment, the assignment 
of the groups was made by an expert in order to ensure blindness. 
The flow chart of the control and intervention groups was prepared in line with the 
guidelines specified in CONSORT 2022 (Figure 1) (Junqueira et al, 2023).  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Control group (n=39) 
Eligibility assessed (n=131) 
Randomized (n=78) 
Excluded (n=53) 
• Having a second disease (Diabetes, 
Cancer, Rheumatic diseases, Heart 
disease) (n=24) 
• Not volunteering (n=29)  
No intervention 
Intervention group (n=39)  
Nursing interventions based on Protection Motivation 
Theory (Hypertension education and sending SMS 
messages) intervention 
Voluntarily withdrawn from 
the study (n=4) 
Voluntarily withdrawn from the study (n=1) 
Removed by the researcher (n=2) 

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Figure 1. CONSORT (2022) Flowchart of the study. 
*ITT analysis 
 
 
1.7. Reasons for Leaving the Study 
The study started with a total of 78 participants and ended with “three” from the 
intervention group and “four” from the control group. After the participants left, the study was 
completed with a total of 71 patients, 36 from the intervention group and 35 from the control 
group. The patients who left the study stated the following reasons for leaving the study: “I am 
very busy, I can no longer spare time for your work” (n=3), “My blood pressure is no longer 
high, I am better, I want to leave your intervention” (n=1), “I cannot walk or diet, I cannot lose 
weight, I do not want to fill out your survey” (n=1) (5 patients in total). In addition, a total of 2 
patients had to be removed from the study because the phone numbers they provided could not 
be reached by the researcher.  
1.8. Blindfold 
The patients were invited to the study by the researcher involved in the study and 
participant registration was carried out until the targeted sample size (78 participants) was 
reached. During participant registration, the names and contact information of the patients were 
collected, and it was stated that they would be contacted and called for the process related to 
the study. When the targeted sample size was reached in the study, participant registration was 
terminated and a participant list was created. It is essential that those conducting the randomized 
controlled experimental study and the participants do not know who is in the intervention group 
and who is in the control group until the study starts (Akın and Koçoğlu, 2017). Using the 
participant list created for this purpose, random selection and assignment were made by 
someone other than the researcher in the study. Thus, selection bias was controlled in the study. 
After the groups were determined, the patients were not blinded since their consent would be 
obtained for the application to be made to them during the intervention process.  
Post-test administration (n=35) 
Analyzed = 35* 
Post-test administration (n=36) 
Analyzed = 36* 

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In this study, a blind technique was applied by concealing from the researcher who was 
in the control and intervention groups until the nursing interventions based on KMT began. 
However, the researcher was not blinded during the intervention period.  
Since the aim of the nursing profession is to produce information related to real-world 
practice beyond the boundaries of the laboratory, it is stated that the action approach will more 
accurately reflect nursing practice, however, it is said that blinding in action (pragmatic) 
experiments can generally be difficult (ethical, practical, etc. reasons) and sometimes even 
impossible, and in this case, it can be recommended to blind only those who evaluate the outputs 
and perform data analysis (Akın and Koçoğlu, 2017). For this purpose, in order to prevent bias 
in the evaluation of the data; statistical analyses of the coded data (A and B) in the prepared 
database were performed by a statistician, independent of the researcher. After the statistical 
analyses of the study and the appropriate tables for the results were made and the research report 
was written, the codings made for the control and intervention groups were explained. Thus, 
statistician and reporting blinding was performed during the research process. Intention to treat 
analysis (ITT) was applied to prevent attrition bias due to missing data in the outcome/outcome 
measurements during the study process after randomization. In this way, selection, attrition, 
statistical and reporting bias were controlled.  
1.9. Data Collection Tools 
In collecting the data of the study; Exclusion Criteria Form, Personal Information Form, 
Antihypertensive Drug Treatment Adherence Scale, Healthy Lifestyle Behaviors Scale 
(SYBDÖ-II), Blood Pressure Monitoring Form, Telephone Monitoring Form, and Short 
Message Service Monitoring Schedule were used.  
1.9.1. Exclusion criteria form  
This form was created according to the exclusion and inclusion criteria of the study in 
order to determine the participants to be included in the study. The form consists of a total of 7 
questions (age, education level, primary hypertension diagnosis, a second chronic disease, 
pregnancy or breastfeeding, mobile phone use, compliance with antihypertensive drug 
treatment) and 1 study inclusion criterion.  
1.9.2. Personal information form  
This form was created by the researchers as a result of a literature review 
(Hacıhasanoğlu et al., 2012; Erci et al., 2018; Deniz Akan et al., 2020; Republic of Turkey 

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Ministry of Health, General Directorate of Public Health, 2021). The form consists of a total of 
20 questions. 9 of which determine the socio-demographic characteristics of individuals (age, 
weight, height, gender, marital status, education status, employment status, monthly income, 
lifestyle) and 11 questions related to hypertension (duration of hypertension diagnosis, number 
of daily anti-hypertensive drugs used, duration of anti-hypertensive drug use, regular use of 
hypertension drug/drugs, place where the treatment is followed, family history of hypertension, 
hypertension-specific diet application status, daily tea/coffee consumption status, smoking 
status, alcohol consumption status, regular exercise status).  
 
 
1.9.3. Antihypertensive drug treatment compliance scale  
The Turkish validity and reliability of the scale developed by Morisky, Green and 
Levine was conducted by Demirezen and Nahcivan (Demirezen and Nahcivan, 2006). The scale 
includes a total of 9 statements that diagnose medication-taking behavior. The first 8 questions 
are answered as Yes and No, and yes answers are coded as “1” and no answers are coded as 
“0”. The ninth question has the options “1” never/rarely, “2” occasionally, “3” sometimes, “4” 
usually, and “5” always, and only one option is marked. In the scoring, Yes = 0 points and No 
= 1 points are evaluated in questions 5 and 6, while Yes = 1 and No is evaluated as 0 in the 
other questions. The last question, item 9, is a Likert-type and is evaluated between 1 and 5. 
The Cronbach alpha coefficient of the scale was reported as 0.82 for the entire scale. In the 
study, the definitions of compliance and non-compliance with antihypertensive drug treatment 
were determined according to the 80% cut-off point. In this study, Cronbach's Alpha reliability 
coefficient was found to be 0.674 in the first measurement, 0.797 in the second measurement 
and 0.748 in the third measurement. In the evaluation of compliance with antihypertensive drug 
treatment, an increase in score indicates that the individual is "non-compliant". The total scale 
score varies between '1-13'. Accordingly, individuals who score "1-7" according to the total 
scale score are defined as compliant with treatment, while participants who score "8 and above" 
are defined as non-compliant with treatment. 
1.9.4. Healthy lifestyle behaviors scale II 
Healthy behaviors were collected with the “Healthy Lifestyle Behaviors Scale (HLBS-
II)”. The scale was developed by Walker et al. (1987) and revised again in 1996 (Walker and 
Hill-Polerecky, 1996). The scale consists of 52 items in total and has 6 subfactors. The 
subgroups are spiritual development, health responsibility, physical activity, nutrition, 

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interpersonal relations, and stress management. All items of the scale are positive. The rating 
is in the form of a 4-point Likert. Never (1), sometimes (2), often (3), and regularly (4) are 
accepted. The Cronbach Alpha coefficient of the original scale is 0.94 and the Cronbach Alpha 
values of the subdimensions of the scale vary between 0.79 and 0.87. The scale was adapted to 
Turkish by Bahar et al. (2008). In the study in question, Cronbach's alpha reliability coefficient 
was determined as 0.92 and the reliability coefficients of the sub-dimensions of the scale were 
determined as; Health responsibility 0.77, Physical activity 0.79, Nutrition 0.68, Spiritual 
development 0.79, Interpersonal relations 0.80, Stress management 0.64. In this study, 
Cronbach's Alpha reliability coefficient was found as 0.904 in the first measurement, 0.928 in 
the second measurement and 0.926 in the third measurement. The scale measures health-
improving behaviors in relation to the individual's healthy lifestyle. The overall score of the 
scale gives the healthy lifestyle behaviors score. The lowest score for the entire scale is 52, and 
the highest score is 208.  
1.9.5. Blood pressure measurement 
Blood pressure was measured by the researcher using a calibrated mercury-manual 
sphygmomanometer (sphygmomanometer-Erka Perfect Aneroid/Germany) and stethoscope. 
Blood pressure values were evaluated according to the information in the Turkish Hypertension 
Consensus Report, and individuals with blood pressure values lower than 120/80 mmHg were 
defined as “well-managed” and individuals with values above this were defined as “poorly 
managed.” The steps followed in blood pressure measurement according to the office blood 
pressure measurement criteria specified in the Directive on Family Medicine Screening and 
Follow-up Coefficient, the Turkish Hypertension Consensus Report, and the ACD are shown 
in Figure 2 (Aydogdu et al., 2019; Official Gazette, 2021; American Heart Association, 2022).  
 
 
 
 
 
 
 
Step 1: The patient should rest quietly and comfortably for 5 minutes with their feet flat on the floor and 
remove the clothes from the arm to be measured.  
Step 2: Supporting the patient's arm at the level of 
the right atrium and placing the cuff on the bare 
arm. 
Step 3: Palpate the radial artery and inflate the cuff by 20-30 mmHg after the pulse disappears, then release 
the cuff pressure at a rate of 2 mmHg per second and listen for Korotkoff sounds. 
Step 2: Using the correct cuff size 
22-26 cm = Child 
27-34 cm = Adult 
35-44 cm = Large Adult 

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Figure 2. Steps followed in blood pressure measurement (Aydogdu et al., 2019; Official Gazette, 2021; American 
Heart Association, 2022).  
Blood pressure measurements were taken a total of three times (between 09:00 and 
17:00 on the day of measurement) for the control group and the intervention group, T0, T1 and 
T2. 
1.9.6. Telephone follow-up form 
This form includes 1 question to assess whether the SMSs sent by the researcher were 
read by the patient. As part of the study, confirmation phone calls were made once a week for 
the first two weeks and twice thereafter to ensure that the messages were received. No 
information was provided other than the confirmation that the SMS was received.  
1.9.7. Short message service tracking chart 
This form, prepared by the researcher using literature (Kes, 2017), includes SMS 
messages created based on KMT, the patient's name, telephone number, and information 
indicating the date and time the SMS will be sent.  
1.9.8. Measuring results 
The primary outcomes of this study were the level of compliance with antihypertensive 
drug treatment and healthy lifestyle behaviors. Secondary outcomes were changes in SBP and 
DBP levels. Primary and secondary outcomes were assessed at the first month (T₀), the end of 
the third month (T₁), and the end of the sixth month (T₂).  
Preliminary application: After obtaining permissions for the study, 8 hypertensive 
individuals (10% of the sample) who met the inclusion criteria were provided with data 
collection tools and an evaluation of the clarity of the questions; no problems were encountered. 
These 8 individuals were excluded from the sample.  
Step 4: Determining the first sound heard (Korotkoff 1) as systolic blood pressure, and the last Korotkoff 
sound as diastolic blood pressure. 
Step 5: Take two measurements 1-2 minutes apart and average the two readings. 
Step 6: Giving the patient systolic blood pressure and diastolic blood pressure values verbally and in writing 

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1.10. Data Collection 
Pre-test forms were administered to hypertensive individuals who agreed to participate 
in the study in November 2023, T1 data in March 2024, and T2 data in May 2024 at the ASM 
and were filled out by the researcher according to the hypertensive individual's self-report.  
1.11. Implementation Process of the Research 
The research consisted of the creation of nursing interventions (hypertension education 
materials (education brochure, education presentation) and SMS messages) and research 
implementation processes.  
1.11.1. Establishing nursing interventions 
Nursing interventions were based on KMT and consisted of hypertension education and 
SMS messages prepared to provide hypertensive patients with medication compliance and 
healthy lifestyle behaviors. The KMT conceptual framework was used to design nursing 
interventions. KMT is a common framework explaining the use of health-protective behaviors 
(Rogers, 1983). In order to engage in health-protective behaviors, it is desired for patients to 
develop protective motivations. According to the theory, protective motivation is formed as a 
result of patients' assessments of threats related to their current situation and coping with this 
threat (Rogers, 1983). In this context, the nursing interventions included in our study were 
prepared in line with the KMT principles of threat assessment (perceived susceptibility, 
perceived severity), coping assessment (response efficacy, self-efficacy, response costs) and 
taking action. In line with these principles, the individuals to be included in the training 
program, the topics to be included in the program, training methods and materials and SMS 
messages were determined.  
Creation of training materials  
The training consisted of a training program including a training presentation and 
training brochure prepared by the researcher according to KMT variables by scanning the 
literature (Rogers W., 1983; Aydogdu et al., 2019; World Health Organization, 2021). The 
hypertension training presentation included the topics specified in Table 1 according to KMT 
variables;  
Table 2 Hypertension training topics 
Protection Motivation Theory Variables 
Topics 
 
 
Threat Assessment 
Definition of hypertension 
Normal and high blood pressure values 
Importance of hypertension 
Unchangeable and changeable risk factors 

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Complications of hypertension 
 
 
Coping Assessment 
Being a treatable disease 
Treatment of hypertension 
Patients' belief that they can control hypertension 
Importance of compliance with antihypertensive drug treatment 
Importance of compliance with healthy lifestyle behaviors 
 
Taking Action 
Compliance with antihypertensive medication 
Performing healthy lifestyle behaviors 
 
The training presentation to be made aims to initiate threat assessment (perceived 
susceptibility, perceived severity) and coping assessment (response efficacy, self-efficacy, 
response costs) of the variables of KMT, to create protective motivation in patients and to 
ensure protective actions (medication compliance and gaining healthy lifestyle behaviors). The 
training brochure was prepared in line with the principles of theory to inform patients, to draw 
attention to the importance of the subject and to ensure that the given training is remembered 
later.  
Expert opinion was sought in the evaluation of the content validity of the educational 
material (brochure and educational presentation) and SMS messages prepared for patients with 
hypertension. The Lawshe technique was used in the process of determining the content validity 
of the developed educational material and SMS messages. The prepared educational material 
(brochure and educational presentation) was presented to expert opinion with “expert 
evaluation forms”. The expert opinions obtained in the last stage were evaluated and “content 
validity rates” and “content validity indices” were determined. Since all experts gave 2-3 
suitability points in the suitability score, the content validity index of the educational material 
(brochure and educational presentation) was determined to be “1”. When the critical values 
determined by Lawshe (1975) by considering 5 experts were taken into consideration, it was 
determined that the content validity of the developed educational material (brochure and 
educational presentation) was high since the content validity index was “1” (KGI ≥ KGO).  
Phone messages 
SMS text messages based on KMT were prepared by the researcher in line with the 
literature (Aydogdu et al., 2019; World Health Organization, 2020; Turkish Endocrinology and 
Metabolism Association, 2022; World Health Organization, 2022; Republic of Turkey Ministry 
of Health, General Directorate of Public Health, 2021, 2023). A total of 24 text messages were 
designed according to KMT variables.  
 

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Implementation of the research 
The intervention consisted of two components and lasted 14 weeks (November 2023–
March 2024). The first component was hypertension education based on KMT. The second 
component was sending regular KMT-based SMS messages aimed at reminding, encouraging 
and motivating patients to maintain medication adherence and healthy lifestyle changes.  
Applications made to the intervention group: 
1. Hypertension Education: 
• Hypertension education was organized as a training session for each participant in the 
ASM training room and was carried out face to face. 
• These trainings were carried out by the researcher. First, the researcher made a 
hypertension training presentation, then the subject was understood and reinforced with 
questions and answers. The training period lasted 30-40 minutes for each participant. 
• First, the training plan was explained, and their opinions were taken regarding the 
application day and time. In case of any unexpected situation, an attempt was made to determine 
a different day of the week with the patients for the make-up training session. 
• PowerPoint presentation and training brochures prepared within the scope of the 
research were used as training materials. 
2. Sending SMS Message:  
Participants received SMS messages prepared with expert opinions after the approval 
of the ethics committee twice a week (Tuesday-Friday) for 12 weeks to remind them of the 
topic after the last training session. 24 different SMS messages prepared according to the KMT 
variables in order to create protection motivation in hypertensive individuals were sent to the 
participants in the intervention group twice a week (Tuesday-Friday) between 09:00-17:00 for 
12 weeks after the last training session.  
Applications made to the control group: 
The control group was not subjected to any intervention by the researcher during the 
study. The control group was given an information note and brochure prepared within the scope 
of the research along with the collection of post-test data.  
1.12. Variables of the Study 
Dependent variables: Antihypertensive drug treatment compliance scale score averages, 
healthy lifestyle behaviors scale score averages, SBP and DBP values.  
Independent variables: Nursing interventions based on Protection Motivation Theory.  
 

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1.13. Limitations of the Study 
- 
The study was limited to only patients diagnosed with hypertension who were followed 
up at the 7th ASM affiliated to the Karaman Provincial Health Directorate during the 
relevant dates. 
- 
The fact that the study was conducted over a six-month period is also a limitation of our 
study. However, despite this, the group*time effect was evaluated during the analysis 
phase and as a result, it was shown that the nursing interventions created a statistically 
significant change during the six-month application period. 
- 
The researcher could not be blinded due to the nature of the study. 
- 
There was an appointment for another time to provide individual education to the 
patients in the intervention group.  
1.14. Strengths of the Research  
- 
The results of this research have shown that remote health services can be provided to 
hypertensive individuals via mobile phones, and in this respect, it has contributed to the 
literature on the use of digital health technologies. 
- 
It is thought that the research will contribute to evidence-based nursing due to the fact 
that the research was conducted in a randomized controlled manner, blind technique 
was used, and ITT analysis included effect size and confidence intervals. 
- 
The fact that the nursing interventions (SMS message and education) applied in the 
research were free, easy and simple shows that they are feasible in terms of cost. 
- 
In addition, the use of theory in the foundation of nursing interventions in this research 
is one of the strengths of the research.  
1.15. Analysis of Data  
In this study, data analyses were performed using the IBM SPSS Statistics Standard 
Concurrent User V 26 (IBM Corp., Armonk, New York, USA) program. Descriptive statistics 
were given as number of units (n), percentage (%), mean (X), standard deviation (SS), median 
(M), minimum (min) and maximum (max) values. Reliability for scales and their sub-
dimensions was examined using Cronbach's Alpha coefficient. Scales with a Cronbach's Alpha 
coefficient above 0.60 were considered reliable. Skewness and kurtosis values were examined 
to test whether the data met the assumption of normality. In the decision phase, if the absolute 
skewness (Skewness) value is below ± 2.0 and the kurtosis value is below 7.0, it is decided that 
the data is normally distributed (Kim, 2013). In the comparison of numerical descriptive 
characteristics of the patients between groups, independent sample t test was used, and in the 

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comparison of categorical descriptive characteristics between groups, chi-square tests (Pearson 
chi-square/Fisher exact test) were used. In the comparison of variables in the groups according 
to the follow-up times, mixed order analysis of variance (ANOVA) was used. Bonferroni 
correction was applied in the comparison of main effects in the analyses. The value of p<0.05 
was considered statistically significant. Intention to treat (ITT) analysis was performed in the 
evaluation of the data. Since it was not possible to reach the 7 individuals who left during the 
research process for the ITT analysis of this study, the post-tests were filled by repeating the 
answers given by the patients in the pre-tests, and the missing data were completed in this way.  
1.16. Ethical Dimension of the Research 
Before the research, ethical approval was obtained from Necmettin Erbakan University 
Health Sciences Scientific Research Ethics Committee with the decision number 404 dated 
05.04.2023 and written permission was obtained from Karaman Provincial Health Directorate. 
This research was conducted in accordance with the Helsinki Declaration Principles. Before 
filling out the questionnaire form, participants were informed about the research and their 
written and verbal consents were obtained. Necessary permissions were obtained via e-mail 
from the authors who adapted the scales into Turkish for scale use.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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RESOURCES 
Akın, B., & Koçoğlu, D. (2017). Randomized controlled trials. Hacettepe University Faculty of Nursing Journal, 
4(1), 73–92. http://hacettepehemsirelikdergisi.org/pdf/pdf_HHD_232.pdf 
Aydogdu, S., Güler, K., Bayram, F., Altun, B., Derici, Ü., et al. (2019). 2019 Turkish hypertension consensus 
report. Turk Kardiyoloji Dernegi Arsivi, 47(6), 535–546. https://doi.org/10.5543/tkda.2019.62565 
American Heart Association. (2022). Understanding bloodpressure readings. https://www.heart.org/en/health-
topics/high-blood-pressure/understanding-blood-pressure-readings 
Bahar, Z., Beşer, A., Gördes, N., Ersin, F., & Kıssal, A. (2008). Validity and reliability study of healthy lifestyle 
behaviors scale II. C.Ü. Journal of Nursing School, 12(1), 1–13. 
https://toad.halileksi.net/sites/default/files/pdf/saglikli-yasam-bicimi-davranislari-olcegi-ii-toad.pdf 
Directive 
on 
family 
medicine 
screening 
and 
follow-up 
coefficient, 
(2021). 
https://hsgm.saglik.gov.tr/depo/Mevzuat/Yonergeler/Aile_Hekimligi_Tarama_ve_Takip_Katsayisina_Ilisk
in_Yonerge.pdf 
Dağıstan Aköz, A. (2022). The effects of multimodal interventions based on integrative nursing principles on 
blood pressure, stress and treatment compliance levels in individuals with uncontrolled hypertension: a 
randomized controlled trial. (Publication No. 742796) [Doctoral Thesis, Akdeniz University]. National 
Thesis Center. 
Demirezen, E. (2006). Adherence to drug treatment in Turks using antihypertensive drugs living in Turkey and 
Germany. (Publication No. 192939) [Doctoral Thesis, Istanbul University]. National Thesis Center.  
Deniz Akan, D., Dedeli Çaydam, Ö., & Çınar Akyüz, S. (2020). Evaluation of knowledge level and adherence to 
drug treatment in patients with hypertension. Journal of Anatolia Nursing and Health Sciences, 23(2), 240–
248. https://doi.org/10.17049/ataunihem.527473 
Erci, B., Elibol, M., & Aktürk, Ü. (2018). Evaluation of correlation between adherence to the treatment of 
hypertensive patients and their quality of life. Florence Nightingale Nursing Journal, 26(2), 79–92. 
https://doi.org/10.26650/fnjn427146 
Family 
Medicine 
Contract 
and 
Payment 
Regulation, 
(2021). 
https://www.resmigazete.gov.tr/eskiler/2021/06/20210630-8.pdf 
https://www.random.org/. (n.d.). What’s this fuss about true randomness? https://www.random.org/  
Hacıhasanoğlu, Rabia Gözüm, S., & Çapık, C. (2012). Validity of the Turkish version of the short form of the 
medication adherence self-efficacy scale in hypertensive patients. Anatolian Cardiology Journal, 12, 241–
248. https://doi.org/10.5152/akd.2012.068 
Junqueira, D. R., Zorzela, L., Golder, S., Loke, Y., Gagnier, J. J., et al. (2023). CONSORT Harms 2022 statement, 
explanation, and elaboration: updated guideline for the reporting of harms in randomised trials. Bmj, 1–15. 
https://doi.org/10.1136/bmj-2022-073725 
Kim, H.-Y. (2013). Statistical notes for clinical researchers: assessing normal distribution (2) using skewness and 
kurtosis. Restorative Dentistry & Endodontics, 38(1), 52. https://doi.org/10.5395/rde.2013.38.1.52 
Kes, D. (2017). The effect of telephone monitoring on blood pressure control and medication adherence in 
individuals with primary hypertension. (Publication No. 496811) [Doctoral Thesis, Gazi University]. 
National Thesis Center  
Lawshe, C. H. (1975). A quantitative approach to content validity. Personnel Psychology, 28(4), 563–575. 
Özpancar, N. (2013). The effect of education given by nurses to patients with hypertension on adherence to 
treatment. Publication No. 344178) [Doctoral Thesis, Marmara University]. National Thesis Center. 
Republic of Turkey Ministry of Health, General Directorate of Public Health. (2021). Turkey non-communicable 
diseases and risk factors cohort study. 
Rogers RW. (1983). Cognitive and psychological processes in fear appeals and attitude change: a revised theory 
of protection motivation. Social Psychophysiol. 153–176. 
Republic of Turkey, Ministry of Health, General Directorate of Public Health. (2023a). What is physical activity? 
https://hsgm.saglik.gov.tr/tr/fiziksel-aktivite.html 
Republic of Turkey, Ministry of Health, General Directorate of Public Health. (2023b). Protection from 

17 
 
cardiovascular diseases. https://hsgm.saglik.gov.tr/tr/dokumanlar-kronikhastaliklar.html 
Republic of Turkey, Ministry of Health, General Directorate of Public Health. (2023c). How is obesity detected? 
https://hsgm.saglik.gov.tr/tr/obezite.html 
Republic of Turkey, Ministry of Health, General Directorate of Public Health. (2023d). Tobacco. 
https://hsgm.saglik.gov.tr/tr/tutun.html 
Republic of Turkey, Ministry of Health, General Directorate of Public Health. (2023e). Adequate and balanced 
nutrition. https://hsgm.saglik.gov.tr/tr/beslenen/yeterli-ve-dengeli-beslenen.htmlT.C. Sağlık Bakanlığı Halk 
Sağlığı Genel Müdürlüğü. (2023a). Fiziksel aktivite nedir? https://hsgm.saglik.gov.tr/tr/fiziksel-
aktivite.html 
Turkish Endocrinology and Metabolism Association. (2022). Hypertension diagnosis and treatment guideline 
2022. 
TUIK. 
(2022). 
Household 
information 
technologies 
(IT) 
usage 
survey, 
2022. 
https://data.tuik.gov.tr/Bulten/Index?p=Hanehalki-Bilisim-Teknolojileri-(BT)-Kullanim-Arastirmasi-2022-
45587 
Walker, S.N., & H.-P. (1996). Excerpted from: Walker, S.N., & Hill-Polerecky, D.M. (1996). Development, 1987–
1988. 
World Health Organization. (2021). Hypertension   
World Health Organization. (2020). Risk-based CVD management. https://www.who.int/news-room/fact-
sheets/detail/cardiovascular-diseases-(cvds) 
World Health Organization. (2022). Guideline for the pharmacological treatment of hypertension in adults : 
summary. 9(Cvd), 5097. 
Zahr, R. S., Anthony, C. A., Polgreen, P. M., Simmering, J. E., Goerdt, C. J., et al. (2019). A texting-based blood 
pressure 
surveillance 
intervention. 
Journal 
of 
Clinical 
Hypertension, 
21(10), 
1463–1470. 
https://doi.org/10.1111/jch.13674