Health literacy, social support, and health education, as factors associating with self-management behaviors among elderly patients with hypertension in China: a structural equation model

Health literacy, social support, and health education, as factors associating with self-management behaviors among elderly patients with hypertension in China: a structural equation model | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Health literacy, social support, and health education, as factors associating with self-management behaviors among elderly patients with hypertension in China: a structural equation model Ziyan Chen, Meijun Chen, Litong Gong, Yu Tian, Chun Chang, Wangnan Cao This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4568125/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Hypertension is one of the world’s leading risk factors for death and disability. With a higher prevalence of hypertension, older adults need to strengthen self-management behaviors. The synergistic effects on self-management behaviors and the potential underlying mechanisms between self-management behaviors, health education, health literacy, and social support remain unclear. Methods A cross-sectional design and stratified multi-stage random sampling method were used to investigate hypertensive patients aged 60 years and older in six provinces from the eastern, central, and western regions of China. We collected data using questionnaires, and examined interactions among the factors using a structural equation model. Results 1140 participants were included in this study. The SEM had a good overall fit. Health literacy, social support, and health education had a direct positive relationship with self-management behaviors (β = 0.157, β = 0.187, β = 0.158, P < 0.001). Social support had an indirectly positive relationship with self-management behaviors through health education and health literacy. Health education had an indirectly positive relationship with self-management behaviors through health literacy. Conclusions The situation of adopting self-management behaviors among elderly patients with hypertension is uneven in this study. Social support, health education, and health literacy all have direct or indirect impacts on self-management behaviors. Hypertension Health literacy Social support self-management behaviors Structural equation model Socia l ecological model Figures Figure 1 1 Background As one of the world’s leading risk factors for death and disability, hypertension was mentioned as the silent killer by the latest report of the World Health Organization (WHO) published in 2023 for it is responsible for more than 10 million deaths every year —— more deaths than from any other risk to health. Prevalence of hypertension is 32% of adults aged 30–79 years in high-income countries and 34% in low-income countries, and for people aged 50–79 years, both men and women globally are estimated to have equivalent hypertension prevalence of 49% 1 . Besides the extremely high prevalence, high blood pressure can also lead to many serious complications. In China, Hypertension has also become one of the major public health concerns. A recent survey showed that the prevalence of hypertension is 27.5% in China, with a continuous upward trend in hypertension rates from 1958–2018 2 . A large cohort study in China from 2004 to 2014 showed that the prevalence of hypertension among Chinese 60–69 and 70–79 years old was 50.7% and 58.4%, associated with significant excess mortality 3 . As a group with a higher prevalence of hypertension, more serious disability and death rates, and more common complications, older adults need to strengthen self-management to reduce mortality and disability. According to WHO’s report, self-care may include making lifestyle changes, such as adopting a healthy diet and engaging in regular physical activity, as well as ensuring proper medication adherence and monitoring blood pressure, which will be essential in the care of nearly all patients diagnosed with hypertension, especially older adults 4 – 7 . Regular home blood pressure monitoring could achieve better blood pressure control 8 and has been recommended by several international guidelines, most of which guidelines recommend 1–2 weekly intervals for long-term continuous assessment in patients with controlled blood pressure 9 . Clinical practice guidelines for managing hypertension in China also recommend self-monitoring of blood pressure at intervals of at least 2 times per week 10 . A cross-sectional study showed only 27.5% of hypertensive patients engaged in home blood pressure monitoring weekly or more frequently 11 . Poor medication adherence severely compromises patient outcomes and increases patient mortality, but the incidence of nonadherence remains high 12 . China's National Basic Public Health Services recommends that hypertensive patients undergo physical examination once a year, and free medical services are provided for older adults over 65 years of age, but only 40.6%-61.0% of the population over 55 years of age in China undergo regular annual physical examination 13 . Given the current status of low incidence of self-management behaviors, it is all the more important to focus our efforts on how to better promote self-management behaviors among older adults. The ecological model for health promotion was derived from the Social Ecological Model 14 , it emphasizes that individual behavior is influenced by multiple levels: intrapersonal, interpersonal, and public policy factors 15 . Health literacy, as an intrapersonal factor, established the base for adopting self-management behaviors. And it has been proved health education (HE) is an effective method to improve health knowledge and health literacy (HL) 16 , which in turn promotes the adoption of self-management behaviors. Interpersonal factors refer to formal and informal social networks, like family and friendship networks. Social support (SS), which has been defined as an exchange of resources between at least two individuals perceived by the provider or recipient to be intended to enhance the well-being of the recipient' 17 , has been proven to motivate people to adopt more self-management behaviors 18 19 , so we used social support as representation of interpersonal factors in this study. There are also studies on the effect of social support on health education utilization and health literacy 20 – 22 , and those with stronger social ties will better utilize their health education and also have better levels of health literacy. As for public policy factors, in China, the National Basic Public Health Services (NBPHS) was first issued in 2009, as an essential public health service provided freely for universal population in China by the Chinese Government 23 , in which health education and health literacy promotion action were defined as the two independent services. Health education of NBPHS provides five public health services, including holding health knowledge lectures, providing health education materials, setting up a health education bulletin board, carrying out public health consultations, and providing individualized health education 24 , all of which aim at promoting health literacy, thus promoting healthy behaviors. Based on the above-mentioned existing literature, health education (HE), health literacy (HL), social support (SS) and self-management behaviors are related and have complex relationships. However, most of the existing literature only focused on the relationship between two factors, without considering the synergistic effects on self-management behaviors at multiple factors and levels and the potential underlying mechanisms. Therefore, the purpose of this study is to construct a structural equation model (SEM) to explore between self-management behaviors, health education, health literacy and social support and clarify the direct and indirect effect of factors affecting self-management behaviors, which can provide a theoretical basis and intervention ideas for us to better improve the self-management behaviors of elderly patients with hypertension. 2 Methods 2.1 Participants and method of selection This study was based on a program in which urban and rural older adults aged 60 years and older were recruited for collecting their core health literacy from May to October 2020 in six provinces of China, each two of which were from the eastern, central, and western regions of China, with two cities in each province. As a cross-sectional survey study, this study adopted a stratified multi-stage random sampling method, firstly, two provinces in the eastern, central and western regions of China were randomly selected, the capital city of each province was selected, and one city with GDP in the last third of the province was also randomly selected; 10 communities and administrative villages were selected from each city to carry out the survey. Inclusion criteria included the following: (i) age of 60 years or older, (ii) willingness to participate voluntarily in the survey. Exclusions were individuals who were (i) mentally impaired, or (ii) refused to sign the information agreement. By this criteria, the program included a total of 3025 participants, from which we selected participants with a self-reported history of hypertension which was confirmed by a certified doctor from a professional organization, and excluded those with missing data on key variables, such as health literacy, social support, health education, and self-management behaviors, and 1140 participants were finally included. 2.2 Data collection and quality control methods The questionnaire survey method was used for data collection. Investigators who were postgraduates and health education professionals from the project province were uniformly trained, and the participants who met the inclusion criteria were organized by communities (villages) to fill out the questionnaires centrally after giving informed consent. Each survey site selected either paper or electronic questionnaires depending on the actual situation, and if the participants could not complete the questionnaire independently, the investigators would use face-to-face interview methods. To ensure study quality, many quality control measures were implemented during investigator training, survey implementation, and questionnaire entry. We created an investigator's manual and conducted uniform online training for investigators around the country to unify the standard terminology and process; a pre-survey was also conducted; during the survey process, investigators were not allowed to use inducing or suggestive language, and the act of explaining answers and answering on behalf of the investigator was strictly prohibited. At the end of each day's survey, quality control personnel must check the quality of the questionnaires promptly. Any logical errors or missing responses discovered in the questionnaires resulted in timely contact with respondents to validate the answers. Paper questionnaires were reviewed and coded by 2 investigators using a two-person parallel data entry method. Upon exporting electronic surveys, members reviewed the rationale and validity of survey data and eliminated questionnaires with outliers and logical errors and those that took less than 5 minutes to complete online. 2.3 Survey measurements and variable definitions The questionnaire we used contained basic demographic characteristics: gender, age, literacy, marital status, income status, occupation, household registration, and education level, health-related behaviors. Self-management behaviors Self-management behaviors in this study include regular exercise, proper diet, and, especially for patients with hypertension, self-monitoring behaviors such as home blood pressure monitoring (HBPM), medication compliance and regular physical examination. In the exercise section of the survey, participants were queried “Have you engaged in consistent physical exercise in the preceding six months, excluding endeavors related to housekeeping or employment.” Responses were grouped into a binary classification of affirmative or negative. The Dietary Diversity Score (DDS) represents the total number of food types consumed by respondents in a week, including dairy products, meat, aquatic products, eggs, fruits, vegetables, soy products, nuts, and grains. Each food type eaten was counted as 1 point, with a maximum of 9 points, regardless of the amount or frequency consumed. The study utilized the median for grouping, where a total score of 0 to 7 was classified as a low DDS score, and > 7 was classified as a high DDS score. The survey inquired about the use of preventive health services, including if the respondents had regular physical examinations, regular medication, and frequency of undergoing regular home blood pressure monitoring (HBPM). The sum of the scores was defined as self-management behaviors using 1 point for each of whether or not they exercised regularly, whether or not they had a DDS score of 7 or higher, whether or not they had regular home blood pressure monitoring at a frequency of more than twice a week, whether or not they had medication compliance, and whether or not they had regular physical examinations; the score of self-management behaviors ranges from 0 to 5, higher scores indicated that the participants possessed a better ability to manage their health. Health literacy The health literacy section of the survey was crafted using the "core health information for older adults" guidelines released by the former China Family Planning Association, as well as the available basic public health services for elderly individuals 25 . The survey features 20 core health information entries and 20 knowledge-based inquiries that encompass subjects such as diet, exercise, smoking, chronic disease treatment, and medication management. Each accurate response is worth 1 point, while an inaccurate one is worth 0. This test is out of 20 points, with a higher score indicating better health knowledge, and in our study, the Cronbach's alpha was 0.733. Social support The study utilized the 10-item Social Support Rating Scale (SSRS) which has been validated in Chinese 26 , and has good reliability and validity when used widely in China. This scale assesses three dimensions of support, including subjective support (4 items), objective support (3 items), and utilization of social support (3 items), with a total score of 66. Objective support is defined as support that exists as a concrete reality, including economic support and participation in social networks and relationships. Subjective support, on the other hand, is based on an individual's perceived subjective feelings of being respected, supported, and satisfied. Utilization of support refers to whether or not an individual accepts support and help from others. Health education Based on China’s National Basic Public Health Services (NBPHS) 23 , which provides five public health services, including holding health knowledge lectures, providing health education materials, setting up a health education bulletin board, carrying out public health consultations, and providing individualized health education 24 , questions included “Have you attended health knowledge lectures that were organized by community health service agencies last year? ”, “Have you browsed through the health education materials from the community health service agencies last year? ”, and “Have you visited the health education bulletin boards of community health service organizations last year? ”, “Have you received free medical consultation provided by community health service organizations last year? ”, and “Have you received health education during seeking medical advice at community health service organizations last year? ”. Response options included "never", "seldom", "sometimes" and "always", which were assigned a score from 1 to 4 to reflect the degree of participation in health education activities. The higher the score, the better the engagement in health education. 2.4 Data Analysis Methods We used SPSS 25.0 to carry out the statistical description, one-way analysis and correlation analyses, and Amos 24 to complete the structural equation model (SEM) analysis. First of all, to descriptively analyze the participants' socio-demographic characteristics, health-related behaviors, and health service utilization, mean and standard deviation were used to express measured data, while percentages were used for count data. Second, the differences among the levels of self-management behaviors were compared using the Mann‒Whitney U or Kruskal‒Wallis test. Thirdly, we conducted Spearman's correlation analysis to establish the relationship between the variables. Subsequently, we examined the path and composite relationships between the variables by utilizing a structural equation model. The parameters of the structural equation modeling were determined using the maximum likelihood estimation method. Goodness-of-fit of the model was examined using the following indexes: χ 2 /df < 3, Root Mean Square Error of Approximation (RMSEA 0.90), Comparative fit Index (CFI > 0.90). The significance level for the test was set at p < 0.05. 3 Results 3.1 Sociodemographic Characteristics of Participants A total of 1140 elderly patients with hypertension were included in the study. The average age of the patients was 70.16 ± 6.62 years old. The majority of the patients were female (616, 54.04%), from The Han nationality, (1120, 98.25%) married (929, 81.49%), had a primary school or lower educational level (566, 49.65%), farmers (514, 45.09%), from urban area (606, 53.16%) and had hypertension less than 10 years (577, 50.61%). With the maximum score for self-management behaviors was 5, and the average score obtained in our study was 3.15 ± 1.13. The results of the one-way analysis of variance showed that age, education level, and occupational status before retirement had a significant effect on self-management behaviors, and those who were 70–79 years old, had a higher education level, were engaged in other jobs than worker-farmer, and lived in the city had better self-management behaviors. The sociodemographic and p -value of one-way analysis between different groups is shown in Table 1 . Table 1 Self-management behaviors in participants with different demographic characteristics Variables Group N(%) Self-management behaviors score( M ± SD ) P Age(years) 60–69 598(52.46) 3.07 ± 1.15 0.041* 70–79 433(37.98) 3.28 ± 1.09 80- 109(9.56) 3.10 ± 1.15 Gender + Male 522(45.79) 3.12 ± 1.16 0.372 Female 616(54.04) 3.18 ± 1.11 Ethnicity The Han nationality 1120(98.25) 3.15 ± 1.13 0.162 China's ethnic minorities 20(1.75) 3.45 ± 1.28 Education level Primary school or lower 566(49.65) 2.86 ± 1.11 < 0.001*** Junior middle school 316(27.72) 3.25 ± 1.11 High middle school or higher 258(22.63) 3.68 ± 0.97 Marital status + Married 929(81.49) 3.16 ± 1.14 0.615 Unmarried/Divorce/Widowed 207(18.16) 3.13 ± 1.10 Occupational status before retirement + Farmers 514(45.09) 2.76 ± 1.06 < 0.001*** Workers 238(20.88) 3.44 ± 1.08 Others 383(33.60) 3.51 ± 1.07 Residence + Urban 606(53.16) 3.46 ± 1.12 10 345(30.26) 3.24 ± 1.11 Medicine insurance the Urban Employee-based Basic Medical Insurance 382(33.51) 3.52 ± 1.11 NA the Urban Resident-based Basic Medical Insurance 345(30.26) 3.09 ± 1.10 Medical treatment at public expense 48(4.21) 3.75 ± 0.86 the New Rural Cooperative Medical Scheme 377(33.07) 2.79 ± 1.07 Commercial medical insurance 22(1.93) 3.23 ± 1.07 Others 5(0.44) 3.60 ± 0.55 No medicine insurance 6(0.53) 3.33 ± 0.52 Total 1140(100) 3.15 ± 1.13 + : Missing data existed in variables “Gender”, “Marital status”, “Occupational status before retirement” and “Residence”, and was excluded. * indicates a p -value of less than 0.05; ** indicates a p -value of less than 0.01; *** indicates a p -value of less than 0.001 3.2 Current situation of social support, health education, health literacy and self-management behaviors Table 2 shows the descriptive statistics of 1140 participants for social support, health education, health literacy, and self-management behaviors. As a fundamental public health service in China, the enrollment of elderly individuals in our survey for engaging in the mandated health education programs was deemed unsatisfactory, with only 20–30% of them never taking part. Of those who never participated, the highest percentage opted out of attending health lectures (36.05%), whereas the lowest percentage disregarded individualized education (20.35%). Of those who did regular home blood pressure monitoring, only 482 individuals (42.34%) followed the recommended guidelines of taking measurements at least twice a week. Additionally, only 636(55.79%) individuals participated in regular exercise. However, the situation was more favorable regarding physical examinations and medication compliance, with 910(79.82%) people participating in regular physical examinations and 1051(92.19%) people perfoming good medication compliance. Table 2 Descriptive statistics for social support, health education, health literacy and self-management behaviors Variables N(%) / M ± SD Health literacy score 10.23 ± 3.62 Social support Objective support 6.80 ± 2.58 Subjective support 23.40 ± 4.71 Utilization of social support 7.01 ± 2.28 Attend health lectures Never 411(36.05) Seldom 353(30.96) Sometime 291(25.53) Always 85(7.46) Browse through health materials Never 320(28.07) Seldom 380(33.33) Sometime 339(29.74) Always 101(8.86) Visit health education bulletin boards Never 312(27.37) Seldom 391(34.30) Sometime 346(30.35) Always 91(7.98) Receive free medical consultation Never 282(24.74) Seldom 374(32.81) Sometime 389(34.12) Always 95(8.33) Receive individualized education Never 232(20.35) Seldom 352(30.88) Sometime 366(32.11) Always 190(16.67) Regular home blood pressure monitoring Twice per week or more 482(42.28) Less than twice a week 658(57.72) Medication compliance Yes 1051(92.19) No 89(7.81) Regular exercises Yes 636(55.79) No 504(44.21) Regular physical examination Yes 910(79.82) No 230(20.18) Dietary diversity score > 7 scores 515(45.18) ≤ 7 scores 625(54.82) Dietary diversity score 7.00 ± 1.67 Self-management behaviors score 3.15 ± 1.13 3.3 Correlations between study variables The correlations among social support, health education, health literacy and self-management behaviors are shown in Table 3 . The Spearman correlation analyses showed that all variables were significantly correlated with one another. Table 3 Correlations between study variables r Health literacy Objective support Subjective support Utilization of support Attend health lectures Browse through health materials Visit health education bulletin boards Receive free medical consultation Receive individualized education Self-management behaviors Health literacy 1.000 Objective Support 0.211 *** 1.000 Subjective Support 0.179 *** 0.382 *** 1.000 Utilization of Support 0.199 *** 0.255 *** 0.286 *** 1.000 Attend health lectures 0.148 *** 0.188 *** 0.214 *** 0.230 *** 1.000 Browse through health materials 0.217 *** 0.176 *** 0.206 *** 0.248 *** 0.743 *** 1.000 Visit health education bulletin boards 0.203 *** 0.146 *** 0.157 *** 0.216 *** 0.677 *** 0.796 *** 1.000 Receive free medical consultation 0.133 *** 0.129 *** 0.166 *** 0.155 *** 0.634 *** 0.647 *** 0.665 *** 1.000 Receive individualized education 0.141 *** 0.165 *** 0.165 *** 0.221 *** 0.521 *** 0.604 *** 0.624 *** 0.654 *** 1.000 Self-management behaviors 0.249 *** 0.127 *** 0.174 *** 0.204 *** 0.232 *** 0.248 *** 0.248 *** 0.175 *** 0.173 *** 1.000 * indicates a p -value of less than 0.05; ** indicates a p -value of less than 0.01; *** indicates a p -value of less than 0.001 3.4 Model Fit The model fit indices for SEM were all within specifications (TLI = 0.983, IFI = 0.991, CFI = 0.991, RMSEA = 0.038), and the chi-square to degrees of freedom ratio was 2.645, suggesting that the model was well fitted (see Table 4 ). Table 4 Model fit index χ 2 /df RMSEA TLI IFI CFI M 2.645 0.038 0.983 0.991 0.991 Evaluation < 3.00 0.90 > 0.90 > 0.90 3.5 SEM Analysis Based on the results mentioned above, the hypothesis model of social support, health education, health literacy and self-management behaviors of elderly hypertension patients was constructed (see Figure. 1). Using the maximum likelihood method for parameter estimation, standardized regression coefficient (path coefficient) was calculated, and all the paths that did reach a significant level ( P 1.96). The standardized parameter estimates are shown in Table 5 . Among the paths, social support had the biggest direct positive effect on self-management behaviors (0.187), followed by health education (0.158) and health literacy (0.157). The model also indicated that social support could positively impact self-management behaviors through health education and health literacy; health education could positively impact self-management behaviors through health literacy. * indicates a p -value of less than 0.05; *** indicates a p -value of less than 0.001 Table 5 Standardized parameter estimates of SEM model Path Estimate S.E. C.R. P Social Support --> Health Education 0.413 0.033 8.376 Health Literacy 0.336 0.152 6.895 Health Literacy 0.077 0.159 2.048 .027 * Health Education --> Attend health lectures 0.848 Health Education --> Browse through health materials 0.916 0.047 22.726 Visit health education bulletin boards 0.871 0.035 28.170 Receive free medical consultation 0.759 0.046 19.105 Receive individualized education 0.718 0.049 18.019 Objective Support 0.514 Subjective Support 0.605 0.230 10.713 Utilization of Social Support 0.567 0.121 10.605 Self-management behaviors 0.187 0.043 3.839 Self-management behaviors 0.158 0.046 4.658 Self-management behaviors 0.157 0.009 4.469 < 0.001 *** * indicates a p -value of less than 0.05; *** indicates a p -value of less than 0.001 S. E. Standard Error in Estimate, C. R. Critical Ratio 4 Discussion Self-management practices, in contrast to passive medical interventions, are essential measures for preventing the progression of the disease, aligning with the notion of proactive health, which was embodied in the Outline of the Healthy China 2030 Plan and the Healthy China Initiative, and then defined as “the sum of all social activities of human beings that revolve around health” 27 . To achieve the strategic goal of proactive health, we need to pay more attention to the factors that influence self-management behaviors. In this study, the average score of self-management behaviors was 3.15 ± 1.13, suggesting that on average the participants were only able to adhere to 3 of the recommended self-management behaviors. Specifically, only 55.79%, 45.18%, 42.28%, 79.82%, and 92.19% participants reported regular exercise, balanced diet, regular home blood pressure monitoring, regular physical examination and medication compliance. These findings indicate that the current state of self-management behaviors among elderly Chinese hypertensive patients needs improvement. However, the incidence of regular physical examination and medication compliance was higher than in current studies 12 13 , while the rate of regular home blood pressure monitoring was lower 9 . Possible reasons for this are that both doctors and people around the patient deeply understand the importance of medication adherence and constantly remind the patient to stick to his/her medication, while in the overall environment, health education on home blood pressure monitoring is not widespread in China. Therefore, home blood pressure measurement of hypertensive patients should be paid more attention in future health education and health promotion work, and for older adults, our findings reflect that they should strengthen their use of home blood pressure measurement and be educated to perform simple operations to monitor blood pressure in real-time. Study showed less than half of the elderly patients owned a home blood pressure (BP) monitor 11 , so improving ownership of monitors could be a better start. We conducted a structural equation model to elucidate the connections among social support, health education, health literacy, and self-management behaviors. The obtained results supported our hypotheses that health education and health literacy positively and directly influence the self-management behaviors of hypertensive elderly patients. Moreover, our findings suggested that health literacy played a role in mediating the association between social support and self-management behaviors, and it indirectly mediated the association between health education and self-management behaviors. Our results validate the ecological model perspective in terms of individual, interpersonal, and social policy factors, all of which influence health behaviors 15 . We also found that social support at the interpersonal level and health education service utilization at the policy level, in addition to directly influencing behavior, both indirectly influence health literacy at the individual level. Therefore, we recommend enhancing the utilization of health education services in the National Basic Public Health Service for elderly patients, improving their access to health information, and enhancing their health literacy. The utilization of health education in this study originated from China's National Basic Public Health Service, which was demonstrated to be effective in enhancing hypertension treatment and control 28 29 . However, the use of health education services was less common in this study, and literature has indicated that residents' satisfaction with the chronic disease health management and education modules of the basic public health service is lower 30 . Expanding the existing basic public health system not only aids in managing chronic disease patients, but also enhances patients' health literacy via health education and other approaches, thus promoting their health behaviors. Strengths and limitations This study has some limitations. Firstly, being a cross-sectional study, this study has limitations in inferring causality. Secondly, most variables were self-reported, which involves potential recall bias of information, misclassification and overestimation. Thirdly, the original project was not considered comprehensively enough, some variables, such as other health behaviors, were not included in our study. However, this study covered cities with varied economic status in six provinces of China, and employed structural equation modeling to examine the correlation between the variables of social support, health education, health literacy, and self-management behaviors in elderly hypertensive patients for the first time, which can provide a theoretical basis and intervention ideas for us to better improve the self-management behaviors of elderly hypertensive patients. 5 Conclusion The situation of adopting self-management behaviors among elderly patients with hypertension is uneven in this study. We provide a unique perspective to explore the relationships between self-management behaviors, social support, health education and health literacy. The SEM analysis showed that social support, health education and health literacy all have an impact on self-management behaviors and complex interactions exist. Improving the social support, health education and health literacy of patients with hypertension can positively influence their self-management behaviors and therapeutic outcomes. This study is also helpful for the community to consider how to improve health education and health literacy by strengthening the utilization of basic public health services, and targeting SS to improve self-management behaviors among elder patients with hypertension, ultimately improving their health. Declarations Ethics approval and consent to participate This study was given ethics approval and all participants signed an informed consent form and gave their informed consent to participate in the study. Consent for publication Not applicable. Availability of data and materials The datasets used and analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This work was supported by National Health Commission of the PRC [grant numbers: 20190517]. Authors' contributions C.C., W.C. contributed to the conception of the study; Z.C., M.C., L.G., Y.T. and C.C. contributed to data collection, Z.C., M.C. performed the data analysis; Z.C. wrote the manuscript; All authors reviewed the manuscript. Acknowledgements We wish to thank investigators from all six provinces, whose hard work helped us to obtain comprehensive data, as well as all the seniors who completed the survey. References Organization WH. Global report on hypertension: the race against a silent killer 2023 [updated 2023.10.10. https://www.who.int/publications/i/item/9789240081062 . Hu SS. 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Zhonghua liu xing bing xue za zhi = Zhonghua liuxingbingxue zazhi 2023;44(7):1037-45. 10.3760/cma.j.cn112338-20230207-00061 [published Online First: 2023/07/24]. Bronfenbrenner U. Toward an experimental ecology of human development. Am Psychol. 1977;32(7):513–31. 10.1037/0003-066X.32.7.513 . McLeroy KR, Bibeau D, Steckler A, et al. An ecological perspective on health promotion programs. Health Educ Q. 1988;15(4):351–77. 10.1177/109019818801500401 . [published Online First: 1988/01/01]. Zhu LX, Ho SC, Wong TK. Effectiveness of health education programs on exercise behavior among patients with heart disease: a systematic review and meta-analysis. J evidence-based Med. 2013;6(4):265–301. 10.1111/jebm.12063 . [published Online First: 2013/12/12]. Callaghan P, Morrissey J. Social support and health: a review. J Adv Nurs. 1993;18(2):203–10. 10.1046/j.1365-2648.1993.18020203.x . [published Online First: 1993/02/01]. Thoits PA. Mechanisms linking social ties and support to physical and mental health. J Health Soc Behav. 2011;52(2):145–61. 10.1177/0022146510395592 . [published Online First: 2011/06/16]. Scheurer D, Choudhry N, Swanton KA, et al. Association between different types of social support and medication adherence. Am J Manag Care. 2012;18(12):e461–7. [published Online First: 2013/01/05]. Liu Y, Meng H, Tu N, et al. The Relationship Between Health Literacy, Social Support, Depression, and Frailty Among Community-Dwelling Older Patients With Hypertension and Diabetes in China. Front public health. 2020;8:280. 10.3389/fpubh.2020.00280 . [published Online First: 2020/07/28]. Liu YB, Hou P, Xue HP, et al. Social Support, Health Literacy, and Health Care Utilization Among Older Adults. Asia Pac J Public Health. 2019;31(4):359–66. 10.1177/1010539519851674 . [published Online First: 2019/07/17]. Guo A, Jin H, Mao J, et al. Impact of health literacy and social support on medication adherence in patients with hypertension: a cross-sectional community-based study. BMC Cardiovasc Disord. 2023;23(1):93. 10.1186/s12872-023-03117-x . [published Online First: 2023/02/22]. China NHCotPsRo. The Office of the Leading Group for Medical Reform Held a Teleconference to Initiate and Deploy the National Basic Public Health Service Project. 2009 [updated 2023.10.14. http://www.nhc.gov.cn/tigs/s9661/200907/5386fa1ff8eb42c7885b76f8fffdfe29.shtml . Li Y, Lv X, Liang J, et al. The development and progress of health literacy in China. Front public health. 2022;10:1034907. 10.3389/fpubh.2022.1034907 . [published Online First: 2022/11/25]. Association CFP, Circular of China Family Planning Association on the Issuance of Core Information on Elderly Health. 2014 [updated 2023.10.14. https://www.chinafpa.org.cn/zcfg/xgfg/201901/t20190125_42928.html . Zheng YP, Wei LA, Goa LG, et al. Applicability of the Chinese Beck Depression Inventory. Compr Psychiatr. 1988;29(5):484–9. 10.1016/0010-440x(88)90063-6 . [published Online First: 1988/09/01]. Liu J, Li W, Yao H, et al. Proactive Health: An Imperative to Achieve the Goal of Healthy China. China CDC Wkly. 2022;4(36):799–801. 10.46234/ccdcw2022.156 . [published Online First: 2022/10/27]. Pang L, Kottu L, Guo Z, et al. Dawning public health services dogma: An indigenous Southwest Chinese perspective in managing hypertension-with or without the BPHS? Front public health. 2022;10:1017795. 10.3389/fpubh.2022.1017795 . [published Online First: 2022/11/29]. Fang G, Yang D, Wang L, et al. Experiences and Challenges of Implementing Universal Health Coverage With China's National Basic Public Health Service Program: Literature Review, Regression Analysis, and Insider Interviews. JMIR public health surveillance. 2022;8(7):e31289. 10.2196/31289 . [published Online First: 2022/07/23]. Liu J, Mao Y, Rural Resident Experience on National Basic Public Health Services. A Cross-Sectional Survey in 10 Western Provinces of China. Healthc (Basel Switzerland). 2019;7(4). 10.3390/healthcare7040160 . [published Online First: 2019/12/11]. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4568125","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":314313750,"identity":"b319e0e5-44b3-441a-82fe-955fa45105d7","order_by":0,"name":"Ziyan Chen","email":"","orcid":"","institution":"Peking University","correspondingAuthor":false,"prefix":"","firstName":"Ziyan","middleName":"","lastName":"Chen","suffix":""},{"id":314313751,"identity":"2c920802-e943-4b5d-bec3-21e10a433573","order_by":1,"name":"Meijun Chen","email":"","orcid":"","institution":"University of Hong Kong","correspondingAuthor":false,"prefix":"","firstName":"Meijun","middleName":"","lastName":"Chen","suffix":""},{"id":314313752,"identity":"715ef405-a309-4d9c-8640-774789605a3a","order_by":2,"name":"Litong Gong","email":"","orcid":"","institution":"Department of Daxing Center for Disease Control and Prevention, Beijing, China","correspondingAuthor":false,"prefix":"","firstName":"Litong","middleName":"","lastName":"Gong","suffix":""},{"id":314313753,"identity":"cc1ecbac-d2ac-4177-b8c2-5b7ea8f0b0db","order_by":3,"name":"Yu Tian","email":"","orcid":"","institution":"Xicheng District Xinjiekou Community Health Center","correspondingAuthor":false,"prefix":"","firstName":"Yu","middleName":"","lastName":"Tian","suffix":""},{"id":314313754,"identity":"1a32818e-bd97-488b-9c8f-786b230e729b","order_by":4,"name":"Chun Chang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA40lEQVRIiWNgGAWjYDACCTB5gIGBvYfBAMYmUgvPGZK1SORARQhp4Z/d/Ozhl5o7idsl3x4outnGIMd3I4HxcwE+S+4cMzeWOfYscefsvATj3DYGY8kbCczSM/BoMZBIMJOWbDicuOF2jgFIS+KGGwlszDx4taR/g2i5eQaspZ4ILTlmkh9BWm7wgLUkGBDSInEjp0ya4dhh4w1ngH7JOSdhOPPMw2ZpfFr4Z6Rvk/xRc1h2w/Gzx4xzymzk+Y4nH/yMTwsIwJzBZgCJJsYGAhqASn5AtT4gqHQUjIJRMApGJAAA9CNQ+PghwsoAAAAASUVORK5CYII=","orcid":"","institution":"Peking University","correspondingAuthor":true,"prefix":"","firstName":"Chun","middleName":"","lastName":"Chang","suffix":""},{"id":314313755,"identity":"14588125-33dd-41df-bc41-49cd0290affa","order_by":5,"name":"Wangnan Cao","email":"","orcid":"","institution":"Peking University","correspondingAuthor":false,"prefix":"","firstName":"Wangnan","middleName":"","lastName":"Cao","suffix":""}],"badges":[],"createdAt":"2024-06-12 07:02:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4568125/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4568125/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":60184767,"identity":"702ea82a-8c27-42d9-85aa-3ee0ea445c4a","added_by":"auto","created_at":"2024-07-12 18:38:38","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":168205,"visible":true,"origin":"","legend":"\u003cp\u003eStructural Equation Model of self-management behaviors among elderly patients with hypertension\u003c/p\u003e\n\u003cp\u003e* indicates a \u003cem\u003ep\u003c/em\u003e-value of less than 0.05;\u003c/p\u003e\n\u003cp\u003e*** indicates a \u003cem\u003ep\u003c/em\u003e-value of less than 0.001\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4568125/v1/aa586357939b13bc55fbffdf.png"},{"id":76989504,"identity":"6e28b5e4-81de-4aed-841e-52c46d7a969b","added_by":"auto","created_at":"2025-02-24 04:46:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1278341,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4568125/v1/2379aab1-3afd-4f81-a430-3475324a66ac.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Health literacy, social support, and health education, as factors associating with self-management behaviors among elderly patients with hypertension in China: a structural equation model","fulltext":[{"header":"1 Background","content":"\u003cp\u003eAs one of the world\u0026rsquo;s leading risk factors for death and disability, hypertension was mentioned as the silent killer by the latest report of the World Health Organization (WHO) published in 2023 for it is responsible for more than 10\u0026nbsp;million deaths every year \u0026mdash;\u0026mdash; more deaths than from any other risk to health. Prevalence of hypertension is 32% of adults aged 30\u0026ndash;79 years in high-income countries and 34% in low-income countries, and for people aged 50\u0026ndash;79 years, both men and women globally are estimated to have equivalent hypertension prevalence of 49%\u003csup\u003e1\u003c/sup\u003e. Besides the extremely high prevalence, high blood pressure can also lead to many serious complications. In China, Hypertension has also become one of the major public health concerns. A recent survey showed that the prevalence of hypertension is 27.5% in China, with a continuous upward trend in hypertension rates from 1958\u0026ndash;2018\u003csup\u003e2\u003c/sup\u003e. A large cohort study in China from 2004 to 2014 showed that the prevalence of hypertension among Chinese 60\u0026ndash;69 and 70\u0026ndash;79 years old was 50.7% and 58.4%, associated with significant excess mortality\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. As a group with a higher prevalence of hypertension, more serious disability and death rates, and more common complications, older adults need to strengthen self-management to reduce mortality and disability.\u003c/p\u003e \u003cp\u003eAccording to WHO\u0026rsquo;s report, self-care may include making lifestyle changes, such as adopting a healthy diet and engaging in regular physical activity, as well as ensuring proper medication adherence and monitoring blood pressure, which will be essential in the care of nearly all patients diagnosed with hypertension, especially older adults\u003csup\u003e\u003cspan additionalcitationids=\"CR5 CR6\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. Regular home blood pressure monitoring could achieve better blood pressure control\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e and has been recommended by several international guidelines, most of which guidelines recommend 1\u0026ndash;2 weekly intervals for long-term continuous assessment in patients with controlled blood pressure\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. Clinical practice guidelines for managing hypertension in China also recommend self-monitoring of blood pressure at intervals of at least 2 times per week\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. A cross-sectional study showed only 27.5% of hypertensive patients engaged in home blood pressure monitoring weekly or more frequently\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Poor medication adherence severely compromises patient outcomes and increases patient mortality, but the incidence of nonadherence remains high\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. China's National Basic Public Health Services recommends that hypertensive patients undergo physical examination once a year, and free medical services are provided for older adults over 65 years of age, but only 40.6%-61.0% of the population over 55 years of age in China undergo regular annual physical examination\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. Given the current status of low incidence of self-management behaviors, it is all the more important to focus our efforts on how to better promote self-management behaviors among older adults.\u003c/p\u003e \u003cp\u003eThe ecological model for health promotion was derived from the Social Ecological Model\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e, it emphasizes that individual behavior is influenced by multiple levels: intrapersonal, interpersonal, and public policy factors\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. Health literacy, as an intrapersonal factor, established the base for adopting self-management behaviors. And it has been proved health education (HE) is an effective method to improve health knowledge and health literacy (HL)\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e, which in turn promotes the adoption of self-management behaviors. Interpersonal factors refer to formal and informal social networks, like family and friendship networks. Social support (SS), which has been defined as an exchange of resources between at least two individuals perceived by the provider or recipient to be intended to enhance the well-being of the recipient'\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e, has been proven to motivate people to adopt more self-management behaviors\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e, so we used social support as representation of interpersonal factors in this study. There are also studies on the effect of social support on health education utilization and health literacy\u003csup\u003e\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e, and those with stronger social ties will better utilize their health education and also have better levels of health literacy. As for public policy factors, in China, the National Basic Public Health Services (NBPHS) was first issued in 2009, as an essential public health service provided freely for universal population in China by the Chinese Government\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e, in which health education and health literacy promotion action were defined as the two independent services. Health education of NBPHS provides five public health services, including holding health knowledge lectures, providing health education materials, setting up a health education bulletin board, carrying out public health consultations, and providing individualized health education\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e, all of which aim at promoting health literacy, thus promoting healthy behaviors.\u003c/p\u003e \u003cp\u003eBased on the above-mentioned existing literature, health education (HE), health literacy (HL), social support (SS) and self-management behaviors are related and have complex relationships. However, most of the existing literature only focused on the relationship between two factors, without considering the synergistic effects on self-management behaviors at multiple factors and levels and the potential underlying mechanisms. Therefore, the purpose of this study is to construct a structural equation model (SEM) to explore between self-management behaviors, health education, health literacy and social support and clarify the direct and indirect effect of factors affecting self-management behaviors, which can provide a theoretical basis and intervention ideas for us to better improve the self-management behaviors of elderly patients with hypertension.\u003c/p\u003e"},{"header":"2 Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Participants and method of selection\u003c/h2\u003e \u003cp\u003eThis study was based on a program in which urban and rural older adults aged 60 years and older were recruited for collecting their core health literacy from May to October 2020 in six provinces of China, each two of which were from the eastern, central, and western regions of China, with two cities in each province.\u003c/p\u003e \u003cp\u003eAs a cross-sectional survey study, this study adopted a stratified multi-stage random sampling method, firstly, two provinces in the eastern, central and western regions of China were randomly selected, the capital city of each province was selected, and one city with GDP in the last third of the province was also randomly selected; 10 communities and administrative villages were selected from each city to carry out the survey.\u003c/p\u003e \u003cp\u003eInclusion criteria included the following: (i) age of 60 years or older, (ii) willingness to participate voluntarily in the survey. Exclusions were individuals who were (i) mentally impaired, or (ii) refused to sign the information agreement. By this criteria, the program included a total of 3025 participants, from which we selected participants with a self-reported history of hypertension which was confirmed by a certified doctor from a professional organization, and excluded those with missing data on key variables, such as health literacy, social support, health education, and self-management behaviors, and 1140 participants were finally included.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Data collection and quality control methods\u003c/h2\u003e \u003cp\u003eThe questionnaire survey method was used for data collection. Investigators who were postgraduates and health education professionals from the project province were uniformly trained, and the participants who met the inclusion criteria were organized by communities (villages) to fill out the questionnaires centrally after giving informed consent. Each survey site selected either paper or electronic questionnaires depending on the actual situation, and if the participants could not complete the questionnaire independently, the investigators would use face-to-face interview methods.\u003c/p\u003e \u003cp\u003eTo ensure study quality, many quality control measures were implemented during investigator training, survey implementation, and questionnaire entry. We created an investigator's manual and conducted uniform online training for investigators around the country to unify the standard terminology and process; a pre-survey was also conducted; during the survey process, investigators were not allowed to use inducing or suggestive language, and the act of explaining answers and answering on behalf of the investigator was strictly prohibited. At the end of each day's survey, quality control personnel must check the quality of the questionnaires promptly. Any logical errors or missing responses discovered in the questionnaires resulted in timely contact with respondents to validate the answers. Paper questionnaires were reviewed and coded by 2 investigators using a two-person parallel data entry method. Upon exporting electronic surveys, members reviewed the rationale and validity of survey data and eliminated questionnaires with outliers and logical errors and those that took less than 5 minutes to complete online.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Survey measurements and variable definitions\u003c/h2\u003e \u003cp\u003eThe questionnaire we used contained basic demographic characteristics: gender, age, literacy, marital status, income status, occupation, household registration, and education level, health-related behaviors.\u003c/p\u003e \u003cp\u003eSelf-management behaviors\u003c/p\u003e \u003cp\u003eSelf-management behaviors in this study include regular exercise, proper diet, and, especially for patients with hypertension, self-monitoring behaviors such as home blood pressure monitoring (HBPM), medication compliance and regular physical examination.\u003c/p\u003e \u003cp\u003eIn the exercise section of the survey, participants were queried \u0026ldquo;Have you engaged in consistent physical exercise in the preceding six months, excluding endeavors related to housekeeping or employment.\u0026rdquo; Responses were grouped into a binary classification of affirmative or negative. The Dietary Diversity Score (DDS) represents the total number of food types consumed by respondents in a week, including dairy products, meat, aquatic products, eggs, fruits, vegetables, soy products, nuts, and grains. Each food type eaten was counted as 1 point, with a maximum of 9 points, regardless of the amount or frequency consumed. The study utilized the median for grouping, where a total score of 0 to 7 was classified as a low DDS score, and \u0026gt;\u0026thinsp;7 was classified as a high DDS score. The survey inquired about the use of preventive health services, including if the respondents had regular physical examinations, regular medication, and frequency of undergoing regular home blood pressure monitoring (HBPM). The sum of the scores was defined as self-management behaviors using 1 point for each of whether or not they exercised regularly, whether or not they had a DDS score of 7 or higher, whether or not they had regular home blood pressure monitoring at a frequency of more than twice a week, whether or not they had medication compliance, and whether or not they had regular physical examinations; the score of self-management behaviors ranges from 0 to 5, higher scores indicated that the participants possessed a better ability to manage their health.\u003c/p\u003e \u003cp\u003eHealth literacy\u003c/p\u003e \u003cp\u003eThe health literacy section of the survey was crafted using the \"core health information for older adults\" guidelines released by the former China Family Planning Association, as well as the available basic public health services for elderly individuals\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. The survey features 20 core health information entries and 20 knowledge-based inquiries that encompass subjects such as diet, exercise, smoking, chronic disease treatment, and medication management. Each accurate response is worth 1 point, while an inaccurate one is worth 0. This test is out of 20 points, with a higher score indicating better health knowledge, and in our study, the Cronbach's alpha was 0.733.\u003c/p\u003e \u003cp\u003eSocial support\u003c/p\u003e \u003cp\u003eThe study utilized the 10-item Social Support Rating Scale (SSRS) which has been validated in Chinese\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e, and has good reliability and validity when used widely in China. This scale assesses three dimensions of support, including subjective support (4 items), objective support (3 items), and utilization of social support (3 items), with a total score of 66. Objective support is defined as support that exists as a concrete reality, including economic support and participation in social networks and relationships. Subjective support, on the other hand, is based on an individual's perceived subjective feelings of being respected, supported, and satisfied. Utilization of support refers to whether or not an individual accepts support and help from others.\u003c/p\u003e \u003cp\u003eHealth education\u003c/p\u003e \u003cp\u003eBased on China\u0026rsquo;s National Basic Public Health Services (NBPHS) \u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e, which provides five public health services, including holding health knowledge lectures, providing health education materials, setting up a health education bulletin board, carrying out public health consultations, and providing individualized health education\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e, questions included \u0026ldquo;Have you attended health knowledge lectures that were organized by community health service agencies last year? \u0026rdquo;, \u0026ldquo;Have you browsed through the health education materials from the community health service agencies last year? \u0026rdquo;, and \u0026ldquo;Have you visited the health education bulletin boards of community health service organizations last year? \u0026rdquo;, \u0026ldquo;Have you received free medical consultation provided by community health service organizations last year? \u0026rdquo;, and \u0026ldquo;Have you received health education during seeking medical advice at community health service organizations last year? \u0026rdquo;. Response options included \"never\", \"seldom\", \"sometimes\" and \"always\", which were assigned a score from 1 to 4 to reflect the degree of participation in health education activities. The higher the score, the better the engagement in health education.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Data Analysis Methods\u003c/h2\u003e \u003cp\u003eWe used SPSS 25.0 to carry out the statistical description, one-way analysis and correlation analyses, and Amos 24 to complete the structural equation model (SEM) analysis. First of all, to descriptively analyze the participants' socio-demographic characteristics, health-related behaviors, and health service utilization, mean and standard deviation were used to express measured data, while percentages were used for count data. Second, the differences among the levels of self-management behaviors were compared using the Mann‒Whitney U or Kruskal‒Wallis test. Thirdly, we conducted Spearman's correlation analysis to establish the relationship between the variables. Subsequently, we examined the path and composite relationships between the variables by utilizing a structural equation model. The parameters of the structural equation modeling were determined using the maximum likelihood estimation method. Goodness-of-fit of the model was examined using the following indexes: χ\u003csup\u003e2\u003c/sup\u003e /df\u0026thinsp;\u0026lt;\u0026thinsp;3, Root Mean Square Error of Approximation (RMSEA\u0026thinsp;\u0026lt;\u0026thinsp;0.08), Incremental fit Index (IFI\u0026thinsp;\u0026gt;\u0026thinsp;0.90), Comparative fit Index (CFI\u0026thinsp;\u0026gt;\u0026thinsp;0.90). The significance level for the test was set at \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"3 Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Sociodemographic Characteristics of Participants\u003c/h2\u003e \u003cp\u003eA total of 1140 elderly patients with hypertension were included in the study. The average age of the patients was 70.16\u0026thinsp;\u0026plusmn;\u0026thinsp;6.62 years old. The majority of the patients were female (616, 54.04%), from The Han nationality, (1120, 98.25%) married (929, 81.49%), had a primary school or lower educational level (566, 49.65%), farmers (514, 45.09%), from urban area (606, 53.16%) and had hypertension less than 10 years (577, 50.61%). With the maximum score for self-management behaviors was 5, and the average score obtained in our study was 3.15\u0026thinsp;\u0026plusmn;\u0026thinsp;1.13. The results of the one-way analysis of variance showed that age, education level, and occupational status before retirement had a significant effect on self-management behaviors, and those who were 70\u0026ndash;79 years old, had a higher education level, were engaged in other jobs than worker-farmer, and lived in the city had better self-management behaviors. The sociodemographic and \u003cem\u003ep\u003c/em\u003e-value of one-way analysis between different groups is shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSelf-management behaviors in participants with different demographic characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSelf-management behaviors score(\u003cem\u003eM\u003c/em\u003e\u0026thinsp;\u0026plusmn;\u0026thinsp;\u003cem\u003eSD\u003c/em\u003e)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge(years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60\u0026ndash;69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e598(52.46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e3.07\u0026thinsp;\u0026plusmn;\u0026thinsp;1.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.041*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70\u0026ndash;79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e433(37.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e3.28\u0026thinsp;\u0026plusmn;\u0026thinsp;1.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e109(9.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e3.10\u0026thinsp;\u0026plusmn;\u0026thinsp;1.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003csup\u003e+\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e522(45.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e3.12\u0026thinsp;\u0026plusmn;\u0026thinsp;1.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.372\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e616(54.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e3.18\u0026thinsp;\u0026plusmn;\u0026thinsp;1.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEthnicity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe Han nationality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1120(98.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e3.15\u0026thinsp;\u0026plusmn;\u0026thinsp;1.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.162\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChina's ethnic minorities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20(1.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e3.45\u0026thinsp;\u0026plusmn;\u0026thinsp;1.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary school or lower\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e566(49.65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e2.86\u0026thinsp;\u0026plusmn;\u0026thinsp;1.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJunior middle school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e316(27.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e3.25\u0026thinsp;\u0026plusmn;\u0026thinsp;1.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh middle school or higher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e258(22.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e3.68\u0026thinsp;\u0026plusmn;\u0026thinsp;0.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarital status\u003csup\u003e+\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e929(81.49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e3.16\u0026thinsp;\u0026plusmn;\u0026thinsp;1.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.615\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnmarried/Divorce/Widowed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e207(18.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e3.13\u0026thinsp;\u0026plusmn;\u0026thinsp;1.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOccupational status before retirement\u003csup\u003e+\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFarmers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e514(45.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e2.76\u0026thinsp;\u0026plusmn;\u0026thinsp;1.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWorkers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e238(20.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e3.44\u0026thinsp;\u0026plusmn;\u0026thinsp;1.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e383(33.60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e3.51\u0026thinsp;\u0026plusmn;\u0026thinsp;1.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResidence\u003csup\u003e+\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e606(53.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e3.46\u0026thinsp;\u0026plusmn;\u0026thinsp;1.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e528(46.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e2.80\u0026thinsp;\u0026plusmn;\u0026thinsp;1.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of hypertension(year)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e146(12.81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e3.03\u0026thinsp;\u0026plusmn;\u0026thinsp;1.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.132\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u0026ndash;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e284(24.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e3.06\u0026thinsp;\u0026plusmn;\u0026thinsp;1.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e365(32.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e3.19\u0026thinsp;\u0026plusmn;\u0026thinsp;1.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e345(30.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e3.24\u0026thinsp;\u0026plusmn;\u0026thinsp;1.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedicine insurance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ethe Urban Employee-based Basic Medical Insurance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e382(33.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e3.52\u0026thinsp;\u0026plusmn;\u0026thinsp;1.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ethe Urban Resident-based Basic Medical Insurance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e345(30.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e3.09\u0026thinsp;\u0026plusmn;\u0026thinsp;1.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedical treatment at public expense\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48(4.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e3.75\u0026thinsp;\u0026plusmn;\u0026thinsp;0.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ethe New Rural Cooperative Medical Scheme\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e377(33.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e2.79\u0026thinsp;\u0026plusmn;\u0026thinsp;1.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCommercial medical insurance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22(1.93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e3.23\u0026thinsp;\u0026plusmn;\u0026thinsp;1.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5(0.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e3.60\u0026thinsp;\u0026plusmn;\u0026thinsp;0.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo medicine insurance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6(0.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e3.33\u0026thinsp;\u0026plusmn;\u0026thinsp;0.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1140(100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e3.15\u0026thinsp;\u0026plusmn;\u0026thinsp;1.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003csup\u003e+\u003c/sup\u003e: Missing data existed in variables \u0026ldquo;Gender\u0026rdquo;, \u0026ldquo;Marital status\u0026rdquo;, \u0026ldquo;Occupational status before retirement\u0026rdquo; and \u0026ldquo;Residence\u0026rdquo;, and was excluded.\u003c/p\u003e \u003cp\u003e* indicates a \u003cem\u003ep\u003c/em\u003e-value of less than 0.05;\u003c/p\u003e \u003cp\u003e** indicates a \u003cem\u003ep\u003c/em\u003e-value of less than 0.01;\u003c/p\u003e \u003cp\u003e*** indicates a \u003cem\u003ep\u003c/em\u003e-value of less than 0.001\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Current situation of social support, health education, health literacy and self-management behaviors\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the descriptive statistics of 1140 participants for social support, health education, health literacy, and self-management behaviors. As a fundamental public health service in China, the enrollment of elderly individuals in our survey for engaging in the mandated health education programs was deemed unsatisfactory, with only 20\u0026ndash;30% of them never taking part. Of those who never participated, the highest percentage opted out of attending health lectures (36.05%), whereas the lowest percentage disregarded individualized education (20.35%).\u003c/p\u003e \u003cp\u003e Of those who did regular home blood pressure monitoring, only 482 individuals (42.34%) followed the recommended guidelines of taking measurements at least twice a week. Additionally, only 636(55.79%) individuals participated in regular exercise. However, the situation was more favorable regarding physical examinations and medication compliance, with 910(79.82%) people participating in regular physical examinations and 1051(92.19%) people perfoming good medication compliance.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescriptive statistics for social support, health education, health literacy and self-management behaviors\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN(%) / \u003cem\u003eM\u003c/em\u003e\u0026thinsp;\u0026plusmn;\u0026thinsp;\u003cem\u003eSD\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth literacy score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.23\u0026thinsp;\u0026plusmn;\u0026thinsp;3.62\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObjective support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.80\u0026thinsp;\u0026plusmn;\u0026thinsp;2.58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubjective support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.40\u0026thinsp;\u0026plusmn;\u0026thinsp;4.71\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUtilization of social support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.01\u0026thinsp;\u0026plusmn;\u0026thinsp;2.28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAttend health lectures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e411(36.05)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeldom\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e353(30.96)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSometime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e291(25.53)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlways\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85(7.46)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBrowse through health materials\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e320(28.07)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeldom\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e380(33.33)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSometime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e339(29.74)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlways\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e101(8.86)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVisit health education bulletin boards\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e312(27.37)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeldom\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e391(34.30)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSometime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e346(30.35)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlways\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e91(7.98)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReceive free medical consultation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e282(24.74)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeldom\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e374(32.81)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSometime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e389(34.12)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlways\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e95(8.33)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReceive individualized education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e232(20.35)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeldom\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e352(30.88)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSometime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e366(32.11)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlways\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e190(16.67)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegular home blood pressure monitoring\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTwice per week or more\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e482(42.28)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLess than twice a week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e658(57.72)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedication compliance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1051(92.19)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e89(7.81)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegular exercises\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e636(55.79)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e504(44.21)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegular physical examination\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e910(79.82)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e230(20.18)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDietary diversity score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;7 scores\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e515(45.18)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;7 scores\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e625(54.82)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDietary diversity score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.00\u0026thinsp;\u0026plusmn;\u0026thinsp;1.67\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-management behaviors score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.15\u0026thinsp;\u0026plusmn;\u0026thinsp;1.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Correlations between study variables\u003c/h2\u003e \u003cp\u003eThe correlations among social support, health education, health literacy and self-management behaviors are shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The Spearman correlation analyses showed that all variables were significantly correlated with one another.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCorrelations between study variables\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"11\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003er\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHealth literacy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eObjective support\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSubjective support\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUtilization of support\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAttend health lectures\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBrowse through health materials\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eVisit health education bulletin boards\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eReceive free medical consultation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eReceive individualized education\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eSelf-management behaviors\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth literacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObjective Support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.211\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubjective Support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.179\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.382\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUtilization of Support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.199\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.255\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.286\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAttend health lectures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.148\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.188\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.214\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.230\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBrowse through health materials\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.217\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.176\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.206\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.248\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.743\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVisit health education bulletin boards\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.203\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.146\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.157\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.216\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.677\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.796\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReceive free medical consultation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.133\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.129\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.166\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.155\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.634\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.647\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.665\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReceive individualized education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.141\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.165\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.165\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.221\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.521\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.604\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.624\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.654\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-management behaviors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.249\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.127\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.174\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.204\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.232\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.248\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.248\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.175\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.173\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"11\"\u003e* indicates a \u003cem\u003ep\u003c/em\u003e-value of less than 0.05;\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"11\"\u003e** indicates a \u003cem\u003ep\u003c/em\u003e-value of less than 0.01;\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"11\"\u003e*** indicates a \u003cem\u003ep\u003c/em\u003e-value of less than 0.001\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Model Fit\u003c/h2\u003e \u003cp\u003eThe model fit indices for SEM were all within specifications (TLI\u0026thinsp;=\u0026thinsp;0.983, IFI\u0026thinsp;=\u0026thinsp;0.991, CFI\u0026thinsp;=\u0026thinsp;0.991, RMSEA\u0026thinsp;=\u0026thinsp;0.038), and the chi-square to degrees of freedom ratio was 2.645, suggesting that the model was well fitted (see Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eModel fit index\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e/df\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRMSEA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTLI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIFI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCFI\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.645\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.038\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.983\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.991\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.991\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEvaluation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;3.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.90\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.5 SEM Analysis\u003c/h2\u003e \u003cp\u003eBased on the results mentioned above, the hypothesis model of social support, health education, health literacy and self-management behaviors of elderly hypertension patients was constructed (see Figure. 1). Using the maximum likelihood method for parameter estimation, standardized regression coefficient (path coefficient) was calculated, and all the paths that did reach a significant level (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05, \u003cem\u003eC.R.\u003c/em\u003e \u0026gt; 1.96). The standardized parameter estimates are shown in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e. Among the paths, social support had the biggest direct positive effect on self-management behaviors (0.187), followed by health education (0.158) and health literacy (0.157). The model also indicated that social support could positively impact self-management behaviors through health education and health literacy; health education could positively impact self-management behaviors through health literacy.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e* indicates a \u003cem\u003ep\u003c/em\u003e-value of less than 0.05;\u003c/p\u003e \u003cp\u003e*** indicates a \u003cem\u003ep\u003c/em\u003e-value of less than 0.001\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eStandardized parameter estimates of SEM model\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePath\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEstimate\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eS.E.\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eC.R.\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial Support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e--\u0026gt;\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHealth Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.413\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.033\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e8.376\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial Support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e--\u0026gt;\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHealth Literacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.336\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.152\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e6.895\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e--\u0026gt;\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHealth Literacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.077\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.159\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.048\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.027\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e--\u0026gt;\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAttend health lectures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.848\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e--\u0026gt;\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBrowse through health materials\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.916\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.047\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e22.726\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e--\u0026gt;\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVisit health education bulletin boards\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.871\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.035\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e28.170\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e--\u0026gt;\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReceive free medical consultation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.759\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.046\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e19.105\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e--\u0026gt;\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReceive individualized education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.718\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.049\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e18.019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial Support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e--\u0026gt;\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eObjective Support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.514\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial Support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e--\u0026gt;\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSubjective Support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.605\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.230\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e10.713\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial Support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e--\u0026gt;\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUtilization of Social Support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.567\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.121\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e10.605\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial Support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e--\u0026gt;\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSelf-management behaviors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.187\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.043\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3.839\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e--\u0026gt;\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSelf-management behaviors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.158\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.046\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4.658\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth Literacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e--\u0026gt;\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSelf-management behaviors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.157\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4.469\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e* indicates a \u003cem\u003ep\u003c/em\u003e-value of less than 0.05;\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e*** indicates a \u003cem\u003ep\u003c/em\u003e-value of less than 0.001\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eS. E.\u003c/em\u003e Standard Error in Estimate, \u003cem\u003eC. R.\u003c/em\u003e Critical Ratio\u003c/p\u003e \u003c/div\u003e"},{"header":"4 Discussion","content":"\u003cp\u003eSelf-management practices, in contrast to passive medical interventions, are essential measures for preventing the progression of the disease, aligning with the notion of proactive health, which was embodied in the Outline of the Healthy China 2030 Plan and the Healthy China Initiative, and then defined as \u0026ldquo;the sum of all social activities of human beings that revolve around health\u0026rdquo;\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. To achieve the strategic goal of proactive health, we need to pay more attention to the factors that influence self-management behaviors. In this study, the average score of self-management behaviors was 3.15\u0026thinsp;\u0026plusmn;\u0026thinsp;1.13, suggesting that on average the participants were only able to adhere to 3 of the recommended self-management behaviors. Specifically, only 55.79%, 45.18%, 42.28%, 79.82%, and 92.19% participants reported regular exercise, balanced diet, regular home blood pressure monitoring, regular physical examination and medication compliance. These findings indicate that the current state of self-management behaviors among elderly Chinese hypertensive patients needs improvement. However, the incidence of regular physical examination and medication compliance was higher than in current studies\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e, while the rate of regular home blood pressure monitoring was lower\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. Possible reasons for this are that both doctors and people around the patient deeply understand the importance of medication adherence and constantly remind the patient to stick to his/her medication, while in the overall environment, health education on home blood pressure monitoring is not widespread in China. Therefore, home blood pressure measurement of hypertensive patients should be paid more attention in future health education and health promotion work, and for older adults, our findings reflect that they should strengthen their use of home blood pressure measurement and be educated to perform simple operations to monitor blood pressure in real-time. Study showed less than half of the elderly patients owned a home blood pressure (BP) monitor\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e, so improving ownership of monitors could be a better start.\u003c/p\u003e \u003cp\u003eWe conducted a structural equation model to elucidate the connections among social support, health education, health literacy, and self-management behaviors. The obtained results supported our hypotheses that health education and health literacy positively and directly influence the self-management behaviors of hypertensive elderly patients. Moreover, our findings suggested that health literacy played a role in mediating the association between social support and self-management behaviors, and it indirectly mediated the association between health education and self-management behaviors. Our results validate the ecological model perspective in terms of individual, interpersonal, and social policy factors, all of which influence health behaviors\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. We also found that social support at the interpersonal level and health education service utilization at the policy level, in addition to directly influencing behavior, both indirectly influence health literacy at the individual level. Therefore, we recommend enhancing the utilization of health education services in the National Basic Public Health Service for elderly patients, improving their access to health information, and enhancing their health literacy.\u003c/p\u003e \u003cp\u003eThe utilization of health education in this study originated from China's National Basic Public Health Service, which was demonstrated to be effective in enhancing hypertension treatment and control\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e. However, the use of health education services was less common in this study, and literature has indicated that residents' satisfaction with the chronic disease health management and education modules of the basic public health service is lower\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e. Expanding the existing basic public health system not only aids in managing chronic disease patients, but also enhances patients' health literacy via health education and other approaches, thus promoting their health behaviors.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStrengths and limitations\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis study has some limitations. Firstly, being a cross-sectional study, this study has limitations in inferring causality. Secondly, most variables were self-reported, which involves potential recall bias of information, misclassification and overestimation. Thirdly, the original project was not considered comprehensively enough, some variables, such as other health behaviors, were not included in our study. However, this study covered cities with varied economic status in six provinces of China, and employed structural equation modeling to examine the correlation between the variables of social support, health education, health literacy, and self-management behaviors in elderly hypertensive patients for the first time, which can provide a theoretical basis and intervention ideas for us to better improve the self-management behaviors of elderly hypertensive patients.\u003c/p\u003e"},{"header":"5 Conclusion","content":"\u003cp\u003eThe situation of adopting self-management behaviors among elderly patients with hypertension is uneven in this study. We provide a unique perspective to explore the relationships between self-management behaviors, social support, health education and health literacy. The SEM analysis showed that social support, health education and health literacy all have an impact on self-management behaviors and complex interactions exist. Improving the social support, health education and health literacy of patients with hypertension can positively influence their self-management behaviors and therapeutic outcomes. This study is also helpful for the community to consider how to improve health education and health literacy by strengthening the utilization of basic public health services, and targeting SS to improve self-management behaviors among elder patients with hypertension, ultimately improving their health.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was given ethics approval and all participants signed an informed consent form and gave their informed consent to participate in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by National Health Commission of the PRC [grant numbers: 20190517].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eC.C., W.C. contributed to the conception of the study; Z.C., M.C., L.G., Y.T. \u0026nbsp;and C.C. contributed to data collection, Z.C., M.C. performed the data analysis; Z.C. wrote the manuscript; All authors reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe wish to thank investigators from all six provinces, whose hard work helped us to obtain comprehensive data, as well as all the seniors who completed the survey.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eOrganization WH. 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[published Online First: 2019/12/11].\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Hypertension, Health literacy, Social support, self-management behaviors, Structural equation model, Socia l ecological model","lastPublishedDoi":"10.21203/rs.3.rs-4568125/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4568125/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eHypertension is one of the world\u0026rsquo;s leading risk factors for death and disability. With a higher prevalence of hypertension, older adults need to strengthen self-management behaviors. The synergistic effects on self-management behaviors and the potential underlying mechanisms between self-management behaviors, health education, health literacy, and social support remain unclear.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA cross-sectional design and stratified multi-stage random sampling method were used to investigate hypertensive patients aged 60 years and older in six provinces from the eastern, central, and western regions of China. We collected data using questionnaires, and examined interactions among the factors using a structural equation model.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e1140 participants were included in this study. The SEM had a good overall fit. Health literacy, social support, and health education had a direct positive relationship with self-management behaviors (β\u0026thinsp;=\u0026thinsp;0.157, β\u0026thinsp;=\u0026thinsp;0.187, β\u0026thinsp;=\u0026thinsp;0.158, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Social support had an indirectly positive relationship with self-management behaviors through health education and health literacy. Health education had an indirectly positive relationship with self-management behaviors through health literacy.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe situation of adopting self-management behaviors among elderly patients with hypertension is uneven in this study. Social support, health education, and health literacy all have direct or indirect impacts on self-management behaviors.\u003c/p\u003e","manuscriptTitle":"Health literacy, social support, and health education, as factors associating with self-management behaviors among elderly patients with hypertension in China: a structural equation model","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-12 18:38:33","doi":"10.21203/rs.3.rs-4568125/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0434f9ea-dfd5-47e1-b008-234d148aca16","owner":[],"postedDate":"July 12th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-02-24T04:38:43+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-12 18:38:33","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4568125","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4568125","identity":"rs-4568125","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}