# A Mixed Methods Evaluation of Ecological Momentary Assessments: The Impact of Self-Monitoring and Lifestyle Education in Patients With Uncontrolled Hypertension

## TL;DR

This study explores how self-monitoring and education affect blood pressure and emotions in patients with uncontrolled hypertension.

## Contribution

The study introduces a mixed methods approach to evaluate real-time emotional and lifestyle influences on blood pressure in diverse patients.

## Key findings

- Positive emotions were associated with lower home blood pressure over time.
- Participants reported that negative emotions influenced health behaviors and blood pressure.
- Healthy habits helped reduce the impact of emotions on blood pressure for some participants.

## Abstract

Background: Psychological stress is known to influence blood pressure (BP) and cardiovascular health, yet limited research has explored real-time associations between emotions, lifestyle behaviors (diet and physical activity), and BP in diverse primary care populations with uncontrolled hypertension. This study evaluated the relationship between momentary emotions, diet, physical activity, and home BPs in patients participating in a six-week self-monitoring program that included ecological momentary assessments (EMAs) and coping skills and lifestyle education.

Methods: Patients with uncontrolled hypertension (defined as BP>130/80 mm Hg) who preferred lifestyle changes over medication intensification participated in a feasibility study involving EMA-based self-monitoring of BP, diet, physical activity, sleep, and emotions. Linear mixed effects models and time-varying effect models (TVEMs) were used to examine change over time in negative affect, positive affect, diet, physical activity, sleep, and home BPs. A convergent mixed methods design was used, combining linear mixed effects models to analyze BP trends and thematic analysis of qualitative participant feedback.

Results: A total of 29 participants (mean age: 55.3±10.6 years, 22 (75.9%) female, 13 (44.8%) Black) completed the intervention. Systolic and diastolic BP and positive affect changed significantly over time (p<0.0001). No significant changes were observed in diet, sleep, physical activity, and negative affect within day or in-between days over time. TVEMs showed that increasing positive affect was associated with lower home BPs and increasing negative affect was associated with higher home BPs. Qualitative analysis revealed that most participants perceived negative emotions influenced BP and health behavior choices. However, some participants who maintained consistent health behaviors reported minimal emotional effects on BP.

Conclusions: In diverse primary care patients with uncontrolled hypertension, momentary home BP and positive emotions improved over time with the self-monitoring and education intervention, while negative emotions remained unchanged. Patient-perceived emotions affected health behaviors and BP. Healthy habits were perceived to attenuate the effect of emotions on BP. Future studies should consider a longer duration of intervention and additional instrumental support for negative affect and lifestyle behavior modifications to jointly improve cardiovascular and psychological health. Larger future studies are needed to better understand the direct and indirect relationships between emotions, lifestyle behaviors, and home BPs.