Determinants of self-rated health among elderly patients with hypertension: a cross-sectional analysis based on the Chinese longitudinal healthy longevity survey

ABSTRACT

Background

The total number of elderly patients with hypertension in China has been increasing year by year, it is necessary to adopt simple and valid measures to evaluate the health status of elderly patients with hypertension to reduce the heavy burden faced by this group.

Method

This study is a cross-sectional analysis. Participants aged at least 65 years were included. Self-Rated Health (SRH) assessment of respondents was classified into two groups: participants who responded as “very good” and “good” were considered as having good SRH, and participants who answered as “average,” “poor,” and “very poor” were considered as having poor SRH. Chi-square tests were used to determine differences in patient characteristics between the two groups. Binary logistic regression models were used to identify factors associated with SRH.

Results

The results of the logistic regression analysis indicated that having a spouse, better economic status, exercise, eating fruits and vegetables, nighttime sleep of 7 to 9 hours, good living environment, interaction with friends, and hypertension with comorbidity such as diabetes mellitus, heart disease, stroke or hyperlipidemia were influencing factors of SRH (P < .05). Another finding was that alcohol use significantly affected SRH (P < .05). Depression, anxiety, and community nursing services did not figure as determinants of health in this group.

Conclusion

The findings of this study provide evidence for the need to develop effective health promotion programs for the well-being of hypertensive patients.

KEYWORDS:

• CLHLS
• elderly patients
• environment
• human
• hypertension
• nursing
• self-rated health

Introdution

Hypertension is a major chronic non-communicable disease and a serious risk factor for cardiovascular diseases. Prevalence of hypertension among the elderly in China is as high as 50% (1). It is estimated that every 10 mmHg increase in systolic blood pressure increases the risk of ischemic heart disease by 45% and the risk of stroke by about 65% (2). In China, hypertension accounts for over 10.8 million deaths (3). China’s total health expenditure was US$ 457.6 billion, of which the direct economic burden of hypertension accounted for 6.61% (4), and imposing a significant burden on families and society. Healthy China 2030 noted that cardiovascular diseases such as hypertension restricted healthy life expectancy, and hence, emphasized management of blood pressure for improved health of people with hypertension (5). Additionally, hypertension among the elderly population in China needs considerable attention.

Self-rated health (SRH) is an individual’s perception of one’s current health status. Large-scale studies have shown that SRH is a reliable indicator that can comprehensively assess an individual’s physical and mental health and is an important supplement to the objective evaluation of physical health monitoring indicators (6–9). SRH assessments have been widely used in clinical decision-making (10), health education (11), and in health promotion and disease prevention (12). Thus, SRH assessments by elderly patients with hypertension are beneficial in formulating personalized clinical strategies, providing appropriate health education content, and ultimately promoting their health level while delaying the progression of chronic diseases. In recent years, research on SRH in hypertension in China and abroad has mainly focused on the correlation with hypertension (13,14), and paid little attention to the SRH status of hypertensive patients themselves. Therefore, it is of great practical significance to screen and assess SRH for the management of hypertension among the elderly in China.

Four paradigms of nursing include people, environment (internal environment: physiology and psychology; and external environment: natural environment and social environment), nursing, and health (15), which influence one another mutually. Environment and nursing modify human behavior and influence individual health. Previous studies mainly emphasized the impact of the environment, such as living environment (16), social interaction (17), and so on, on health, and research has seldom focused on the role of individual characteristics and nursing on health. Therefore, the SRH status and its determinants in 4,860 elderly patients with hypertension selected from the Chinese Longitudinal Healthy Longevity Survey (CLHLS) of 2018 were assessed from the perspectives of individual characteristics, environment, and nursing as guided by four paradigms of nursing.

Materials and methods

Study design

This was a cross-sectional analysis of the longitudinal study.

Data sources

Study participants were selected from the CLHLS database of 2018 (18), which included elderly citizens aged 65 years and above. The survey covered 23 provinces, municipalities, and autonomous regions in China, and had two types of questionnaires: the deceased questionnaire and the survivor’s questionnaire. Data from the survivor’s questionnaire were selected for this study, which mainly consists of the elderly’s living situation, evaluation of their status, personality, and emotional characteristics, reaction ability, lifestyle, ability to perform daily life activities, personal background, family structure, and physical health. The survey is nationally representative and can reflect the health status of the elderly in China.

The elderly aged 65 years and above, and those who had answered as “hypertension” to the question “Are you suffering from the following chronic diseases?” in the CLHLS database of 2018, were selected. The cases with missing values were deleted, and 4,860 samples were retained after removing ambiguous target values or missing samples.

Study variables

Health: self-rated health

Research shows that SRH presents good reliability and validity in reflecting individual health status (19), and is generally measured by the question “How do you rate your health status?” (20). SRH was considered as a dependent variable. For SRH, participants were asked based on the CLHLS “How do you rate your health at present?” Based on the SRH assignment method used in previous studies (21,22), we classified participants who responded “very good” and “good” as having good health status, assigning them a value of 1. For participants who responded “average,” “poor,” and “very poor” were considered to have a poor health status and were given a value of 0 in this study.

Individual characteristics

Individual characteristics included variables pertaining to individual demographics and individual lifestyle. Demographic variables included gender, age, occupation, marital status, and economic status. Variables concerning lifestyle in this study included smoking, alcohol use, exercise, eating fruits and vegetable and sleep, as per Wang et al. study (23). Smoking, alcohol use, and exercise were assigned as binary variables (yes = 1, no = 0). Eating fruits and vegetable both had four levels (everyday or almost everyday = 1, quite often = 2, occasionally = 3, rarely or never = 4). Sleep duration had three levels (<7 h = 1, 7–9 h = 2, > 9 h = 3).

Environment: internal environment and external environment

Physiology

Comorbidity is defined as the presence of two or more chronic diseases or medical conditions occurring at the same time (24,25). Hypertension is a common chronic disease in the elderly, often associated with hyperlipidemia, diabetes, and cardiovascular and cerebrovascular diseases. Comorbidity with hypertension increases the risk of adverse health outcomes and poses a serious threat to the health of the elderly in China. Considering these, hyperlipidemia, diabetes, heart disease, and stroke were used as indicators to measure physical health. Comorbidity with hypertension was assigned binary variables (yes = 1, no = 0).

Psychology

Anxiety and depression are common negative emotions, and are the main indicators of mental health. Hypertension commonly co-exists with depression or anxiety and is associated with adverse health outcomes (26,27). This study used the 10-item Centre for Epidemiologic Studies Depression Scale (CES-D − 10) and the Generalized Anxiety Disorder − 7 (GAD −7) questionnaire to measure the mental health of patients. The CES-D − 10 includes 10 items, each item is scored from 1 to 4, the total score is 40 points, and a score of ≥ 20 indicates depression. The GAD − 7 includes 7 items, each item is scored between 0–3 points, the total score is 21 points, and a score of ≥ 5 points indicates anxiety. Anxiety and depression are assigned as binary variables (yes = 1, no = 0).

Natural environment

The residential environment and air quality were used to measure the natural environment in this study. For assessing the natural environment, participants were asked six questions. First, where is your current residential area? (city = 1, town = 2, village = 3); Second, what type of dwelling is your house? (independent house = 1, duplex/triplex = 2, low-rise apartment (1–3 floors) = 3, high-rise apartment (>3 floors, without elevators) = 4, high-rise apartment (>3 floors, with elevators) = 5, others = 6); Third, during the past 1 year, was your home damaged due to broken pipes or heavy rain? (yes = 1, no = 0); Four, does your home frequently have a mildew odor or musty smell? (yes = 1, no = 0); Five, which fuel is normally used for cooking in your home? (yes = 1, no = 0); Finally, does your home use air purifiers or activated carbon to improve indoor air quality? (yes = 1, no = 0).

Social environment (social support).

Social support mainly comes from family and friends (28). The frequency of interaction with friends (never = 0, almost every day = 1, not daily, but once in a week = 2, not weekly, but at least once in a month = 3, not monthly, but occasionally = 4), frequency of social activities (never = 0, almost every day = 1, not daily, but once in a week = 2, not weekly, but at least once in a month = 3, not monthly, but occasionally = 4), and the number of cohabitants, and time spent with family members in a week (1–2 days = 1, 3–5 days = 2, 5–7 days = 3) were used to assess social support.

Nursing: community nursing

The document “Opinions on Comprehensively Promoting Home Care Services” emphasized that the government and society should aim to provide community-based care services reliant on community platforms (29). Community nursing, as an important supplement to hospital care, has been advocated in China (30). Offering personalized care, psychological counseling, making home visits, and imparting healthcare education are the most common modes of providing nursing care in the community in China (31). To assess community nursing, participants were asked four questions based on the CLHLS: (1) “Are personal daily care services available in your community?” (2) “Are psychological counseling services available in your community?” (3) “Are home visit services available in your community?” and (4) “Are healthcare education services available in your community?” Accordingly, each component of community nursing was set as a binary variable depending on whether they were available in the participant’s community (yes = 1, no = 0).

Statistical analysis

Statistical analyses were performed using SPSS 26 software. Frequencies (percentages) were used to describe categorical variables. χ2 tests and odds ratios (OR) were used to assess bivariate associations of variables with self-rated health. P < .05 was used to determine statistical significance for analyses. Binary logistic regression model analysis was used to determine the influencing factors of SRH. A two-tailed P value of less than 0.05 was regarded as statistically significant.

Ethical considerations

All components of this survey were approved by the institutional review board (IRB) of Peking University (IRB document number: 00001052–13074) (32). This study was part of the author’s master’s degree research project, and it was approved by the institutional review board (IRB) of the University of South China (IRB document number: N20221121–08).

Results

Self-rated health status

Of the 4,860 respondents included in the study, 2,059 (42.4%) of them reported good health status, and 2,081 (57.6%) had poor health status. (Table 1)

Table 1. Single factors of self-rated health in personal characteristics.

	Variable	Poor SRH (n = 2801)	Good SRH (n = 2059)	χ^2	P
Demographic characteristics	gender			4.338	.037
	male	1192(42.6%)	938(45.6%)
	female	1609(57.4%)	1121(54.4%)
	age			1.187	0.392
	≤75	856(30.6%)	615(29.9%)
	76–90	1341(47.9%)	966(46.9%)
	>90	604(21.5%)	478(23.2%)
	Profession			10.351	0.241
	unemployed	27(1%)	27(1.3%)
	professional or technical personnel/doctors/teachers	224(8%)	160(7.8%)
	governmental, institutional or managerial personnel	123(4.4%)	91(4.4%)
	staff/service worker/industrial worker	467(16.7%)	320(15.5%)
	self-employer	45(1.6%)	54(2.6%)
	agriculture, forestry, animal husbandry, fishery	1367(48.8%)	980(47.6%)
	housewife	136(4.9%)	96(4.7%)
	military personnel	20(0.7%)	18(0.9%)
	other	392(13.9%)	313(15.2%)
	marital status			18.426	0.001
	never married	28(1%)	4(0.2%)
	currently married and living with spouse	1390(49.6%)	954(46.3%)
	separated	38(1.4%)	28(1.4%)
	divorced	10(0.4%)	7(0.8%)
	widowed	1335(47.6%)	1066(51.8%)
	economic status			213.377	0.000
	poor	361(12.9%)	89(4.3%)
	so so	2009(71.7%)	1358(66%)
	rich	431(15.4%)	612(29.7%)
	Smoking			2.402	0.121
	no	2431(86.8%)	1755(85.2%)
	yes	370(13.2%)	304(14.8%)
	Drinking			30.195	0.000
	no	2486(88.8%)	1715(83.3%)
	yes	315(11.2%)	344(16.7%)
	Exercise			68.983	0.000
	no	1904(68%)	1160(56.3%)
	yes	897(32%)	899(43.7%)
	Sleep times			85.687	.000
	<7	1247(44.5%)	647(31.4%)
	7–9	1157(41.3%)	1044(50.7%)
	>9	397(14.2%)	368(17.9%)

Individual characteristics

Table 1 shows that the age range of the respondents was 76–90 years, of whom 56.2% were female, and 48.3% worked in forestry, animal husbandry, and fishery. Female respondents had worse SRH status compared to males (P < .05). Nearly half of the respondents (48.2%) were currently married and living with spouses. The economic status of a majority of respondents (69.3%) was average. Differences in SRH with respect to age, gender, marital status, living with spouse, and economic status were statistically significant (P < .05, P < .001). Majority were nonsmokers (86.1%), nondrinkers (86.4%) and more than half were non-exercisers (63.0%). Being a nondrinker and non-exerciser were associated with worse SRH scores (P < .001). Eating fruits (31.0%) and vegetable (70.3%) everyday or almost everyday were associated with better SRH scores (P < .001). About 45.3% of patients slept for 7–9 hours at night. Night-time sleep duration of 7–9 hours was associated with better SRH scores (P < .001). (Table 1).

Environmental factors

Table 2 shows the physical health status, mental health status, natural environment, and social environment of elderly patients with hypertension. Regarding physical health status, approximately 17.0% had diabetes mellitus, 24.4% had heart disease, 15.1% had stroke, and 8.7% had hyperlipidemia as hypertension comorbidities. Compared with respondents who reported poor SRH, respondents who reported good SRH were less likely to have diabetes mellitus, heart disease, stroke, or hyperlipidemia (P < .001). With respect to mental health status, 18.3% of the patients reported feeling depressed, 14.5% of them reported that they always felt anxious. There was no significant difference between mental health status and SRH. Regarding the natural environment, 41.2% were from rural areas. Most respondents lived in an independent house, and this was associated with better SRH scores (P < .001). Compared with those who reported poor SRH, respondents who reported good SRH were residing in dwellings that were less likely to be damaged and have musty smell (P < .001). The proportion of respondents without air purification in their houses who reported poor SRH was significantly higher than those that reported good SRH (P < .05). With respect to the social environment, 37.3% never interacted with friends (P < .001), and 91.0% of respondents reported that their family time was no more than two days (P < .05). There was no significant difference between frequency of social interaction and number of cohabitants with SRH.

Table 2. Single factors of self-rated health in environmental factors.

	Variable	Poor SRH (n = 2801)	Good SRH (n = 2059)	χ^2	P
Internal Environment: physical status	combined diabetes	573(20.5%)	251(12.2%)	57.605	0.000
	concomitant heart disease	814(29.1%)	373(18.1%)	80.617	0.000
	combined stroke	517(18.5%)	215(10.4%)	60.363	0.000
	Combined hyperlipidemia	303(10.8%)	121(5.9%)	38.026	0.000
Internal environment: mental status	depression			1.592	0.207
	no	2273(81.1%)	1700(82.6%)
	yes	528(18.9%)	359(17.4%)
	anxiety			1.604	0.302
	no	2381(85%)	1772(86.1%)
	yes	420(15%)	287(13.9%)
External environment: nature environment	place of residence			2.684	0.261
	city	791(28.2%)	572(27.8%)
	town	883(31.5%)	613(29.8%)
	rural	1127(40.3%)	874(42.4%)
	type of residence			39.826	0.000
	detached house	1541(55%)	1187(57.6%)
	duplex/triplex	346(12.4%)	156(7.6%)
	low rise apartment (1–3 floors)	173(6.2%)	123(6%)
	high rise apartment (>3 floors, without elevators)	446(15.9%)	384(18.6%)
	high rise apartment (>3 floors, with elevators)	202(7.2%)	165(8%)
	other	93(3.3%)	44(2.2%)
	Is the house damaged?			52.619	0.000
	no	2155(76.9%)	1756(85.3%)
	yes	646(23.1%)	303(14.7%)
	Is the house moldy?			46.878	0.000
	no	2316(82.7%)	1846(89.7%)
	yes	485(17.3%)	213(10.3%)
	Does the house purify the air?			4.962	0.026
	no	2565(91.6%)	1847(89.7%)
	yes	236(8.4%)	212(10.3%)
External environment: Society environment	communicate with friends			47.43	0.000
	almost everyday	702(25.1%)	690(33.5%)
	not daily, but once for a week	495(17.7%)	355(17.2%)
	not weekly, but at least once for a month	235(8.4%)	132(6.4%)
	not monthly, but sometimes	279(10%)	157(7.6%)
	never	1090(38.8%)	725(35.3%)
	Social activities			9.061	0.060
	almost everyday	76(2.7%)	87(4.2%)
	not daily, but once for a week	89(3.2%)	63(3.1%)
	not weekly, but at least once for a month	123(4.4%)	83(4%)
	not monthly, but sometimes	182(6.5%)	123(6%)
	never	2331(83.2%)	1703(82.7%)
	Number of cohabitants	2.19 ± 1.577	2.44 ± 1.577	12.452	0.570
	Family time			7.029	0.030
	2 days or less	2545(90.9%)	1876(91.1%)
	3–5 days	146(5.2%)	81(3.9%)
	more than 5 days	110(3.9%)	102(5%)

Community nursing

The majority of the respondents had no personalized care (90.2%), no psychological counseling (85.4%), and more than half had no home visit (65.5%) and no healthcare education (55.7%). Having no personalized care and having no psychological counseling were associated with better SRH scores (P < .05). There was no significant difference between home visits and healthcare education with SRH. (Table 3)

Table 3. Single factors of self-rated health in community nursing.

	Variable	Poor SRH (n = 2801)	Good SRH (n = 2059)	χ^2	P
community nursing	personal care			4.712	0.03
	no	2550(91%)	1836(89.2%)
	yes	251(9%)	223(10.8%)
	psychological counseling			5.16	0.023
	no	2420(86.4%)	1731(84.1%)
	yes	381(13.6%)	328(15.9%)
	home visit			1.418	0.234
	no	1858(66.3%)	1332(64.7%)
	yes	943(33.7%)	727(35.3%)
	healthcare education			0.04	0.841
	no	1563(55.8%)	1143(55.5%)
	yes	1238(44.2%)	916(44.5%)

Binary logistic regression model

The adjusted association of three dependent variables (individual characteristics, environment, and community nursing) with self-rated health (independent variable of interest) were examined using logistic regression analysis. Model 1 adjusted for gender, marital status, economic status, alcohol use, eating fruits and vegetables, and exercise. Model 2 included variables from model 1 plus physical status (hypertension comorbidities). The results revealed that there was significant difference between gender and SRH. Models 3 included variables from model 2 plus the natural environment. The results showed that living in a duplex/triplex residence, living in a dwelling that was damaged, and living in a dwelling that had a musty smell, and living in a dwelling that was not air-purified negatively impacted SRH status. Interaction with friends almost every day positively impacted SRH status. Model 4 included all the variables in the survey. There was no significant difference between personalized care/psychological counseling and SRH. Overall, determinants of SRH included marital status, economic status, alcohol use, exercise, duration of sleep, hypertension with comorbidities, natural environment, and interaction with friends almost every day. (Table 4)

Table 4. Logistic regression analysis results of self-rated health influencing factors in elderly hypertensive patients.

		Model 1		Model 2		Model 3		Model 4
personal characteristics	gender	OR	P	OR	P	OR	P	OR	P
	male	1		1		1		1
	female	0.986	0.832	0.987	0.848	0.957	0.527	0.959	0.546
	marital status
	never married	1		1		1		1
	currently married and living with spouse	3.581	0.021	4.073	0.012	4.201	0.010	4.222	0.010
	separated	3.693	0.031	4.308	0.017	4.276	0.018	4.316	0.017
	divorced	4.675	0.041	5.935	0.019	6.214	0.016	6.222	0.016
	widowed	4.832	0.004	5.44	0.002	5.545	0.002	5.562	0.002
	economic status
	poor	1		1		1		1
	so so	2.490	0.000	2.567	0.000	2.361	0.000	2.352	0.000
	rich	4.985	0.000	5.514	0.000	4.811	0.000	4.796	0.000
	Drinking
	no	1		1		1		1
	yes	1.619	0.000	1.465	0.000	1.466	0.000	1.467	0.000
	Exercise
	no	1		1		1		1
	yes	1.546	0.000	1.600	0.000	1.532	0.000	1.532	0.000
	Sleep times
	<7	1		1		1		1
	7–9	1.683	0.000	1.605	0.000	1.556	0.000	1.554	0.000
	>9	1.777	0.000	1.643	0.000	1.628	0.000	1.627	0.000
Internal Environment: physicalstatusstatus status	diabetes			0.619	0.000	0.614	0.000	0.615	0.000
	heart disease			0.566	0.000	0.572	0.000	0.571	0.000
	stroke			0.581	0.000	0.586	0.000	0.586	0.000
	hyperlipidemia			0.595	0.000	0.586	0.000	0.584	0.000
External environment:natureenvironmentnatureenvironment nature environment	type of dwelling
	detached house					1		1
	duplex/triplex					0.705	0.002	0.707	0.002
	low rise apartment (1–3 floors)					0.888	0.370	0.885	0.358
	high rise apartment(>3 floors, without elevators)(>3 floors, without elevators) (>3 floors, without elevators)					1.082	0.388	1.074	0.441
	high rise apartment(>3 floors, with elevators)(>3 floors, with elevators) (>3 floors, with elevators)					0.940	0.621	0.934	0.589
	other					0.756	0.164	0.759	0.172
	Is the house damaged?
	no					1		1
	yes					0.77	0.005	0.772	0.005
	Is the house moldy?
	no					1		1
	yes					0.780	0.019	0.778	0.020
	Does the house purify the air?
	no					1		1
	yes					1.272	0.027	1.268	0.029
External environment:socialenvironmentsocialenvironment social environment	communicate with friends
	almost everyday					1		1
	not daily, but once for a week					1.345	0.000	1.347	0.000
	not weekly, but at least once for a month					1.090	0.352	1.092	0.344
	not monthly, but sometimes					0.885	0.346	0.881	0.328
	never					0.877	0.274	0.880	0.287
	Family time
	2 days or less					1		1
	3–5 days					0.864	0.338	0.863	0.337
	more than 5 days					1.354	0.050	1.350	0.052
community nursing	personal care
	no							1
	yes							1.127	0.273
	psychological counseling
	no							1
	yes							1.005	0.947

Discussion

Individual characteristics

Determinants of SRH among individual characteristics included marital status, economic situation, exercise, alcohol use, and sleep.

Marital status

Amongst all determinants of SRH in the study, marital status was found to be a strong influencing factor. Sasivimol et al (33) found that family caregivers can provide social support, and assist and supervise the elderly to control blood pressure, and this was of great significance in improving the health of elderly hypertensive patients. Spouse and children are the main and immediate family caregivers (34). The findings of the current study confirm that compared with unmarried respondents, those who had a spouse earlier (divorced and widowed) and those who still have a spouse (married and separated) had better SRH. Elderly patients having spouses can supervise one another mutually, identify problems, and receive better home care. Notably, compared with those who still have spouses (married and separated), the elderly hypertensive patients who are divorced and widowed have better SRH. The divorced population may have better SRH due to reduced long-term family conflicts (35), which warrants further analysis. On the other hand, the widowed population may lack spiritual care from their spouses, such as companionship and comfort. However, the elderly have rich life experience and the ability to cope with negative events, which can promote their SRH (36). Additionally, divorced and widowed persons may get more attention from their children, however, they are more reluctant to trouble their children and become a burden on their children, and they tend to maintain their health more carefully. It is important for the unmarried elderly to make efforts to change their lifestyle and involve themselves more in social activities to reduce the sense of loneliness caused by the absence of family. For the elderly with spouses, their efforts must be toward strengthening effective communication and interaction with their spouses such as emotional sharing, sharing interests, and getting and offering timely feedback on their physical and mental difficulties. Those elderly who have lost their spouses should pay more attention to their emotional changes to maintain better health.

Economic status

Economic status was another factor influencing SRH among elderly hypertensive patients in the study. Respondents with better economic status had better SRH, which may be related to the fact that people with better economic status can receive more professional care and have access to more channels to get health information to protect their own health. According to Maslow’s hierarchy of needs, individuals consider their quality of life and basic family functions before their health, only after their physiological needs are met (37). For the elderly with poor economic conditions, most of them may be engaged in manual labor. Overwork can easily lead to illness and affect their physical health; in addition, for people with limited economic conditions, when they are ill, their health behavior and opportunities for medical treatment are greatly reduced, thus affecting their self-assessed health. Therefore, communities or health centers should allocate medical resources reasonably, strengthen step-wise diagnosis and treatment, and provide better medical care for elderly hypertensive patients. The government should strengthen financial security and increase social welfare toward ensuring the basic living needs of elderly hypertensive patients.

Exercise

Previous studies had shown that exercise was the most important auxiliary antihypertensive measure in hypertensive patients (38). A randomized controlled trial conducted by Palmeira et al. showed that exercise can effectively control blood pressure; 63% of patients had a systolic blood pressure drop of more than 5 mmHg with exercise, and the risk of stroke, coronary artery disease, and death could be reduced by at least 7%. In addition, studies have found that exercise can reduce cardiac fibrosis and prevent cardiac insufficiency in elderly hypertensive patients (39). In conclusion, exercise can lower blood pressure, improve cardiopulmonary function, and improve the health level of patients. The results of the current study also revealed that the elderly who exercised, had better health status, however, only one-third of elderly hypertensive patients persisted with exercise. To promote the health benefits of exercise among elderly hypertensive patients, it is important to encourage them to engage in regular aerobic physical exercise, such as walking, jogging, and swimming, for at least 30 minutes per day, five days a week. Strenuous exercise is not recommended for older people, and patients should be instructed to prioritize safety while exercising (40). Additionally, other traditional Chinese exercises, such as Tai Chi, may also be beneficial for improving the SRH of older adults (41). Only 23.8% of elderly hypertensive patients with poor economic status participated in exercise in the current study. At the same time, the data showed that respondents with poor economic status were mainly engaged in agriculture, forestry, animal husbandry, fishing, and other jobs. It is evident that physical labor also affected the rate of participation in exercise among elderly patients with hypertension. Therefore, for people who are mainly engaged in physical work, they should pay attention to get rest at regular intervals and not exercise excessively, so as to not aggravate the progression of the disease.

Alcohol use

Studies have shown that alcohol can damage the nervous system and cause cardiorespiratory dysfunction, seriously affecting health. However, the effect of alcohol on the cardiovascular system is controversial (42). Current epidemiological data provides strong evidence that low or moderate alcohol consumption (but not no or moderate alcohol consumption) reduces all-cause mortality and cardiovascular risk; for women it was 1 drink per day and 2 drinks for men (alcohol use of 1–2 drinks refers to 12.5–25 g of alcohol), which had the greatest benefit in reducing blood pressure (43). At the same time, alcohol drinkers had better SRH, which was different from the findings of Phillips et al (44). This may be because moderate alcohol use is beneficial in dilating blood vessels, lowering blood pressure, and reducing the incidence of cardiovascular events. In addition, some people like to drink specific wine considered beneficial to health. Thus, elderly hypertensive patients can gain better physical and mental satisfaction by moderate consumption of health-benefitting wine, so their health status is better. It is important that elderly hypertensive patients maintain good health behavior. If they do not have a drinking habit, it is recommended that they do not drink alcohol; if they drink alcohol, they should choose a moderate amount and choose drinks with low alcohol content and avoid drinking alcohol with high spirit content. The preferred daily alcohol intake for men should not exceed 25 g, and no more than 15 g for women (45), keeping in mind that they should not drink alcohol in excess.

Eating fruits and vegetables

Diet is an essential part of lifestyle and closely related to the occurrence of hypertension in the elderly (46). A balanced intake of fruits and vegetables can enhance overall health (47). Fruits and vegetables are abundant in vitamins and minerals, and their moderate consumption can facilitate blood pressure control, decrease cardiovascular risk, and improve health outcomes (48,49). The present study showed that consuming fruits and vegetables daily or almost everyday was associated with better SRH, which is consistent with the findings by Hrezova et al (50). Therefore, medical staff should encourage elderly hypertensive patients to strengthen diet control, including an increased intake of fruits and vegetables, to effectively manage blood pressure and improve their overall health status.

Sleep

Sleep affects human hormone secretion and metabolic balance, and is an important factor affecting human health (51). In 2015, the American Academy of Sleep Medicine and the Sleep Research Association recommended that the optimal duration of sleep for adults should be at least 7 hours, and recognized that sleep less than 6 hours per night is sleep deprivation or too little sleep, and sleep more than 9 hours per night is too much sleep (52). Both too long and too short duration of sleep has adverse effects on cardiovascular health (53). Studies have shown that both insufficient and excessive sleep can lead to abnormal diurnal variation in blood pressure and increase cardiovascular risk (54). Based on the results of the current study, SRH was good when the duration of sleep was 7 hours and more. Compared with <7 h, > 9 h, the SRH status was the best when the sleep duration was at 7–9 hours. Thus, moderate sleep is crucial to human health. Therefore, it is important to pay attention to sleep in elderly hypertensive patients, popularize information about healthy sleep, strengthen the management of duration of sleep, ensure proper sleep hygiene, and prevent and reduce health problems caused by too little or too much sleep.

Environmental factors

The determinants of SRH in environmental factors included hypertension with other comorbidity, good living environment, and interaction with friends.

Internal environment

Physical status: hypertension with other comorbidity

Hypertension with other comorbidity was another factor affecting the SRH of elderly hypertensive patients in the current study. Elderly patients who had hypertension complicated with diabetes, heart disease, stroke, or hyperlipidemia, had poorer health status. It could be assumed that comorbidities with hypertension increased the incidence and recurrence rates of cardiovascular disease (55,56). Hypertension and diabetes are risk factors for stroke (57). Studies have shown that new strokes and recurrent strokes were significantly increased in patients with hypertension and diabetes (58). The recurrence rate of stroke was significantly increased (59) and hospital admissions more than doubled in patients with hypertension and stroke (60). High blood pressure and heart disease can eventually lead to heart failure. Wang et al (60) investigated 11 695 study participants and found that compared with patients with only hypertension or only hyperlipidemia, patients with hypertension and hyperlipidemia had a higher risk of ischemic stroke. The results showed that 3% of the overall risk of ischemic stroke was due to the synergy between hypertension and hyperlipidemia. Therefore, it is necessary to strengthen the management of comorbidities in hypertensive patients, prevent and control risk factors for cardiovascular disease, promote physical and mental health, improve the quality of life, and reduce their medical burden.

Mental health status: anxiety and depression

In terms of mental health status, anxiety and depression are two common negative emotions among elderly hypertensive patients, which can adversely affect the control, development, and prognosis of blood pressure (61). Tully et al (62) found that anxiety or depression was an independent risk factor for cardiovascular disease. Studies have shown that negative emotions can lead to adverse living habits, such as overeating, poor medication compliance, and so on, which can compromise the quality of life and lead to poor health (63). In the current study, the prevalence of depression in elderly hypertensive patients was 18%, and the incidence of anxiety was 14%. The analysis of the relationship between mental health status and SRH scores in patients with hypertension did not reveal any correlation between the two. The probable reasons are as follows: ① Most of the people surveyed in this study were over 75 years old. They have experienced difficult times in China, and they have also witnessed the progress made in the country. They have rich life experiences which have made them more open-minded with a lower level of anxiety and depression; ② Most of the respondents were still accompanied by their spouses, and they could express their feelings to each other and resolve their negative emotions. Despite this, it is still paramount to pay attention to the mental health of elderly hypertensive patients and avoid health problems caused by negative emotions as much as possible. Additional research is required to further evaluate the relationship between anxiety and depression and self-rated health of the elderly with hypertension.

External environment

Natural environments

In terms of the type of dwelling, previous studies had observed the impact of the type of dwelling on health (64). The findings of the current study indicate that the elderly who lived in duplex/triplex residences had better SRH. As the saying goes, “a good neighbor is better than a brother far off.” Living in duplex/triplex residences means more neighbors. Neighborhood interactions can diversify one’s social network, increase the sense of community identity and belonging, and improve quality of life. The quality of housing is another influencing factor of SRH. An unsatisfactory environment (such as a damaged house, rain leakage, and presence of mold) can affect the health of patients, while on the other hand, maintaining clean air in the house promotes health. Older hypertensive patients with high quality housing were more likely to report better health outcomes. This finding is consistent with those in the study by Qu et al (65). The probable reasons are as follows: ① Poor housing conditions affect the psychological state of patients, and depression is more likely to occur when living in an unsatisfactory environment for a long time; ② Poor housing conditions may mean that the respondents have poor family conditions and are unable to manage their living needs and seek or get prompt medical treatment, resulting in poorer SRH. For improving the health of elderly hypertensive patients, it is recommended that a good living environment and comfortable living space is created for them. For those with a poor living environment, the government and community should strengthen measures to provide basic guarantees for these groups and protect the health of elderly hypertensive patients.

Social environment

Communicating with friends as a form of social connectedness is part of an individual’s social support. As is evidenced in the current study, elderly hypertensive patients who communicated with friends frequently, had better SRH status. The probable reasons are as follows: by communicating with friends, people can share happy and sad events in life and relieve loneliness; communicating with friends can help people get more health information to maintain health; friends can monitor each other, encourage each other and set an example for each other. Therefore, it is necessary to encourage elderly hypertensive patients to communicate with friends and participate in social activities to strengthen their social connections and improve their physical and mental health.

Community nursing

There was no correlation between the relationship between community nursing and SRH scores in patients with hypertension. A further analysis revealed that the proportion of elderly who used personalized care in the community was only 9.8%. This may be because residents of China have more trust in the medical resources of high-level hospitals, and they have access to treatment in tertiary hospitals regardless of the severity of the disease, resulting in only a small proportion using personalized care in the community. Hosseinnejad et al (66) pointed out that community workers were unable to provide appropriate care and follow-up for hypertensive patients due to their heavy workload, and pointed out that patients did not trust the care provided in the community. Also, previous evidence has shown that as high as 42.6% of older adults with hypertension in China did not receive advices on hypertension management (67,68). The current findings suggest that the government should strengthen the establishment of graded diagnosis and treatment at the grassroots and increase investment in community nursing and medical resources. With the advancing technology, mHealth intervention can be used for hypertension management (69,70), potentially enhancing SRH. Community hospitals can improve remote services for hypertensive patients by encouraging the creation of community nursing teams through mobile technology. At the same time, patients also need to be able to choose the appropriate treatment site according to the severity of the disease. Further, only 14.5% of the respondents had used psychological counseling services in the community, which may be related to the lack of attention to such services from the patients themselves: the findings revealed that the incidence of anxiety and depression among elderly hypertensive patients was low, so they may have paid less attention to the information about psychological counseling being provided in the community. In addition, the shortage of psychological counseling professionals could also affect the growth of psychological counseling services in the community. Therefore, both the patients and the community should pay more attention to psychological counseling to maintain the physical and mental health of elderly hypertensive patients.

Advantages and limitations of the study

This study analyzes the status quo and determinants of SRH of elderly hypertensive patients based on CLHLS data of 2018. The data has a large sample size and wide coverage, and the results are more representative. Factors influencing SRH of elderly hypertensive patients were analyzed from three aspects: individual characteristics, environment, and nursing, and the analysis was comprehensive. Not only were the statistically significant factors analyzed, but also the variables that were not statistically significant such as mental health status and community nursing services based on the actual situation were studied, and appropriate suggestions proposed. Exercise is the main auxiliary antihypertensive measure for hypertension. The role of economic status was comprehensively analyzed when reviewing the effect of exercise on SRH of elderly hypertensive patients. However, there are still some limitations in this study: in terms of data, the SRH outcomes of this study were measured by a single item rather than a more comprehensive and accurate questionnaire. The study did not include data such as relevant laboratory test results and more detailed clinical results. This was a cross-sectional survey, and the analysis does not establish causality and there are limitations in this sense. In terms of results, the influence of mental health status and community nursing services on self-rated health were not explored.

Conclusion

Based on four paradigms of nursing, the determinants of SRH of elderly hypertensive patients were comprehensively analyzed from the aspects of individual characteristics, environment, and nursing, in this study, and reasonable suggestions for promoting better health among elderly hypertensive patients are proposed. In the future, based on the foundation provided by this research, the mechanisms that influence SRH in elderly hypertensive patients and intervention targets will be further explored, and the influence of mental health status and community nursing services on the SRH of elderly hypertensive patients will be more comprehensively analyzed, to provide a reference for facilitating the creation of personalized comprehensive assessment and intervention measures for this group.

Abbreviations

SRH	=	Self-Rated Health
CLHLS	=	Chinese Longitudinal Healthy Longevity Survey

Availability of data and materials

The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request.

Ethics approval and consent to participate

This study was conducted with approval from the Ethics Committee of University of South China (No: N2021121–08). This study was conducted in accordance with the declaration of Helsinki. Written informed consent was obtained from all participants.

Acknowledgments

We would like to acknowledge the hard and dedicated work of all the staff that implemented the intervention and evaluation components of the study.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

This work was supported by grants from Science and technology innovation project of Hunan Province (2020SK51810), and project of education department of Hunan Province (19A426).