|Year : 2021 | Volume
| Issue : 4 | Page : 280-286
Children as adherence enhancing agents in management of primary hypertension of adult family members
Sandra Roshni Monteiro, Meena Hariharan
Centre for Health Psychology, University of Hyderabad, Hyderabad, Telangana, India
|Date of Submission||19-Nov-2020|
|Date of Decision||05-Apr-2021|
|Date of Acceptance||24-May-2021|
|Date of Web Publication||17-Nov-2021|
Dr. Sandra Roshni Monteiro
Senior Research Fellow (Indian Council of Medical Research), Centre for Health Psychology, University of Hyderabad, Hyderabad, Telangana
Source of Support: None, Conflict of Interest: None
BACKGROUND: Self-management of hypertension requires timely medication, prescribed diet, consistent exercise, and daily monitoring of health parameters to avoid its fatal consequences. Compliance is often difficult without family support, and this study aims to explore the agency of children in the mitigation of the disease.
OBJECTIVES: To examine the effectiveness of children in their family member's hypertension management, an antihypertensive educational module was provided to them.
METHODS: A sample of 43 children between 11 and 14 years of age, who had each identified a hypertensive family member, was provided with holistic information about hypertension through a video, information booklet, and interactive discussions reinforced at three intermissions over a span of 6 weeks. Children and adults were assessed for hypertension knowledge before and following intervention. Change in hypertension compliance and blood pressure (BP) was observed for the adults.
RESULTS: The results showed that children had a significant improvement in overall hypertension knowledge test including its domains. The monitoring records reported to highlight the efforts put by the children during the course of the study. Assuming its intended effects, a significant reduction in the systolic and diastolic BP reading was observed with an overall improvement in compliance. Interestingly, the knowledge status in adult participants had not increased.
CONCLUSION: The results have been discussed which highlight the role of children in influencing “their patients.” It unlocks a gateway of research involving children, especially in primary and tertiary approaches to secure chronic disease prevention and management.
Keywords: Children's agency, hypertension management, primary prevention, tertiary management
|How to cite this article:|
Monteiro SR, Hariharan M. Children as adherence enhancing agents in management of primary hypertension of adult family members. Int J Health Allied Sci 2021;10:280-6
|How to cite this URL:|
Monteiro SR, Hariharan M. Children as adherence enhancing agents in management of primary hypertension of adult family members. Int J Health Allied Sci [serial online] 2021 [cited 2022 Jan 25];10:280-6. Available from: https://www.ijhas.in/text.asp?2021/10/4/280/330551
| Introduction|| |
Late childhood normally facilitates an intellectual boom and sophisticated cognitive comprehension of health concepts.,, Extending the functionality of children in monitoring adult health is a relatively unexplored area owing to associated popular negative stereotypes. Contrarily, studies have put forth a scientific proposition which propounds reliability of children who when equipped with an accurate knowledge base are stimulated to employ their creative wisdom to achieve goals. It is to emphasize that, in actuality, children tend to be less prejudiced, especially by fatalistic beliefs. Furthermore, evidence suggests that children when equipped with optimal knowledge can have considerable impact on their peers, their parents, and others adults. Intergenerational transfers of knowledge in cases of overall health and hygiene have been reported to improve knowledge and health protective activity in their home environment,,, such as increased physical activity, reduced salt intake, compliance to dietary patterns, and other daily healthy habits. Interventions related to cardiovascular prevention and antihypertensive lifestyle modification have advocated that children not only helped to improve the cardiovascular status of their parents but also avoided their own vulnerabilities of health.,, These studies provide valuable insight to the proposal that, if children possess the right information, they can be the much-needed warriors to fight the consequence of several chronic illnesses which require consistent and indulgent self-care.
This study centers on the case of hypertension or high blood pressure (BP) described as a persistent elevated force of the blood against the walls of the blood vessels in a body. It is recorded as systolic BP – which measures the pressure when the heart is in action, and diastolic pressure – when the heart rests. Broadly, it is categorized as primary hypertension (or essential hypertension) and secondary hypertension. Despite hypertension being the leading cause of death in India, its poor management is highly prevalent even if the patient is aware of his/her diagnosis. This information is important because hypertension is a manageable disease and a 2 mmHg population-wide decrease in hypertensive status can prevent up to 151,000 stroke and 153,000 coronary heart disease deaths in India.,
The fact of the matter encourages the use of a sustainable and cost-effective novel to counter the treatable epidemic. A pressure for adherence behavior and an effective management of any chronic illness has been known to ideally involve the participation of the patient and the family. Adjunct within this concept, children constitute a very important segment of the family and their alacrity, alertness, and their perseverance in achieving their goals cannot be underestimated. It is understandable that any voluntary change in health behavior or lifestyle requires strong conviction and a strong cognitive base and utilizing their unique tenacity in influencing family members and ensuring compliance for better management of hypertension., Previous studies have also emphasized the integral role of “perceived ability of supportive functions” and its relationship to lower probability of health risk behavior.,,, The innovative idea originating from this evolved into verifiable research intent to assess if this can be used tactfully yielding important health outcomes.
This study attempted to find the agency of children in hypertension management of their adult family member through three implicated research questions:
- Will a knowledge intervention increase the hypertension knowledge among children?
- Will the knowledge intervention provided to children reflect in enhancement of hypertension knowledge in the hypertensive adult family members?
- Will knowledge intervention and entrusting of caregiver responsibility to children result in improvement in clinical adherence and BP (in terms of lowered BP readings) among the hypertensive adult family members?
In pursue of the research questions, the following objectives of the study were formulated:
- To examine if knowledge intervention creates a cognitive base with respect to hypertension knowledge among children and hypertensive adult family members
- To assess the agency of children in lifestyle monitoring of hypertensive adult family members to gauge change in hypertension management and prognosis, if any.
| Methods|| |
A quasi-experimental interrupted time series design as advocated by Biglan, Ary, and Wagenaar (2000) has been adopted as a framework for this study.
Four schools were selected to be included in the sample. The study was conducted with 43 pairs of students and their adult hypertensive family members. They were recruited using purposive sampling. The children (13 boys and 30 girls) were from Classes 6, 7, and 8 with their age ranging between 11 years and 14 years. Their adult hypertensive counterparts comprised fathers, mothers, grandfathers, grandmothers, and aunts. Their age range was between 28 years and 75 years (mean = 48.02; standard deviation [SD] = 5.91). Among adult participants, 12 of them were literate, whereas 31 of them were illiterate. The mean duration of their diagnosed hypertension condition was 6.67 years (SD = 5.91).
Hypertension knowledge test (HKT) is a 22-item knowledge test with five multiple choice options with only one correct answer. The items cover four dimensions – general awareness of hypertension, lifestyle factors, causes care and casualty of hypertension, and medical management. The total score is calculated as a sum of the scores of each of the subscales. Higher scores indicate higher levels of hypertension knowledge. Cronbach's α for the test was found to be 0.79.
Hypertension compliance scale (HyComps). HyComps is a 15-item scale provided with five alternatives depending on frequency of behavior and is used for assessing compliance to diet, exercise, lifestyle, and self-monitoring aspects of clinical adherence – four dimensions of hypertension management. Higher the score indicates better the adherence. For this test, Cronbach's α found was 0.73.
A digital sphygmomanometer was used to measure the BP of the hypertensive unit of the sample. The recorded BP was calculated as an average of three readings taken over a brief duration of time (about 30 min). Preintervention recording was done in the recruitment session, and a second set of data was recorded in the postintervention testing session.
The study was approved by the Institutional Ethics Committee. Administrative permission was obtained from schools for conducting the study. The school assigned one teacher to help the investigator with the students. A letter was sent to the parents of all the children along with patient pro forma which noted details of the family members with hypertension, its duration, and their relationship with the child. Informed consent forms were sent to the parents of those children from Classes 6 to 8 where an adult member was diagnosed with primary hypertension. The children whose parents signed the informed consent were given the assent form to confirm their willingness to participate in the study. Children for whom we had both informed consent and assent were included in the study. The baseline data were collected from the children and adult participants having hypertension.
Parameters recorded for patients with hypertension
The adult participants had their BP recorded, and they were administered the HKT and HyComps to measure their knowledge about hypertension and their level of adherence to its treatment.
Intervention for the children
The children were given knowledge intervention in the form of a 30 min video show which consisted of a physician explaining all the aspects of hypertension, prevalence of the disease; detailed explanation of the disease mechanism affecting the human anatomy – causes and casualty; the recommended medical management; common myths and mistakes associated with the treatment process; diet and exercise requirements; and consequences of nonadherence. The informational video was exposed to the children on day 1, day 7, and day 21 from the onset of the study. The reason for repeated exposure followed by discussions was to create a strong cognitive base in children about “primary hypertension.” After every exposure, a discussion was held about the significance of managing hypertension, the importance of following the prescribed diet and exercise regimen as a part of the treatment process, the possible adversities of nonadherence, and the benefits of adherence. The sessions were managed by a trained health psychologist specializing in the area of behavioral cardiology who was also able to placate any health anxiety stemming from the exposure to the video and also positively invoke the children of their rights and responsibilities to good health and positive lifestyle modification.
Orientation on the role of children to monitor the adult hypertensive in the family
Children were trained to partake in an activity to monitor their adult hypertensive family member to responsibly take care of them as “their patient.” Taking care meant ensuring that the patient took the medication in time, did not deviate from the low fat low salt diet, and did carry out the physical exercise as advised by the doctor. Their “patient care” was documented on a daily basis on a booklet they were provided with which had demarcations of date, medicine, diet, and exercise. The provision on each page was for a period of 1 week. Under each of the labels, children were instructed to check upon “their patient” daily to make sure if they had taken their medicine on time, complied with the prescribed diet, and exercised as prescribed. They were instructed to record the daily observations as “Yes,” “No,” or “Don't Know.” In case they forgot to monitor them for the day, they were instructed to write “Forgot or forgot to Record” under the date. At the end of each week, the week's recording was collected from them. Children were asked to maintain this record for a period of 6 weeks.
The relevant statistics applied to the data were descriptive statistics such as mean, SD, and percentage and inferential statistics – paired t-test.
| Results|| |
The obtained quantitative data were analyzed by means of descriptive statistics and t-test using computer software SPSS version 21 (IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp). All assumptions required to carry out t-test analyses were confirmed. The results are presented in three implicated steps. First, a postintervention change was examined in children by comparing their pretest and posttest scores in hypertension knowledge and its subscales, as shown in [Table 1]. Second, differences in hypertension knowledge and its subscales, adherence, and BP were examined in the adult hypertensive participants, as shown in [Table 2]. Third, the children's accountability of daily monitoring efforts was analyzed portrayed in [Figure 1].
|Table 1: Mean, standard deviation and t-values of hypertension knowledge and its subscales among children participants|
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|Table 2: Mean, standard deviation and t-values of hypertension knowledge and its subscales, hypertension compliance, and its subscales and of systolic and diastolic blood pressure, among adult hypertensive participants|
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|Figure 1: Percentage of monitoring efforts (medicine, exercise, and diet) in terms of “Yes,” “No,” and “Don't Know” for high blood pressure management by the child|
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The results in [Table 1] are of t-test analysis conducted on hypertension knowledge scores of children before and after intervention. Findings indicated a significant knowledge enhancement in hypertension across all dimensions of HKT. The mean increase in total hypertension knowledge and its subscales is observed under mean along with a 95% confidence interval (CI) range as mentioned under lower and upper 95% CI. The Eta-squared value shows a large effect size for the total score and all dimensions except for the dimension of causes, care, and casualty awareness which showed a medium effect size.
[Table 2] shows the results of t-test for the measures conducted on the hypertensive family members of the children, i.e., for hypertension knowledge and its domains, hypertension compliance and its domains, and systolic and diastolic readings of BP. Inferred from the table, for hypertension knowledge, there is no significant difference observed in the adult participants. For hypertension compliance, there is a significant difference in the overall adherence but not for any particular domain. Importantly, it is seen that there is a significant change in the systolic and diastolic BP in the adult hypertensive participants. The range of overall adherence with a 95% CI is mentioned under lower and upper 95% CI.
Third, analysis was carried out to examine the effectiveness of children's monitoring of the compliance of adult family member with hypertension condition. Children's weekly diary responses were taken into consideration to evaluate this aspect. The records were collated for each of the basic and essential facets of hypertension management parameters, i.e., compliance to antihypertensive medicine, prescribed diet, and prescribed exercise. Successful monitoring was calculated in terms of percentage for each of the lifestyle parameter illustrated in [Figure 1]. “Yes” signifies the percentage of times the child reminded the paired adult and was able to support adherence; “No” indicates the number of times the child had reminded but the adult did not comply; and “Forgot/Don't Know” indicates the absence of monitoring. The graph in the figure tells us that children were successful in monitoring 84.44%, 79.62%, and 76.30% for antihypertensive medication compliance, exercise, and diet, respectively. They failed to monitor and record the outcome for compliance to medication, exercise, and diet 2.33%, 2.55%, and 2.55%, respectively.
| Discussion|| |
This study aimed to investigate whether children can be agents of change in hypertension management for their hypertensive adult family members. The trajectory for becoming change agents is to first equip oneself with required knowledge which helps in building the conviction and then acting upon the required change consistently to increase compliance. While children were found to have an increase in hypertension knowledge, the same was insufficient in the adult group. However, significant difference in compliance rates and BP readings of the hypertensive adults suggests the underlying influence of children in prompting the change.
Based on the results obtained, it would be appropriate to highlight the importance of the knowledge intervention provided to the children which has been indirectly dissipated in the form of good practice of hypertension control. Previous studies done on a similar age group of children have established that school children's concept of hypertension is vague, and a number of misconceptions have been found among high school children. In a study by Hariharan et al., the concept of high BP was assessed in middle and high school children between Classes 6 and 12. Only 40% of students were able to mention the causes, <10% indicated the consequences, and only about 11% hinted at the importance of management of hypertension. Thus, to strengthen the cognitive base about hypertension before assigning the children, the role of monitors of adherence in adult hypertensive family members and knowledge intervention was provided with three repeated exposures. The significant improvement in knowledge enhancement of the children indicates that the intervention was successful in providing a sound cognitive base related to hypertension.
The second objective of the study may be deemed fulfilled as the adult family member diagnosed with hypertension was found to have increased antihypertension compliance and decreased BP. These were considered the parameters to measure the success of children's monitoring of the adult hypertension compliance. It is through the adjunct activity children were majorly successful in their responsibility of being effective reminders and insisted toward antihypertensive therapy. An improvement in adherence is what constitutes effective disease management that leads to better prognosis. It may be argued that confounding factors may have played a role in the improved health state, although it is imperative to acknowledge the efforts of daily monitoring which would invariably build the interest of the adult in meeting their health goals.
The nonsignificant change in hypertension knowledge is of equal importance as dissipation of information by children is insinuated without having concrete evidence. This does not imply the failure of the agentic role of the child as principally the aim was to induce better compliance and not the transference of knowledge. The valuable necessitation can be summarized categorically. First, the instructions from the investigator were specific to “care giving” and monitoring the compliance of “their patients” and specifically did not include disseminating knowledge to “their patients.” Second, children might not have felt competent enough to transfer this medical knowledge to their adult family members. Finally, even if the children attempted, 72% of adult participants were illiterate and therefore may not have absorbed the information with scientific perspective. Limited literacy has been known to be one of the most significant predictors of poor hypertension knowledge and control. Reduction in BP and holistic change in adherence may suggest the persuasion skills of children in making small daily changes in the adult's lifestyle without influencing the knowledge levels. A meta-analyses study by DiMatteo established that practical support provided in cohesive families bears the highest association with patient adherence. Another experimental finding evaluated the role of family health education to build social support for long-term management of high BP and through main effects analysis proved that family member support intervention accounted for greatest decrease in diastolic BP variablility.
The findings when collaborated suggest that, with a holistic knowledge intervention, children may be assigned the responsibility to enhance clinical adherence in adults with hypertension, and they would be able to bring in the desirable change in the adherence behavior of adults, leading to better management of the disease even without knowledge enhancement in the adults. It is advocated that the adults need social support in the form of reminders, insistence, and close monitoring for optimizing adherence behavior. The fact that relationships help to bring about motivated changes in the health behavior in the absence of a cognitive base is supported by a number of theories such as relationship motivation theory, organismic integration theory, and Bandura's agentic perspective in social cognitive theory. Furthermore, in a randomized clinical trial, it was found that active participation from family members through home BP monitoring had better compliance rate (17% more) than simply periodic home visits by medical professionals such as nurses and pharmacists. This finding must be read in the light of the effectual contributions of active family support for sustenance of long-term compliance in the management of high BP. This management strategy is also admittedly more feasible and cost effective. Family support refers to support from any family member. It is possible that the adults in the family are quite preoccupied with their life, whereas children are found to be very perseverant, sincere, and steadfast in carrying out the responsibility entrusted on them. This can be positively exploited for any chronic illness management in adult family members.
| Conclusion|| |
First, the active involvement of children highlights a cost-effective measure of using an inherent built-in family system to manage hypertension and thereby prevent severe adversities due to nonadherence. Second, by creating a strong cognitive base in children at the right critical age, the nation will be building the future youth who would likely be vigilant in their lifestyle practices to avoid an onset of chronic illness. This perhaps is the right method of meeting the challenges of high projected rates of hypertension prevalence because they are in fact the warnings to nations to come up with proactive measures such as this to resist the hike in incidence.
We sincerely thank to all the school heads and teachers in their help to conduct the study. Gratitude extended to all the participants of the study for their timely response.
Financial support and sponsorship
This study was financially supported by Indian Council of Medical Research (Reference No. 3/1/3/JRF-2018/HRD [SS]).
Conflicts of interest
There are no conflicts of interest.
| References|| |
Natapoff JN. A developmental analysis of children's ideas of health. Health Educ Q 1982;9:130-41.
Williams JM, Binnie LM. Children's concepts of illness: An intervention to improve knowledge. Br J Health Psychol 2002;7:129-47.
Reeve S, Bell P. Children's self-documentation and understanding of the concepts 'healthy' and 'unhealthy'. Int J Sci Educ 2009;31:1953-74.
Iyengar S, Jackman S. Technology and Politics: Incentives for Youth Participation. Center for Information and Research on Civic Learning and Engagement, University of Maryland: CIRCLE; 2004.
Molloy D, White C, Hosfield N, Great Britain, Office of the Deputy Prime Minister (United Kingdom). Youth Participation in Local Government: A Qualitative Study. London (United Kingdom): Office of the Deputy Prime Minister; 2002.
Pilgrim NK. Landslides, risk and decision-making in Kinnaur District: Bridging the gap between science and public opinion. Disasters 1999;23:45-65.
Sonavane R, Deepthi R, Rodrigues R, Chikkaraju KR. Children as change agents in creating peer awareness for ear health. Al Ameen J Med Sci 2012;5:376-80.
Gibbs S, Mann G, Mathers N. (2002). Child-to-child: A practical guide. Empowering children as active citizens [Internet]. Retrived on: November 19, 2019.
Onyango-Ouma W, Aagaard-Hansen J, Jensen BB. The potential of schoolchildren as health change agents in rural western Kenya. Soc Sci Med 2005;61:1711-22.
Damerell P, Howe C, Milner-Gulland EJ. Child-orientated environmental education influences adult knowledge and household behaviour. Environ Res Lett 2013;8:015016.
Vaughan C, Gack J, Solorazano H, Ray R. The effect of environmental education on school children, their parents, and community members: A study of intergenerational and intercommunity learning. J Environ Educ 2003;34:12-21.
Rhodes RE, Lim C. Promoting parent and child physical activity together: Elicitation of potential intervention targets and preferences. Health Educ Behav 2018;45:112-23.
Gunawardena N, Kurotani K, Indrawansa S, Nonaka D, Mizoue T, Samarasinghe D. School-based intervention to enable school children to act as change agents on weight, physical activity and diet of their mothers: A cluster randomized controlled trial. Int J Behav Nutr Phys Act 2016;13:45.
Yuasa M, Shirayama Y, Kigawa M, Chaturanga I, Mizoue T, Kobayashi H. A Health Promoting Schools (HPS) program among primary and secondary school children in Southern Province, Sri Lanka: A qualitative study on the program's effects on the school children, parents, and teachers. Kokusai Hoken Iryo, J Int Health) 2015;30:93-101.
Ray M, Guha S, Ray M, Kundu A, Ray B, Kundu K, et al.
Cardiovascular health awareness and the effect of an educational intervention on school-aged children in a rural district of India. Indian Heart J 2016;68:43-7.
Schwandt P, Geiss HC, Ritter MM, Ublacker C, Parhofer KG, Otto C, et al.
The prevention education program (PEP). A prospective study of the efficacy of family-oriented life style modification in the reduction of cardiovascular risk and disease: Design and baseline data. J Clin Epidemiol 1999;52:791-800.
Fornari LS, Giuliano I, Azevedo F, Pastana A, Vieira C, Caramelli B. Children first study: How an educational program in cardiovascular prevention at school can improve parents' cardiovascular risk. Eur J Prev Cardiol 2013;20:301-9.
Zneid BA, Al-Zidi M, Al-Kharazi T. Non-invasive blood pressure remote monitoring instrument based microcontroller. In: 2014 IEEE REGION 10 SYMPOSIUM. IEEE: Kuala Lumpur, Malaysia; 2014. p. 248-53.
Wahl L, Tubbs RS. A review of the clinical anatomy of hypertension. Clin Anat 2019;32:678-81.
Prabhakaran D, Jeemon P, Roy A. Cardiovascular diseases in India: Current epidemiology and future directions. Circulation 2016;133:1605-20.
Yi-Bing W, De-Gui K, Long-Le M, Le-Xin W. Patient related factors for optimal blood pressure control in patients with hypertension. Afr Health Sci 2013;13:579-83.
Gupta R. Trends in hypertension epidemiology in India. J Hum Hypertens 2004;18:73-8.
Rodgers A, Lawes C, MacMahon S. Reducing the global burden of blood pressure-related cardiovascular disease. J Hypertens Suppl 2000;18:S3-6.
Johnson J, Vijayakumar K, Nujum ZT, Thankamoniamma PM. Compliance and its determinants to pharmacologic management of hypertension. Indian J Community 2019; 31:63-72.
Hariharan M, Andrew A, Kallevarapu V, Rao CR, Chivukula U. Conceptualizing hypertension: A developmental trend in school children. Int J Health Allied Sci 2018;7:177. [Full text]
Anderman EM, Austin CC, Johnson DM. The development of goal orientation. In: Wigfield A, Eccles JS, editors. A Volume in the Educational Psychology Series. Development of Achievement Motivation. The University of Kentucky, Lexington, Kentucky: Academic Press; 2002. p. 197-220.
Monteiro SR, Hariharan M. Family support in effective management of hypertension: Role of children as passive change agents. Int J Health Sci 2019;9:363-77.
Alderson P. Young Children's rights: Exploring Beliefs. United Kingdom: Jessica Kingsley Publishers; 2008.
Wills TA, Ainette MC. Social networks and social support. In: Baum A, Revenson TA, Singer J, editors. Handbook of Health Psychology. United Kingdom: Psychology Press; 1987. p. 465-92.
Cohen S, Wills TA. Stress, social support, and the buffering hypothesis. Psychol Bull 1985;98:310-57.
Sandler IN, Miller P, Short J, Wolchik SA. Social support as a protective factor for children in stress. In: Belle D, editor. Children's Social Networks and Social Supports. United Kingdom: Wiley InterScience Publications; 1989. p. 277-307.
Seeman TE. Social ties and health: The benefits of social integration. Ann Epidemiol 1996;6:442-51.
Andrew A, Hariharan M. Hypertension knowledge test: Development and validation. Int J Indian Psychol 2017;5:44-55.
Swain S, Hariharan M, Rana S, Chivukula U, Thomas M. Doctor-patient communication: Impact on adherence and prognosis among patients with primary hypertension. Psychol Stud 2015;60:25-32.
Pandit AU, Tang JW, Bailey SC, Davis TC, Bocchini MV, Persell SD, et al.
Education, literacy, and health: Mediating effects on hypertension knowledge and control. Patient Educ Couns 2009;75:381-5.
DiMatteo MR. Social support and patient adherence to medical treatment: A meta-analysis. Health Psychol 2004;23:207-18.
Morisky DE, DeMuth NM, Field-Fass M, Green LW, Levine DM. Evaluation of family health education to build social support for long-term control of high blood pressure. Health Educ Q 1985;12:35-50.
Deci EL, Ryan RM. Autonomy and need satisfaction in close relationships: Relationships motivation theory. In: Weinstein N, editor. Human Motivation and Interpersonal Relationships. Dordrecht: Springer; 2014. p. 53-73.
Bandura A. Social cognitive theory: An agentic perspective. Annu Rev Psychol 2001;52:1-26.
Earp JA, Ory MG, Strogatz DS. The effects of family involvement and practitioner home visits on the control of hypertension. Am J Public Health 1982;72:1146-54.
[Table 1], [Table 2]