{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,28]],"date-time":"2026-06-28T03:46:06Z","timestamp":1782618366561,"version":"3.54.5"},"reference-count":40,"publisher":"Belitung Raya Foundation","issue":"3","license":[{"start":{"date-parts":[[2026,5,23]],"date-time":"2026-05-23T00:00:00Z","timestamp":1779494400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"award":[""],"award-info":[{"award-number":[""]}]}],"content-domain":{"domain":["belitungraya.org"],"crossmark-restriction":true},"short-container-title":["Belitung Nurs J"],"abstract":"<jats:p>Background: Uncontrolled hypertension leads to a number of complications. To achieve effective self-management, adults with uncontrolled hypertension need health literacy to promote and maintain good health. Transformative learning is a key adult learning paradigm that supports perspective transformation, self-management, and blood pressure control.\nObjective: This study aimed to evaluate the effects of a Transformative Learning Theory-Based Health Literacy Enhancement Program on self-management behaviors and blood pressure among adults with uncontrolled hypertension.\nMethods: This cluster-randomized controlled trial was conducted at two sub-district health-promoting hospitals in northeastern Thailand. Hospitals were randomly allocated to either the experimental or control group to prevent treatment contamination. A total of 58 participants (n = 29 per group) were consecutively recruited. Data were collected between February and June 2025 using a validated Self-Management Behavior Scale and digital BP monitoring. Data were analyzed using independent- and dependent-samples t-tests and repeated-measures ANOVA, and ANCOVA was used to compare groups while controlling for baseline values.\nResults: At 8 and 12 weeks after the program, the experimental group had significantly higher self-management scores than the control group (t = 2.117, p = 0.039; t = 3.416, p = 0.001, respectively) and than their own baseline (F = 31.958, p &lt; 0.001). Regarding clinical outcomes, ANCOVA revealed a significant main effect of the program on mean arterial pressure (MAP) at both 8 weeks (F(1, 55) = 9.014, p = 0.004, hp2 = 0.141) and 12 weeks (F(1, 55) = 9.133, p = 0.004,\u00a0 hp2 = 0.142). The adjusted mean MAP for the experimental group was significantly lower than the control group at the final follow-up (108.90 vs. 111.37 mmHg). A significant reduction was noted for systolic blood pressure (p = 0.028) but not diastolic blood pressure.\nConclusion: The study highlights the effectiveness of the program for improving self-management behaviors and systolic blood pressure. Nurses can integrate adult learning theories into health education to enhance outcomes for hypertensive patients in primary care.\nTrial Registry Number: Thai Clinical Trial Registry (TCTR20250202009)<\/jats:p>","DOI":"10.33546\/bnj.4543","type":"journal-article","created":{"date-parts":[[2026,6,28]],"date-time":"2026-06-28T03:02:43Z","timestamp":1782615763000},"page":"298-307","update-policy":"https:\/\/doi.org\/10.33546\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Effects of a transformative learning theory-based health literacy enhancement program on self-management behaviors and blood pressure in adults with uncontrolled hypertension in Thailand: A cluster randomized controlled trial"],"prefix":"10.33546","volume":"12","author":[{"ORCID":"https:\/\/orcid.org\/0009-0003-2247-117X","authenticated-orcid":false,"given":"Uraiwan","family":"Sasang","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1121-0850","authenticated-orcid":false,"given":"Decha","family":"Tamdee","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4095-7363","authenticated-orcid":false,"given":"Sivaporn","family":"Aungwattana","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1294-280X","authenticated-orcid":false,"given":"Chiraporn","family":"Tachaudomdach","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"19163","published-online":{"date-parts":[[2026,6,28]]},"reference":[{"key":"155118","doi-asserted-by":"crossref","unstructured":"Abdulsalam, F. I., Srichaijaroonpong, S., Phoosuwan, N., & Phoosuwan, N. (2025). Effectiveness of a Health Literacy and Diabetes Self\u2010Management Education (DSME) Improvement Program for people with type 2 diabetes mellitus: A community\u2010based quasiexperimental study in Thailand. Journal of Diabetes Research, 2025(1), 2640702. https:\/\/doi.org\/10.1155\/jdr\/2640702","DOI":"10.1155\/jdr\/2640702"},{"key":"155119","doi-asserted-by":"crossref","unstructured":"Barclay-Goddard, R., King, J., Dubouloz, C.-J., Schwartz, C. E., & Response Shift Think Tank Working, G. (2012). Building on transformative learning and response shift theory to investigate health-related quality of life changes over time in individuals with chronic health conditions and disability. Archives of Physical Medicine and Rehabilitation, 93(2), 214\u2013220. https:\/\/doi.org\/10.1016\/j.apmr.2011.09.010","DOI":"10.1016\/j.apmr.2011.09.010"},{"key":"155120","doi-asserted-by":"crossref","unstructured":"Charchar, F. J., Prestes, P. R., Mills, C., Ching, S. M., Neupane, D., Marques, F. Z., Sharman, J. E., Vogt, L., Burrell, L. M., & Korostovtseva, L. (2024). Lifestyle management of hypertension: International Society of Hypertension position paper endorsed by the World Hypertension League and European Society of Hypertension. Journal of Hypertension, 42(1), 23\u201349. https:\/\/doi.org\/10.1097\/HJH.0000000000003563","DOI":"10.1097\/HJH.0000000000003563"},{"key":"155121","unstructured":"Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Lewis\u2019s medical-surgical nursing: Assessment and management of clinical problems (11th ed.). Elsevier. https:\/\/books.google.co.th\/books?id=iB3GwgEACAAJ"},{"key":"155122","doi-asserted-by":"crossref","unstructured":"Hopewell, S., Chan, A.-W., Collins, G. S., Hr\u00f3bjartsson, A., Moher, D., Schulz, K. F., Tunn, R., Aggarwal, R., Berkwits, M., & Berlin, J. A. (2025). CONSORT 2025 statement: Updated guideline for reporting randomised trials. The Lancet, 405(10489), 1633\u20131640. https:\/\/doi.org\/10.1016\/S0140-6736(25)00672-5","DOI":"10.1016\/S0140-6736(25)00672-5"},{"key":"155123","doi-asserted-by":"crossref","unstructured":"Intarakamhang, U., & Macaskill, A. (2022). Effectiveness of a health literacy intervention based on transformative learning and incorporating positive psychology on health behavior and well-being of Thai families with NCDs risk. Journal of Public Health Research, 11(2), jphr\u20132021. https:\/\/doi.org\/10.4081\/jphr.2021.1935","DOI":"10.4081\/jphr.2021.1935"},{"key":"155124","doi-asserted-by":"crossref","unstructured":"Karami, M., Ashtarian, H., Rajati, M., Hamzeh, B., & Rajati, F. (2023). The effect of health literacy intervention on adherence to medication of uncontrolled hypertensive patients using the M-health. BMC Medical Informatics and Decision Making, 23(1), 289. https:\/\/doi.org\/10.1186\/s12911-023-02393-z","DOI":"10.1186\/s12911-023-02393-z"},{"key":"155125","doi-asserted-by":"crossref","unstructured":"Kulshreshtha, M., & Chandel, S. (2025). Mean arterial pressure may be a valuable tool for classifying blood pressure in physically actives: A cross-sectional study among females from North India. Clinical Epidemiology and Global Health, 31, 101912. https:\/\/doi.org\/10.1016\/j.cegh.2025.101912","DOI":"10.1016\/j.cegh.2025.101912"},{"key":"155126","doi-asserted-by":"crossref","unstructured":"Lemessa, F., & Lamessa, M. (2021). Uncontrolled hypertension and associated factors among hypertensive adults in Bale Zone Public Hospitals, Ethiopia. Journal of Hypertension and Management, 7(1), 185\u2013190. https:\/\/doi.org\/10.23937\/2474-3690\/1510057","DOI":"10.23937\/2474-3690\/1510057"},{"key":"155127","doi-asserted-by":"crossref","unstructured":"Lorig, K. R., & Holman, H. R. (2003). Self-management education: history, definition, outcomes, and mechanisms. Annals of Behavioral Medicine, 26(1), 1\u20137. https:\/\/doi.org\/10.1207\/S15324796ABM2601_01","DOI":"10.1207\/S15324796ABM2601_01"},{"key":"155128","unstructured":"Lorig, K. R., Sobel, D. S., Ritter, P. L., Laurent, D., & Hobbs, M. (2001). Effect of a self-management program on patients with chronic disease. Effective Clinical Practice: ECP, 4(6), 256\u2013262."},{"key":"155129","unstructured":"Mezirow, J. (1991). Transformative dimensions of adult learning (Vol. 350). San Francisco, CA: Jossey-Bass."},{"key":"155130","doi-asserted-by":"crossref","unstructured":"Mills, K. T., Stefanescu, A., & He, J. (2020). The global epidemiology of hypertension. Nature Reviews Nephrology, 16(4), 223\u2013237. https:\/\/doi.org\/10.1038\/s41581-019-0244-2","DOI":"10.1038\/s41581-019-0244-2"},{"key":"155131","unstructured":"Ministry of Public Health of Thailand. (2022). Morbidity and mortality rates in 2016-2021. http:\/\/www.thaincd.com\/2016\/mission\/documents.php?tid=32&gid=1-020"},{"key":"155132","unstructured":"Ministry of Public Health of Thailand. (2024). Annual report 2024. https:\/\/ddc.moph.go.th\/uploads\/publish\/1668120250117072316.pdf"},{"key":"155133","doi-asserted-by":"crossref","unstructured":"Mourouti, N., Michou, M., & Costarelli, V. (2022). Health literacy in relation to health outcomes in hypertension: A systematic review. Journal of Atherosclerosis Prevention and Treatment, 13(2), 109\u2013118.","DOI":"10.53590\/japt.02.1040"},{"key":"155134","doi-asserted-by":"crossref","unstructured":"Nutbeam, D. (2008). The evolving concept of health literacy. Social Science & Medicine, 67(12), 2072\u20132078. https:\/\/doi.org\/10.1016\/j.socscimed.2008.09.050","DOI":"10.1016\/j.socscimed.2008.09.050"},{"key":"155135","doi-asserted-by":"crossref","unstructured":"Nutbeam, D., & Lloyd, J. E. (2021). Understanding and responding to health literacy as a social determinant of health. Annual Review of Public Health, 42(1), 159\u2013173. https:\/\/doi.org\/10.1146\/annurev-publhealth-090419-102529","DOI":"10.1146\/annurev-publhealth-090419-102529"},{"key":"155136","doi-asserted-by":"crossref","unstructured":"Oh, J. S., Lee, C. H., Park, J.-i., Park, H.-K., & Hwang, J. K. (2020). Hypertension-mediated organ damage and long-term cardiovascular outcomes in Asian hypertensive patients without prior cardiovascular disease. Journal of Korean Medical Science, 35(48), e400. https:\/\/doi.org\/10.3346\/jkms.2020.35.e400","DOI":"10.3346\/jkms.2020.35.e400"},{"key":"155137","unstructured":"Ongkulna, K., Pothiban, L., Panuthai, S., & Chintanawat, R. (2022). Enhancing self-management through Geragogy-based education in older adults with uncontrolled hypertension: A randomized controlled trial. Pacific Rim International Journal of Nursing Research, 26(4), 690\u2013705."},{"key":"155138","unstructured":"Patanavanich, R., & Aekpalakorn, W. (2025). The seventh national health examination survey 2024\u20132025 [in Thai]. Thailand: Faculty of Medicine Ramathibodi Hospital, Mahidol University."},{"key":"155139","doi-asserted-by":"crossref","unstructured":"Persell, S. D., Karmali, K. N., Lee, J. Y., Lazar, D., Brown, T., Friesema, E. M., & Wolf, M. S. (2020). Associations between health literacy and medication self-management among community health center patients with uncontrolled hypertension. Patient Preference and Adherence, 14, 87\u201395. https:\/\/doi.org\/10.2147\/PPA.S226619","DOI":"10.2147\/PPA.S226619"},{"key":"155140","unstructured":"Pieasakran, T., Jiewpattanakul, Y., & Rerkluenrit, J. (2023). Effects of a health literacy exercise program on the exercise behaviors and health literacy of older adults with hypertension in the communities, Bangkok Metropolis. Nursing Science Journal of Thailand, 41(4), 44\u201355."},{"key":"155141","doi-asserted-by":"crossref","unstructured":"Redon, J., & Carmena, R. (2024). Present and future of drug therapy in hypertension: An overview. Blood Pressure, 33(1), 2320401. https:\/\/doi.org\/10.1080\/08037051.2024.2320401","DOI":"10.1080\/08037051.2024.2320401"},{"key":"155142","doi-asserted-by":"crossref","unstructured":"Sakboonyarat, B., Rangsin, R., Kantiwong, A., & Mungthin, M. (2019). Prevalence and associated factors of uncontrolled hypertension among hypertensive patients: A nation-wide survey in Thailand. BMC Research Notes, 12(1), 380. https:\/\/doi.org\/10.1186\/s13104-019-4417-7","DOI":"10.1186\/s13104-019-4417-7"},{"key":"155143","doi-asserted-by":"crossref","unstructured":"Santiparp, P. (2021). Health promotion program via social media for hypertension and diabetes mellitus patients. Advance in Public Health, Community and Tropical Medicine(3), 131. https:\/\/doi.org\/10.37722\/APHCTM.2021302","DOI":"10.37722\/APHCTM.2021302"},{"key":"155144","doi-asserted-by":"crossref","unstructured":"Schillaci, G., Pirro, M., & Mannarino, E. (2009). Assessing cardiovascular risk: Should we discard diastolic blood pressure? Circulation, 119(2), 210\u2013212. https:\/\/doi.org\/10.1161\/CIRCULATIONAHA.108.827931","DOI":"10.1161\/CIRCULATIONAHA.108.827931"},{"key":"155145","doi-asserted-by":"crossref","unstructured":"Shahaj, O., Denneny, D., Schwappach, A., Pearce, G., Epiphaniou, E., Parke, H. L., Taylor, S. J. C., & Pinnock, H. (2019). Supporting self-management for people with hypertension: A meta-review of quantitative and qualitative systematic reviews. Journal of Hypertension, 37(2), 264\u2013279. https:\/\/doi.org\/10.1097\/HJH.0000000000001867","DOI":"10.1097\/HJH.0000000000001867"},{"key":"155146","doi-asserted-by":"crossref","unstructured":"Singer-Brodowski, M. (2025). The potential of transformative learning for sustainability transitions: Moving beyond formal learning environments. Environment, Development and Sustainability, 27(9), 20621\u201320639. https:\/\/doi.org\/10.1007\/s10668-022-02444-x","DOI":"10.1007\/s10668-022-02444-x"},{"key":"155147","doi-asserted-by":"crossref","unstructured":"Song, Z., Zhao, H., Wei, Z., Zhao, W., Tan, Y., Yang, P., Chen, S., Wu, Y., Li, Y., & Wu, S. (2023). Mean arterial pressure trajectory with premature cardiovascular disease and all-cause mortality in young adults: The Kailuan prospective cohort study. Frontiers in Cardiovascular Medicine, 10, 1222995. https:\/\/doi.org\/10.3389\/fcvm.2023.1222995","DOI":"10.3389\/fcvm.2023.1222995"},{"key":"155148","doi-asserted-by":"crossref","unstructured":"Sriklo, M., Tamdee, D., Aungwattana, S., & Kaewthummanukul, T. (2023). Effects of enhance health literacy through transformative learning program on self-management and hemoglobin A1C level among adults with uncontrolled type 2 diabetes: A randomized controlled trial. Pacific Rim International Journal of Nursing Research, 27(2), 317\u2013333.","DOI":"10.60099\/prijnr.2023.262041"},{"key":"155149","doi-asserted-by":"crossref","unstructured":"Sukcharoen, P., Sakunpong, N., Polruk, J., & Chumdaeng, S. (2024). Impact of a transformative health literacy model for Thai older adults with hypertension. BMC Research Notes, 17(1), 278. https:\/\/doi.org\/10.1186\/s13104-024-06782-z","DOI":"10.1186\/s13104-024-06782-z"},{"key":"155150","doi-asserted-by":"crossref","unstructured":"Sukpattanasrikul, S., Monkong, S., Leelacharas, S., Krairit, O., & Viwatwongkasem, C. (2022). Comparison of hypertensive outcomes after the implementation of self-management program for older adults with uncontrolled hypertension in Krabi, Thailand: A quasi-experimental study. Journal of Health Research, 36(4), 641\u2013651. https:\/\/doi.org\/10.1108\/JHR-12-2020-0626","DOI":"10.1108\/JHR-12-2020-0626"},{"key":"155151","doi-asserted-by":"crossref","unstructured":"Suneja, M., & Sanders, M. L. (2017). Hypertensive emergency. Medical Clinics, 101(3), 465\u2013478. https:\/\/doi.org\/10.1016\/j.mcna.2016.12.007","DOI":"10.1016\/j.mcna.2016.12.007"},{"key":"155152","unstructured":"Thai Hypertension Society. (2024). 2024 Thai guidelines on the treatment of hypertension. Bangkok: Thai Hypertension Society."},{"key":"155153","doi-asserted-by":"crossref","unstructured":"Ukoha-kalu, B. O., Adibe, M. O., Anosike, C., & Ukwe, C. V. (2020). Knowledge, attitude and practice towards hypertension among patients receiving care in a Nigerian Hospital. Annals of Clinical Hypertension, 4(1), 16\u201319. https:\/\/doi.org\/10.29328\/journal.ach.1001023","DOI":"10.29328\/journal.ach.1001023"},{"key":"155154","doi-asserted-by":"crossref","unstructured":"van der Gaag, M., Heijmans, M., Spoiala, C., & Rademakers, J. (2022). The importance of health literacy for self-management: A scoping review of reviews. Chronic Illness, 18(2), 234\u2013254. https:\/\/doi.org\/10.1177\/17423953211035472","DOI":"10.1177\/17423953211035472"},{"key":"155155","unstructured":"World Health Organization [WHO]. (2025a). Hypertension. https:\/\/www.who.int\/news-room\/fact-sheets\/detail\/hypertension"},{"key":"155156","unstructured":"World Health Organization [WHO]. (2025b). Uncontrolled high blood pressure puts over a billion people at risk. https:\/\/www.who.int\/news\/item\/23-09-2025-uncontrolled-high-blood-pressure-puts-over-a-billion-people-at-risk"},{"key":"155157","doi-asserted-by":"crossref","unstructured":"Zhang, Q., Huang, F., Zhang, L., Li, S., & Zhang, J. (2021). The effect of high blood pressure-health literacy, self-management behavior, self-efficacy and social support on the health-related quality of life of Kazakh hypertension patients in a low-income rural area of China: A structural equation model. BMC Public Health, 21(1), 1114. https:\/\/doi.org\/10.1186\/s12889-021-11129-5","DOI":"10.1186\/s12889-021-11129-5"}],"container-title":["Belitung Nursing Journal"],"original-title":[],"link":[{"URL":"https:\/\/www.belitungraya.org\/BRP\/index.php\/bnj\/article\/download\/4543\/1368","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/www.belitungraya.org\/BRP\/index.php\/bnj\/article\/download\/4543\/1385","content-type":"text\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/www.belitungraya.org\/BRP\/index.php\/bnj\/article\/download\/4543\/1368","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,28]],"date-time":"2026-06-28T03:31:49Z","timestamp":1782617509000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.belitungraya.org\/BRP\/index.php\/bnj\/article\/view\/4543"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,6,28]]},"references-count":40,"journal-issue":{"issue":"3","published-online":{"date-parts":[[2026,6,28]]}},"URL":"https:\/\/doi.org\/10.33546\/bnj.4543","relation":{},"ISSN":["2477-4073"],"issn-type":[{"value":"2477-4073","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,6,28]]},"assertion":[{"value":"2025-12-27","order":0,"name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-01-29","order":1,"name":"revised","label":"Revised","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-05-23","order":2,"name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}}]}}