Investigation of the Effect of Mobile Software Use in Blood Pressure Management of Hypertensive Individuals on Quality of Life and Disease Self-Efficacy

Hypertension (HT) is a chronic disease that is widespread in the population and can lead to serious complications. Its high prevalence in Turkey and worldwide makes prevention and management of this disease critical. HT is a systemic disease characterised by persistently high blood pressure and is an important public health problem because it causes serious complications and is widely prevalent in the community (Hacıhasanoğlu Aşılar, 2015; Obesity, Dyslipidaemia, Hypertension Working Group, 2022). It is known that more than 30% of the adult population worldwide, i.e. more than one billion people worldwide, are affected by hypertension (PAHO, 2020). In our country, according to the data of the Turkish Society of Cardiology, the prevalence of hypertension in the adult population is 31.2% (Turkish Society of Cardiology, 2022). When hypertension is not well managed, it is known to be one of the leading causes of death leading to stroke and heart attack (Turkish Society of Cardiology, 2022; Zhang et al., 2021) and one of the most important risk factors for many chronic diseases such as diabetes and renal failure (Mancia et al., 2013). In a systematic review of the economic burden of cardiovascular disease and hypertension in low- and middle-income countries, it was found that the expenditures for hypertension and cardiovascular diseases in countries vary between 500 and 1500 dollars, and in countries such as Mexico, China, Brazil and India, it constitutes half of health expenditures (Gheorghe et al., 2018). Considering its prevalence in the world and in Turkey, and the high prevalence of material and moral damage, it becomes clear how important it is to prevent and manage hypertension. In recent studies, it has been found that individuals diagnosed with hypertension have a worse quality of life compared to those who do not have this diagnosis (Xu et al., 2016), and interventions for hypertension treatment and compliance positively affect the quality of life of individuals (Arija et al., 2018; Li et al., 2018; Souza et al., 2016; Zhang et al., 2021; Silva et al., 2020; Emre et al., 2020). (2018) examined the effect of physical activity on cardiovascular health, quality of life and blood pressure and found that physical activity increased the risk of cardiovascular disease by 1.19 points, quality of life by 4.45 to 14.62 points, and reduced systolic blood pressure by 8.68 mm Hg. In the meta-analysis study conducted by Souza and colleagues, it was found that training on hypertension management increased quality of life scores by an average of 8.26 (Souza et al., 2016). It has been reported that interventions for hypertension treatment and compliance positively affect the quality of life of individuals (Arija et al., 2018; Li et al., 2018; Souza et al., 2016; Zhang et al., 2021; Silva et al., 2020; Emre et al., 2020). Recent studies have addressed different aspects of hypertension such as quality of life, diet, exercise, and economic burden. However, it was observed that technology was not integrated in the management of hypertension in these studies.

It is seen that lifestyle changes such as nutrition and exercise are effective in both prevention and management of hypertension (Hacıhasanoğlu \& Gözüm, 2011, Jones et al., 2020; Ozemek et al., 2018; Ventura \& Lavia, 2018). Although excessive sodium intake among dietary factors predisposes individuals to the development of hypertension, dietary interventions for sodium restriction are still considered a popular recommendation for lowering blood pressure (Lackland et al., 2007; Whelton et al., 2018; World Health Organization, 2012). The Dietary Approaches to Stop Hypertension (DASH) diet and the Mediterranean diet are examples of effective dietary interventions to lower blood pressure based on healthy eating strategies. The DASH diet is a dietary model that emphasises the consumption of whole grain foods, legumes, oilseeds, fish and poultry, fruits, vegetables and low-fat dairy products, while restricting the consumption of red meat, high-fat and sugary foods and beverages. On the other hand, in this diet model, it was emphasised that the daily sodium intake of hypertensive individuals should be below 1500 mg (3.75 g salt) in order to reduce blood pressure (Filippou et al., 2020). In addition, it is seen that the content of the DASH diet is consistent with the nutritional recommendations of the World Health Organization, the American Heart Association and the Turkish Society of Hypertension and Kidney Diseases, which are effective in lowering blood pressure (). In the meta-analysis study conducted by Schwingshackl et al. (2019), it was revealed that the DASH diet reduced systolic blood pressure by 90% and diastolic blood pressure by 91%. In addition to reducing sodium intake, healthy dietary patterns with high potassium, calcium, magnesium and fibre content and low trans/saturated/total fat and dietary cholesterol content can also be considered as beneficial components of blood pressure. Indeed, recent findings have shown that the combination of low sodium and a healthy diet can lower blood pressure by approximately 50% more than low sodium intake alone (Filippou et al., 2022). In the literature, there are studies revealing that exercise has an effect on hypertension as well as dietary practices. It is seen that these exercises mostly consist of aerobic, resistance and combined exercise applications (Lopes et al., 2018, Pescatello, 2019). Regular aerobic exercise has been found to help reduce systolic and diastolic blood pressure by 8.3 and 5.2 mm Hg, respectively (Cornelissen \& Smart, 2013). Aerobic exercise has also been found to have positive effects on pulse wave velocity, which is used as the gold standard in determining arterial stiffness (Zhang et al., 2018). In addition, it is seen that the content of the DASH diet is consistent with the nutritional recommendations of the World Health Organization, the American Heart Association and the Turkish Society of Hypertension and Kidney Diseases, which are effective in lowering blood pressure (). In the meta-analysis study conducted by Schwingshackl et al. (2019), it was revealed that the DASH diet reduced systolic blood pressure by 90% and diastolic blood pressure by 91%. In addition to reducing sodium intake, healthy dietary patterns with high potassium, calcium, magnesium and fibre content and low trans/saturated/total fat and dietary cholesterol content can also be considered as beneficial components of blood pressure. Indeed, recent findings have shown that the combination of low sodium and a healthy diet can lower blood pressure by approximately 50% more than low sodium intake alone (Filippou et al., 2022). In the literature, there are studies revealing that exercise has an effect on hypertension as well as dietary practices. It is seen that these exercises mostly consist of aerobic, resistance and combined exercise applications (Lopes et al., 2018, Pescatello, 2019). Regular aerobic exercise has been found to help reduce systolic and diastolic blood pressure by 8.3 and 5.2 mm Hg, respectively (Cornelissen \& Smart, 2013). Aerobic exercise has also been found to have positive effects on pulse wave velocity, which is used as the gold standard in determining arterial stiffness (Zhang et al., 2018). Dynamic resistance exercises are also frequently performed in hypertensive individuals. The rationale for this is that during dynamic RE, blood flow is restricted during the contraction phase, but increases during the relaxation phase, resulting in more O2 delivery and oxidative metabolism (Williams et al., 2018). It is stated that there are positive effects on systolic and diastolic blood pressure after the application of resistance exercises with resistance tyres (Henkin et al., 2023). The use of resistance bands offers the opportunity for extremely safe and objective exercise practice. The intensity of the exercise can be determined by determining the degree of difficulty perceived by the practitioner. Therapeutic effect can be seen in hypertensive individuals with resistance exercises to be applied to major muscle groups. It has been stated that diaphragmatic breathing technique inhibits sympathetic nerve activities and chemoreflex activation by activating pulmonary-cardiac mechanoreceptors and thus helps arteriolar dilatation (Wang et al., 2010; Yau \& Loke, 2021). As a result of increased parasympathetic activity and baroreflex sensitivity, a decrease in systolic and diastolic blood pressure is observed in hypertensive adults (Mourya et al., 2009). Voluntary diaphragmatic deep breathing is known to have a relaxing effect and reduce anxiety in hypertensive or prehypertensive individuals other than systolic and diastolic blood pressures (Chen et al., 2017).In the planned project, exercises, which are thought to be effective in disease management, will be created in line with the preferences of the individual and the recommendations of the physiotherapist (age, gender, BMI, etc.) and a notification will be sent when the exercise programme is created. In this way, the body mass index will remain within normal limits as the individual exercises regularly and disease management will be ensured.

In the management of hypertension, treatment compliance is also an important factor that ensures blood pressure control. As a matter of fact, the rate of blood pressure control in the world and in our country is around 25%, and the most important factor in this is non-compliance with treatment (Akan, Çaydam \& Paköz, 2020). In a study conducted in our country, it was reported that 36.3% of patients complied with hypertension treatment (Akan, Çaydam \& Paköz, 2020). Some of the factors that negatively affect treatment compliance are that the time allocated by the physician to the patient is not sufficient in public hospitals where the patient density is too high, and the physician-patient communication is not at the desired level, especially for individuals with chronic diseases such as diabetes, hypertension, and heart diseases (Atıcı, 2007). Significant problems that threaten patient safety may arise from lack of communication between the patient and the physician. When these patients are informed and included in the decision-making process, they are more careful about behavioural changes (such as adherence to treatment, diet, exercise). Factors such as not informing the patient about the diet to be applied during the discharge process, not explaining how to use the prescribed prescription, the physician not allocating time for informing the patient or not having time for informing the patient, and not having a suitable environment for informing in the ward negatively affect treatment compliance (Bol, Gül \& Arbaycu, 2013).