Using motivational interviewing to improve sleep quality among patients with hypertension attending a tertiary hospital in southern Nigeria: a randomized controlled trial

Abstract

Introduction

Restorative sleep is essential for the maintenance of overall health and for the prevention of chronic diseases, including hypertension. The aim of this study was to determine the effect of motivational interviewing (MI) on sleep quality in patients with hypertension.

Methods

The study was a randomised controlled trial (PACTR202301917477205) of 250 adult patients aged 18 to 65 years (125 in each group) with hypertension presenting to the Family Medicine Clinics of Irrua Specialist Teaching Hospital, Irrua, Nigeria from April to December 2023. Patients were selected through systematic random sampling and randomised into intervention and control group with the intervention group having monthly sessions of motivational interviewing in addition to standard care for hypertension and the control group having standard care only. Data were analysed with Stata with level of significance set at p < 0.05.

Results

The participants had a mean age of 51.5 ± 10.0 years, were mostly females 156 (62.4%), married 135 (54.0%), and Christians 134 (53.6%). There was no significant difference in the sleep pattern of both the intervention and control groups (χ² = 1.111 and p = 0.292) at baseline. Post-intervention with MI, there was a significant improvement in sleep quality (p = 0.002) and a corresponding improvement in blood pressure control (p < 0.001) of patients in the intervention group compared to controls.

Conclusion

The use of motivational interviewing led to a significant improvement in sleep quality and a corresponding improvement in blood pressure control. Motivational interviewing should be employed by physicians and other health workers during sleep prescription counselling.

What is already known on this topic

There is an association between poor sleep and uncontrolled blood pressure. Thus, measures that will improve sleep in hypertensives will lead to better blood pressure control.

What this study adds

Motivational interviewing could be used to help patients with hypertension improve their sleep quality thus improving their blood pressure control levels.

How this study might affect research, practice, or policy

Incorporating motivational interviewing into management protocol for patients with poor sleep particularly those with hypertension will help improve sleep quality and blood pressure control.

Introduction

The role of sleep quality in hypertension prevention and management has gained increasing attention. Restorative sleep is essential for the maintenance of overall health and for the prevention of chronic diseases, including hypertension. Restorative sleep is typically defined as 7–9 h of sleep per night (Ayanaw et al. 2022). Abnormal sleep comprising of short sleep duration (less than 7 h), long sleep duration (more than 9 h), and troubled sleep and sleep disorders, such as insomnia and obstructive sleep apnoea, have been associated with adverse health outcomes, including hypertension and diabetes (Bathgate and Fernandez-Mendoza 2018; Birhanu et al. 2020). We reported a prevalence of nonrestorative sleep or poor sleep quality of 64% from the baseline data of this study that was published in BMJ Open (Challa 2021). A study among similar populations in Northwest Africa reported a prevalence of non-restorative sleep of 35.5% and 37.7% respectively (Chueh et al. 2009; Enhancing 2019). A cross-sectional, hospital-based study among hypertensive adults within an urban China Province however reported a prevalence of 60.4% of poor sleep quality (Gou et al. 2023).

Findings from the 2007–2014 National Health and Nutrition Examination Survey (NHANES) in the U.S reported a significant risk of hypertension to include short sleep duration, difficulty in initiating sleep and sleep disorders (Grandner et al. 2018). Having restorative sleep for up to 7 h daily has been shown to help in blood pressure control (Irrua 2007). Therefore, helping patients with hypertension sleep better will lead to a reduction in blood pressure, and a corresponding adjustment on medication use with better outcomes.

Several approaches have been tried to help patients improve their sleep quality but with minimal success. This is because most counselling approaches in hospitals are physician-driven. Patient-driven counselling such as the use of Motivational Interviewing is effective in curbing substance abuse, increasing hospital delivery as well as improving medication adherence (Itani et al. 10,11,; Li and Shang 2021). It has been used successfully in hypertensive patients to improve medication adherence and compliance to treatment (Lundahl et al. 2013). We therefore decided to conduct a randomised controlled trial to know if MI could be used to improve sleep quality among patients with hypertension. The aim of this study was to determine the effect of motivational interviewing on sleep quality in patients with hypertension. This will provide innovative ways of helping patients with hypertension and the general public to improve their sleep quality thus improving health outcomes.

Methods

The study was part of a larger study on Effect of Motivational Interviewing on Lifestyle Modification among Patients with Hypertension attending the Family Medicine Clinics of Irrua Specialist teaching hospital, Irrua, Nigeria: A Randomised Controlled Trial (Makarem et al. 2021). The study was a randomised controlled trial (PACTR202301917477205) conducted between April and December 2023 among 250 (125 each in the intervention and control group) systematically selected adult patients with hypertension and reported using the CONSORT 2010 checklist for reporting a randomised trial.

Study area

It was conducted in the Family Medicine Clinics of Irrua Specialist Teaching Hospital (ISTH), a tertiary hospital in Irrua, a semi-urban town and headquarters of Esan Central Local Government Area, Edo State, South-South Nigeria (Miller and Rollnick 2013). The Family Medicine Clinics comprise the General Outpatient Department (GOPD) and the Staff/National Health Insurance Authority (NHIA) clinics. Between 70 to 80% of patients with hypertension attending ISTH are attended to at the Family Medicine clinic according to hospital records. The clinic receives about 400 patients with hypertension monthly with 300 seen in the GOPD and 100 seen in the Staff/NHIA clinic respectively.

Study design and participants

The study was a randomised controlled trial (PACTR202301917477205). A total of 250 adult patients aged 18 to 65 years with hypertension presenting to the Family Medicine Clinics of the hospital who consented to the study were recruited through systematic random sampling. Both newly diagnosed and those already on management for hypertension were included in the study. However, patients with cognitive impairment, severely ill patients as well as those with hypertensive complications like renal disease and stroke were excluded from the study. The sample size was calculated to be 212 using a confidence level of 95 per cent and the sample size formula for RCT byWalters (Mitra et al. 2021):

$$\mathrm n=\frac{{2\mathrm\sigma}^2\left[{\mathrm Z}_{1-\mathrm\alpha/2}+{\mathrm Z}_{1-\mathrm\beta}\right]^2}{\mathrm\delta^2}$$

where n is the sample size per group; σ = Standard Deviation; Z_1-α/2 is the Z value corresponding to 95% level of significance = 1.96, Z_1-βis the Z value corresponding to 80 per cent power = 0.84 and δ is the target or anticipated difference in mean outcomes between the two groups = 0.14 (Steffen et al (Nijs et al. 2020) in a study to evaluate the effectiveness of motivational interviewing in the management of Type 2 diabetes and arterial hypertension in primary healthcare in Brazil found the mean reduction in systolic BP to be 14.4 ± 10.8), however the study was conducted among 250 patients to increase the power of the study. The Family Medicine clinics of ISTH attend to about 400 patients with hypertension monthly. The sampling interval was determined to be 1:4 to give all eligible subjects equal chances of being selected within the period of study. The first patient was selected from the first four patients with hypertension by simple random sampling; subsequently, every fourth patient was selected. Each patient’s card was tagged. The identification sticker was left on all selected cards until the study was over to avoid a repeat selection. Proportionate recruitment of patients from both the GOPD and the Staff/NHIA clinic was done at a 3:1 ratio as hospital records showed that the GOPD saw about three times the number of patients with hypertension than the Staff/NHIA clinic. Details of the selection criteria, sample size determination, sampling technique, patient and public involvement, and baseline parameters have been published elsewhere (Challa 2021; Makarem et al. 2021). Participants were then randomised into intervention and control groups.

Randomization

Patients were randomised into Intervention and Control Groups with blinding of the participants, data collectors and analysts throughout the process. During randomisation, opaque envelopes were numbered serially and with cards to indicate whether a patient should be in the intervention or control arm with an allocation ratio of 1:1 (125 patients in the intervention arm and 125 patients in the control arm). Blinded allocation was guaranteed by storing the randomised list in an electronic file whose access was restricted to those in charge of recruitment.

Data collection

Baseline and outcome data were collected using a validated semi-structured interviewer-administered questionnaire adapted from the National Health and Nutrition Examination Survey (NHANES) study by Li et al. (Bathgate and Fernandez-Mendoza 2018) The questionnaire was digitally administered over about 20 min per session by the research assistant using a google form which was then transferred to excel spreadsheet for analysis. The questionnaire contained questions on sociodemographic characteristics, medical history, sleep patterns including sleep duration, self-reported trouble sleeping, and history of clinical diagnosis of sleep disorders. It also contained clinical parameters like blood pressure measurements.

The intervention group had sessions of Motivational Interviewing with three trained physician research assistants who had undergone 20 h prior training in MI. The MI sessions were at baseline, and then monthly for six months. This was in addition to the standard care given to patients with hypertension coming to the hospital. The control group had only the standard care without the Motivational Interview Session. This was administered by three physician research assistants who had not undergone prior training in MI.

A standardised sleep questionnaire adapted from the NHANES study was used to assess sleep pattern (Bathgate and Fernandez-Mendoza 2018). Sleep duration was determined through self-report of the number of hours of sleep per night and categorised into inadequate (less than seven hours of night sleep), adequate (7 to 9 h of night sleep) and excess (greater than 9 h of night sleep). Self-reported trouble sleeping, and history of clinical diagnosis of sleeping disorder were also assessed. A score of 1 was assigned to each of normal sleep duration (7–9 h per night), no trouble sleeping and no previous diagnosis of sleep disorder while abnormal sleep duration (< 7 or > 9 h per night) trouble sleeping and previous diagnosis of sleep disorder was given a score of 0. The scores were summed and a total score of 0 to 2 was categorised as non-restorative sleep while a score of 3 was categorised as restorative (healthy) sleep (Bathgate and Fernandez-Mendoza 2018).

Blood pressure was measured using Omron Intellisense electronic sphygmomanometer, with the cuff properly applied to the left arm and with the patient sitting in a relaxed position and the BP measurement was taken at the level of the heart. Three BP measurements were taken 10 min apart and the mean of the last two measurements was recorded as the patient’s BP. Controlled blood pressure was defined as systolic blood pressure < 140 mm Hg and diastolic blood pressure < 90 mm Hg (Nijs et al. 2020).

Patient and public involvement

Patients with hypertension who had sleep problems were involved in setting the research question, design and implementation of the intervention. Formal meetings were held with the patients to determine their views on the topic, whether they will be interested in participating, and how findings could be disseminated to them. The interaction with such patients and other public members informed the decision to conduct this study to test for the association between sleep quality and blood pressure control. The patients and the public, particularly those in the study environment were also involved in the dissemination of the research findings as the findings were made available to them through direct engagements during clinical consultations and through health talk to the public through formal gatherings and print and electronic media including social media platforms like Facebook and LinkedIn.

Outcome

Primary outcome was lifestyle modification (improved sleep quality) and secondary outcome was improved blood pressure control among study participants by 6 months.

Data management

Adequate mechanisms were put in place to safeguard and guarantee data accuracy, and quality devoid of any bias, editing of completed questionnaires, and data entry. Such mechanisms included coding of the data, pass-wording of the computer containing the data to avoid third-party access, and the use of only one computer for entering the information.

Statistical analysis

Data were collected from both groups and analysed using Stata, version 17 (StataCorp LLC, College Station, Texas, USA). Demographic characteristics were summarized in a tabular form, analysed descriptively and reported with their proportions. The Shapiro–Wilk test was used to assess the normality of continuous variables while the McNemar chi-square test was used to compare participants’ outcome variables. Cohen’s d was applied in the assessment of the effect of MI on sleep patterns. For all tests, a p-value < 0.05 was considered statistically significant. The statistical tests were done within groups and the results of the intervention group compared to those of the control group.

Trial registration

The clinical trial was registered with the Pan African Clinical Trial Registry with Trial Registration No PACTR202301917477205.

Results

A randomised controlled trial was conducted for 250 patients with hypertension presenting to the Family Medicine Clinics of Irrua Specialist Teaching Hospital, Irrua, Edo State, Nigeria between April and December 2023 and their results were analysed (Fig. 1) and as presented below. A total of 356 patients were assessed for eligibility during the study period out of which 303 were recruited. The remaining 53 were excluded for not meeting the inclusion criteria (n = 37) or for declining to participate (n = 16). Of the 303 patients that were recruited, 53 withdrew from participation prior to randomisation due to incomplete data at baseline or inability to contact patient. The remaining 250 patients were randomised and allocated to intervention (n = 125) and control (n = 125) groups and followed up for six months. They all completed the study and their data were analysed with the results presented below.

Fig. 1

Consort flow diagram

Baseline results

The age of the participants ranged from 24 to 65 years with a mean age of 51.5 ± 10.0 years. The majority of participants were middle-aged (40 to 59 years) 139 (55.6%) followed by those who were aged 60 and above 65 (26.0%). Participants were mostly females 156 (62.4%), married 135 (54.0%), and Christians 134 (53.6%). They were predominantly non-government employees (artisans, traders, and farmers) 148 (59.2%) with most participants having an average monthly income of between N50,000 and N99,999 118 (47.2%). There was no statistically significant difference in the sociodemographic characteristics of respondents in both the intervention and control groups. Table 1.

Table 1 Sociodemographic characteristics of respondents (N = 250)

Effect of motivational interview on sleep pattern of respondents

A total of 49 (39.2%) respondents in the intervention group and 41 (32.8%) in the control group had restorative sleep at baseline respectively. There was no significant difference in the sleep pattern of both the intervention and control groups (χ² = 1.111 and p = 0.292).

Post-intervention, a total of 19 participants in the intervention group who had non-restorative sleep at baseline recorded a change in their sleep patterns to restorative sleep compared to 3 participants in the control group (Table 2). The difference was statistically significant (p = 0.002).

Table 2 Effect of motivational Interview on sleep pattern (N = 250)

Effect of motivational interview on sleep by sociodemographic characteristics

There was no significant difference among the various sociodemographic characteristics as motivational interviewing led to an improvement in sleep patterns among respondents irrespective of their sociodemographic characteristics. The results are illustrated in Table 3.

Table 3 Effect of motivational interview on sleep by sociodemographic characteristic

Effect of motivational interview on sleep pattern and BP control

Table 4 shows the effect of motivational interviewing on sleep pattern and blood pressure control. The significant improvement in sleep pattern among respondents following intervention with motivational interviewing (Table 2, p = 0.002) led to a corresponding improvement in blood pressure control which was also significant (p < 0.001).

Table 4 Effect of Motivational Interview on Sleep Pattern and BP Control (N = 250)

Discussion

We conducted an RCT to study whether motivational interviewing could be used to improve sleep patterns among patients with hypertension attending the Family Medicine Clinics of a rural teaching hospital in southern Nigeria. Overall, there was a high prevalence of non-restorative sleep (poor sleep) pattern among respondents at baseline for both the intervention (60.8%) and control group(67.2%). Findings from our study are higher than the reported prevalence of nonrestorative sleep or poor sleep quality of 35.5% and 37.7% among similar populations in Northwest Africa (Chueh et al. 2009; Enhancing 2019). It was similar, however, to the findings of a study among hypertensive adults in China that reported a prevalence of 60.4% (Gou et al. 2023). The high prevalence of non-restorative sleep is alarming as there exists an intricate relationship according to literature between sleep disturbances, particularly nonrestorative sleep, and the exacerbation of hypertension (Ayanaw et al. 2022; , Birhanu et al. 2020; Oseni et al. 2024). Findings from the 2007–2014 National Health and Nutrition Examination Survey (NHANES) in the USA reported short sleep duration, difficulty in initiating sleep and sleep disorders as being significant risks for hypertension (Bathgate and Fernandez-Mendoza 2018). Other studies report a significant correlation between poor sleep quality and several factors including stage II hypertension, obesity and female gender (Gou et al. 2023; Grandner et al. 2018; Oseni et al. 2024; Patnode 2017).

Following intervention with physician-administered, patient-driven MI, sleep quality improved in the intervention group with 27 patients who had poor sleep at baseline reporting restorative sleep pattern by 6 months. Importantly, the difference in sleep quality pre- and post-intervention was statistically significant (p = 0.002). There was a corresponding significant improvement in blood pressure control (p< 0.001). Findings from our study suggest a meaningful impact of MI on sleep patterns and blood pressure control. These findings are consistent with previous research suggesting that MI may be an effective tool in improving sleep quality. Notably, Sun et al. in 2020 conducted an intervention among 100 post-operative obese patients in China with obstructive sleep apnea-hypoapnea (OSA) syndrome wherein the intervention group was exposed to motivational interviewing as opposed to routine health education which was given to the control group (Riera-Sampol et al. 2021). He found that MI was associated with significant improvements in sleep quality among individuals in the intervention group compared to the control group (p< 0.05). Similarly, a case report by Zabolypour et al. in 2020 compared the effectiveness of MI with a teach-back approach in Iran and found improved adherence to the hypertension medical regimen (Lundahl et al. 2013). This is in keeping with findings from other studies which linked poor sleep quality from OSA to obesity and an increased prevalence of hypertension among individuals with OSA (Riera-Sampol et al. 2021; Rebora et al. 2021).

A randomized clinical study conducted by Yan et al. in 2023 reported a trend towards improvements in sleep outcomes assessed with the Global Pittsburgh Quality Index following an MI intervention among college students who chose to focus on sleep-related goals (Steffen et al. 2021). This was however statistically insignificant which was further attributed to the small sample size of the study. The intensity of the MI offered may be another reason for this variance as inferred by Rebora et al. who assessed the effectiveness of motivational interviewing on sleep quality among three study arms of heart failure patients in the MOTIVATE-HF randomized controlled trial (St-Onge et al. 2016). The changes in sleep quality observed over 12 months across the three arms in the MOTIVATE-HF RCT were also insignificant. It is also possible that the clinical background of the patients influenced the study outcome being heart failure patients whereas the current study excluded patients in this category.

Numerous studies have employed Motivational Interviewing (MI) as a strategy to enhance adherence to medication regimens, compliance with self-care devices, and adherence to prescriptions, which may encompass discontinuation of detrimental lifestyle habits (Sun et al. 2020; Teshome et al. 2022). Motivational interviewing (MI) has demonstrated efficacy in enhancing adherence to lifestyle interventions, as evidenced by research such as a randomized controlled trial (RCT) conducted by Riera, focusing on achieving adherence to the World Health Organization guidelines recommending 150 min of physical activity weekly (Walters et al. 2019). Additionally, behavioural outcomes are influenced by the nature of interventions, as illustrated in a systematic review conducted by Patnode, which investigated the impact of behavioural counselling on exercise and dietary modifications among individuals with obesity over a 6–12 month period (WHO 2019). The intensity and duration of behavioural interventions are pivotal factors influencing the effectiveness of such approaches. Given the association between poor lifestyle habits like alcohol consumption and smoking and diminished sleep quality, lifestyle interventions stand out as pivotal approaches for enhancing sleep quality (Yan et al. 2023; Zabolypour et al. 2020).

The observed improvements in sleep quality and other lifestyle behaviours following MI intervention may be attributed to several factors. MI is a client-centred approach that aims to enhance intrinsic motivation and self-efficacy by exploring individuals' motivations and goals related to behaviour change as proffered by Miller & Rollnick (Li and Shang 2021). By empowering individuals to identify and address barriers to healthy sleep behaviours, MI may facilitate positive changes in sleep patterns. Furthermore, the collaborative and non-judgmental nature of MI may create a supportive environment conducive to behaviour change (Li and Shang 2021). Individuals may feel more motivated and confident in making changes to their sleep habits when they perceive their autonomy and agency to be respected and supported.

The intervention utilizing MI yielded promising results, with a significant improvement in sleep quality observed among participants in the study under review. Notably, a considerable number of individuals transitioned from poor sleep patterns to restorative sleep following the intervention, indicating the potential efficacy of MI in addressing sleep disturbances. These results are consistent with prior research indicating that MI interventions may result in enhanced sleep outcomes in diverse populations and across a spectrum of disorders (Riera-Sampol et al. 2021; Rebora et al. 2021; Teshome et al. 2022). This aspect of MI is particularly relevant in the context of chronic conditions such as hypertension, where long-term adherence to treatment regimens is crucial for disease management. Intervention with MI has positive implication for management of sleep problems and hypertension. Its use should be advocated in clinical practice particularly in resource constrained settings.

Study strengths

The study evaluated the use of behavioural motivation to bring about improved sleep quality in adult hypertensives in Edo State, Nigeria.

Study limitations

The study was hospital-based, thus excluding hypertensive patients who sought care in other health facilities as well as non-health facilities. This however will not significantly affect the results as a good number of patients with hypertension visit hospitals. Findings could therefore be generalised for all hypertensive patients including those seeking care outside standard hospital settings.

Sleep duration was assessed through patients recall. Recall bias is therefore a possibility. However, this was mitigated by asking patients time of initiation of sleep as well as time of waking up on most days. Also, other aspects of the study instrument including the use of sleep medications and previous diagnosis of sleep disorders were used in addition to sleep duration to assess sleep pattern.

Conclusion

The study found that most patients with hypertension attending the Family Medicine Clinics of ISTH, Irrua, Edo State had poor quality (non-restorative) sleep. The use of motivational interviewing led to a significant improvement in sleep quality leading to an increase in restorative sleep and improvement in blood pressure control.

Thus, this RCT provides evidence supporting the use of motivational interviewing as an effective intervention for improving sleep quality among patients with hypertension. By providing valuable insights into the impact of MI on sleep patterns, this research contributes to the growing body of literature advocating for comprehensive approaches to promoting healthy sleep behaviours and enhancing overall well-being.

Recommendations

Integrating MI into comprehensive care approaches for hypertension management holds promise for enhancing patient outcomes and reducing the burden of disease associated with both hypertension and sleep disturbances.

Further research is however warranted to explore the long-term effects and scalability of MI interventions in addressing sleep-related issues and to inform the development of tailored interventions for optimizing sleep health in hypertensive populations.