1. Introduction
Increased life expectancy and decreased fertility rate in Iran has led to an increase in the number of older people [1]. Hypertension is one of the most common chronic diseases in the elderly that plays an important role in their quality of life [2]. Blood pressure control requires self-care and patient involvment in self-care [3, 4]. Self-care guidelines can play an important role in regulating and controlling blood pressure, but most patients do not follow the instructions [5, 6]. With proper intervention, self-care and quality of life in the elderly with hypertension can be improved. The 5A model for self-management is a behavior change model that is designed based on an evidence-based approach and is suitable for managing health and creating desirable behaviors, including self-care behaviors [7]. This study aims to assess the effect of a 5A model-based intervention program on self-care and quality of life in the elderly with hypertension.
2. Methods
This is a quasi-experimental study with an ethical approval obtained from the Ethics Committee of Gonabad University of Medical Sciences (Code: IR.GMU.REC.1399.044). Participants were 80 older people randomly assigned into two groups of intervention (n=40) and control (n=40) groups. The sample size was estimated 36 for each group according to similar study [8], and increased to 40 due to the possibility of sample drop. Inclusion criteria were: willingness to participate in the study, age 60-75 years, having hypertension, receiving at least one blood pressure medication, no cognitive impairment, speech or hearing problems, and no serious medical condition. Exclusion criteria were: Absent from a training session or not answering the telephone call, having an accident, death during an intervention, and change in medication regimen.
For data collection, a demographic form, recording of blood pressure, behavior subscale of the Hypertension Self-Care Profile (HSCP) questionnaire, the Control, Autonomy, Self-Realization and Pleasure (CASP-19) questionnaire, and a desk mercury sphygmomanometer (Riester Diplomat 1002 model) were used. The Persian version of HSCP was validated (α=0.85) for Iranian elderly by Barati et al. [33], and the Persian version of CASP-19 was validated (α=0.80) by Heravi et al. [34]. Blood pressure was measured from the patient’s right arm in a sitting position [11].
Questionnaires were first completed before the intervention. Educational intervention based on the 5A model was performed for 2 months. The educational content included self-care and dimensions of quality of life for the elderly. The intervention was performed in one session via face-to-face (during five stages of Ask, Advise, Assess, Assist, and Arrange) and in 1-4 sessions via telephone calls. The control group received routine care from community health centers for two months. At the end of the intervention, questionnaires were completed again by two groups. Data were analyzed by Shapiro-Wilk test, independent t-test, Mann-Whitney U test, paired t-test, Chi-square test, and Fisher’s exact test.
3. Results
Participants were 80 older people with a Mean±SD age of 64.58±3.47 years. Most of them were male (51.3%), married (91.3%) and housekeeper (42.5%). The mean duration of hypertension in them was 14.01±6.92 years. The two groups were homogeneous in terms of demographic characteristics including age, body mass index, hours of activity (per month), hours of sleep (per day), disease duration (month), marital status, level of education, economic status, employment status, and diet.
The Mean±SD pre-test self-care score of the intervention group (46.67±5.83) was significantly different from that of the control group (43.75±5.46) (P=0.023). The mean post-test self-care scores of the intervention (50.95±4.77) and control (40.92±4.86) groups was also significantly different (P<0.001).
According to the results of paired t-test in Table 1, there was a statistically significant difference between the mean pre-test and post-test self-care scores of the intervention group (P<0.001), and between pre-test and post-test self-care scores of the control group (P<0.001).


The Mean±SD pre-test quality of life score of the intervention group (33.65±8.03) was significantly different from that of the control group (25.55±8.32) (P<0.001). The mean post-test quality of life score of the intervention group (39.02±6.76) and the control group (24.97±7.19) was also significantly different (P<0.001). According to the results of paired t-test in Table 1, there was a statistically significant difference between the mean pre-test and post-test quality of life scores of the intervention group (P<0.001), but no significant difference was found in the control group (P=0.352).
4. Discussion and Conclusion
Intervention based on 5A model for 8 weeks affects the self-care and quality of life of the elderly with hypertension. It seems that using this technique in the health system as a fast, accessible and easy intervention can be effective in improving the health status of the elderly. Further studies on the elderly with other chronic diseases can be effective in using this model as part of the geriatric nursing care program in Iran.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of Gonabad University of Medical Sciences (Code: IR.GMU.REC.1399.044). All ethical principles are considered in this article. The goals and procedure of the research was explained to the patients. The written informed consent form was taken from them. The patients were free to leave the study at any time.

Funding
This study was extracted from a MA. thesis of the first author at the Department of Geriatric Nursing, Social Development and Health Promotion Research Center, School of Nursing, Gonabad University of Medical Sciences, Gonabad.

Authors' contributions
Conceptualization, methodology, editing, final writing, research: all authors; Analysis: Moosa Sajjadi; Drafting: Matineh Khoshkhoo and Hosein Ajamzibad; Supervision: Hosein Ajamzibad, Moosa Sajjadi and Mohammad Reza Mansoorian; Project management: Hosein Ajamzibad.

Conflicts of interest
The authors declare no conflict of interest.

Acknowledgements
The authors would like to thank the Vice-Chancellor for Education and Research of Gonabad University of Medical Science, Community Health Centers In Gonabad, and the elderly participated in the study for their support and cooperation. 



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