ORIGINAL ARTICLE

Effect on blood pressure of a continued nursing intervention using chronotherapeutics for adult Chinese hypertensive patients
Xiao-Ying Zang, Jin-Feng Liu, Yan-Fen Chai, Frances Kam Yuet Wong and Yue Zhao

Aims and objectives. (1) To explore the effect of continued nursing intervention on hypertensive patients based on chronotherapeutics. (2) To identify the factors affecting hypertensive patients compliance to the chronotherapeutics-oriented nursing interventions. Background. Chronotherapy provides a means of individual treatment for hypertension according to the circadian bloodpressure prole of each patient and constitutes a new option in optimising blood-pressure control and reducing risk from hypertension. Design. Experimental study. Methods. All participants enrolled were randomly divided into the intervention group and the control group and they all took antihypertensive medicine prescribed by their doctors under ambulatory blood pressure monitoring. According to individual ambulatory blood pressure monitoring measures, interventions were implemented. Results. (1) There were signicant differences in blood pressure and compliance to chronotherapeutics between the two groups before and after the intervention. (2) Single variant and multiple factors analysis revealed different characteristics inuencing chronotherapeutic compliance of hypertensive patients. Conclusions. Under ambulatory blood pressure monitoring, continued nursing intervention for hypertensive patients guided by chronotherapeutics could effectively improve blood-pressure control and chronotherapeutic compliance. Relevance to clinical practice. Health care providers who deal with Chinese hypertensive patients can improve patients therapeutic compliance and blood pressure control guided by chronotherapeutics. According to different inuencing factors on patients chronotherapeutic compliance nurses should pay more attention to those whose compliance might be worse. Key words: ambulatory blood pressure monitoring (ABPM), China, chronotherapeutics, nurses, nursing
Accepted for publication: 30 October 2009

Introduction
Hypertension is a highly prevalent disease and a strong risk factor for cardiovascular disease worldwide (Wolf et al. 1997, Bonow et al. 2002, Chinese guidelines for hypertension prevention and control amending committee 2005). There are many therapeutic and nursing programmes purporting to
Authors: Xiao-Ying Zang, PhD, RN, Teacher, School of Nursing, Tianjin Medical University; Jin-Feng Liu, RN, Teacher, School of Nursing, Shandong University of Traditional Chinese Medicine; YanFen Chai, MD, Professor of Treatment, Emergency Department, General Hospital of Tianjin Medical University, Tianjin; Frances Kam Yuet Wong, PhD, RN, Professor, School of Nursing, Hong

control hypertensive patients blood pressure (BP) effectively and to improve their quality of life. However, conventional therapy and nursing have, to date, ignored the chronobiological rhythm of BP. The treatment of diseases has been based on the concept of homeostasis and has not incorporated an understanding of biological rhythms and their underlying mechanisms. Biological rhythms are
Kong Polytechnic University, Hong Kong; Yue Zhao, PhD, RN, Professor, School of Nursing, Tianjin Medical University, Tianjin, China Correspondence: Yue Zhao, Professor, School of Nursing, Tianjin Medical University, Tianjin, China. Telephone: 86 022 23542563. E-mail: yuezhao35@hotmail.com

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implicated in cardiovascular events. Failure to recognise the circadian decline in BP may result in iatrogenic chronopathological events, including anterior ischaemic optic neuropathy and cerebrovascular accidents. Chronotherapeutics is the purposeful alteration of drug levels to match rhythms to optimise therapeutic outcomes and minimise size effects. For the treatment of hypertension, this idea has the potential for a therapeutic paradigm shift (Prisant 2001). The development of ambulatory blood pressure monitoring (ABPM) and the rapidly growing popularity of home BP measurements by patients have generated a series of new clinical questions that are directly linked to the chronobiology of the cardiovascular system (Hassler & Burnier 2005). Recently, chronotherapy provides a means of individualising treatment of hypertension according to the circadian BP prole of each patient, constitutes a new option in optimising BP control and reducing risk. Nocturnal hypertension increases risk of cardiovascular and cerebrovascular events, nephrosclerosis and progression to end-stage kidney failure in renal patients. Normalisation of the circadian blood-pressure pattern is considered an important clinical goal of pharmacotherapy because it may slow the advance of renal injury (Hermida et al. 2005). Chronotherapeutics is advancing hypertension treatments beyond once-daily dosing by synchronising the maximum levels of medication during times when cardiovascular risk is highest. Using novel oral delivery methods, chronotherapeutic medication synchronises the delivery of BP drugs within the period of risk, signicantly reducing both absolute BP and, especially important, the rate of BP increase. These therapies have also shown the ability to maintain adequate BP levels during the trough period (Prisant 2004). Knapp said that hypertensive patients with progressive kidney deterioration might be a consequence of little or no fall in sleeping BP. He urged clinicians and clinical trialists to be more thoughtful about the time of administration of drugs in relation to biological rhythms, including the circadian cycle (Martin 2004). BP exhibits strong circadian variation, this may contribute to the increase of acute cardiovascular events that peak in the morning hours. Reducing morning BP may prevent these occurrences (Weber & Fodera 2004). Despite improvements in the management of hypertension in recent years and the numerous efcacious antihypertensive agents available to todays physician, nearly 70% of patients do not have their hypertension adequately controlled. Non-compliance with prescribed regimens appears to be one of the primary contributors to the large numbers of patients with uncontrolled hypertension. A behaviour that can affect all patients, non-compliance is perplexing
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because it remains largely unrecognised in clinical practice (Burnier 2000). Therefore, continued nursing intervention for hypertensive patients based on chronotherapeutics adapts to the development of nursing programmes for hypertensive patients and may help implement intervention for diseases with circadian rhythms. In this study, we aimed to unite one ABPM measure and repeated home BP measurements in hypertensive patients and develop a continued nursing intervention plan based on chronotherapeutics to inuence their ways of taking medicine and lifestyle for three months. This was then evaluated to provide the basis for designing the best interventions to improve hypertensive patients compliance to treatment and BP control. In the meantime, we could explore the factors inuencing patients compliance.

Methods
Participants
The medical ethics committee of the General Hospital of Tianjin Medical University approved our study and written informed consent was obtained from all participants. Normtension was dened as BP < 140/90 mmHg and not taking antihypertensive medication. Hypertension was dened as systolic BP (SBP) 140 mmHg, diastolic BP (DBP) 90 mmHg, or being on antihypertensive medications (actual or self-reported) regardless of BP measurements (Chinese guidelines for hypertension prevention and control amending committee 2005). Patients with over one-year primary hypertensive history and with medicine treatment were included. The patients with secondary hypertension or mental diseases or other severe somatic diseases were excluded. From October 2006December 2006, the patients who came to see a doctor in the medical clinic of the General Hospital were asked to participate. On the basis of previous data (Chinese guidelines for hypertension prevention and control amending committee 2005) and our pilot study with ten participants (average SBP: 1508, SD 1381), we estimated the sample size of two groups should be 60; considering those lost to follow-up we determined to include 72 participants.

Instruments
A sociodemographic questionnaire was used including age, gender, occupation, education level, source of nance, marital status, living with relatives, monthly income, payment for medical care, nancial burden, course of hypertension, whether smoking or drinking or suffering from diabetes or coronary heart disease, whether with family history, etc.

2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 11491156

Original article

Effect on blood pressure of a continued nursing intervention using chronotherapeutics

Under the model of knowledge, attitude and practice and according to chronotherapeutic theory, the seven-day recall Chronotherapeutic Compliance Questionnaire for hyperpietic (seven-day recall CCQH) was developed based on the questionnaire of Xiao Huimin, etc. (Huimin et al. 2002). On the basis that the number of the participants should be threeve times the number of the items in the questionnaire (Minglong 2000), 133 participants were included to complete the CCQH to test its reliability and validity in our pilot study. Five professionals assessed the content validity and considered that the items and content of the questionnaire indicated most of the treatment concepts of the primary hypertension and the theory of chronotherapeutics. Exploratory factor analysis was used to test construct validity. KaiserMeyer Olkin (KMO) measure and Barletts test were used rst. The KMO result was 0679 and the v2 value of Bartletts test was 6419481 and the signicance was <0001 indicating that the questionnaire was appropriate for factor analysis. After principal component analysis with varimax orthogonal rotation, six common factors were extracted which were compliance to BP monitoring, time of taking medicine, taking medicine, diet, exercise, restriction of cigarettes and alcohol. The six factors interpreted the cumulative variation of 756% and the structure of the questionnaire coincided with the initial hypothesis. Cronbachs a coefcient was 090 which meant the reliability was high, that is to say the internal consistency of the questionnaire was good. Twenty-four hour ABPM was carried out on the nondominant arm using an oscillometric device (Spacelabs 90207; SpaceLabs Inc, Issaquah, WA, USA). The device was set to obtain BP readings every 20 minutes during daytime (8 AM 10 PM ) and every 45 minutes during night-time (10 PM 8 AM ) (Yan et al. 2006). Home BP measurement was measured at getting-up, 78 AM , 10 AM , 12 N1 PM , 46 PM and bedtime (Jie 2005).

nursing based on chronotherapeutics and continued nursing intervention plan and explained the contents to them in detail. According to individual ABPM measurements, we would implement interventions on BP monitoring, time of taking medicine, taking medicine, exercise, diet and restriction of cigarettes and alcohol, etc. The main intervention contents were as follows: the cognition interventions included helping participants to know the risk and inducing factors of hypertension, to make them realise the indication, time prone to complications and their relationship with chronobiological rhythm, etc. The psychological interventions included helping participants accommodate their mode to avoid the uctuation of BP, especially when the pressure was rising according to individual BP rhythm. Behaviour interventions included instructing participants to obey the types and doses of medicine and adjust the time of taking medicine according to chronotherapeutics, advising them to change bad lifestyles such as reducing physical activities when BP was rising, giving the plan for an anti-hypertensive diet and quitting cigarettes and alcohol, etc. Quality control was assured by technician recertication, procedural checklists and data review (Yan et al. 2006).

Data analysis
For database management and statistical analysis, SPSS 13.0 (SPSS Inc., Chicago, IL, USA) was used. Student t-test was used to examine the differences of age between the control and intervention group and chi square test to assess other sociodemographic data between two groups. Differences between two groups preintervention BP and compliance to CCQH measurements were examined using t-test and repeated variant analysis was performed to test data of BP on the end of one, two and three months. To explore the inuencing factors of chronotherapeutic compliance of hypertensive patients, univariate analysis and logistic regression were performed.

Intervention programme
All participants enroled were randomly divided into either the intervention group or the control group. They all took antihypertensive medicine prescribed by their doctors under ABPM. Trained interviewers asked participants to complete the questionnaires with identical words and the interviewers would tell the participants how to apply home BP measurement correctly. Home BP measurement was collected on the second day, the end of one, two and three months after the participants were enroled. The intervention group participants were visited by the interviewers the rst time within one week of the beginning of the study. The interviewers presented them with the manual of primary hypertension

Results
Comparison of intervention group and control group demographics
Seventy-four patients participated and two quitted because of moving house, and in the end, 72 hypertensive patients participated in the following study. All of them were randomly divided into two groups: the intervention group and the control group. There were no statistical differences between two groups in the main sociodemographic characteristics of the study participants.
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X-Y Zang et al. Table 1 MSBP and MDBP of control and intervention groups The end of one month 1253 1235 816 810 276 312 199 172 The end of two months 1313 1313 857 826 431 375 252 228 The end of three months 1392 1311 894 825 327 293 145 141

Group Control group MSBP Intervention group MSBP Control group MDBP Intervention group MDBP

Beginning 1586 2083 1525 1225 883 842 875 769

p 0485 0195

p 0004 0016

MSBP, mean systolic blood pressure; MDBP, mean diastolic blood pressure.

Preintervention- and postintervention-BP measurements

We used a t-test to assess the differences of home BP measurements between two groups before intervention, and the results indicated there were no differences in the mean systolic and diastolic pressure. However, repeated variant analysis showed there were signicant differences of threemonth sequential monitoring after intervention (Table 1). From the data, we saw that both groups of participants BP were controlled steadily at the end of the rst month and the stability of intervention group could maintain, while in the control group, the stability faded away with time and disappeared by the end of the second month.

Table 2 Two groups compliance of each dimension of CCQH before and after intervention s x Intervention (n = 36) Control (n = 36)

Item

Preintervention- and postintervention-compliance of CCQH measurements

The results of t-test showed no difference of the six dimensions of CCQH between two groups before intervention, but after intervention only except restriction of cigarettes and alcohol, there were differences in other ve dimensions which meant the intervention was effective (Table 2).

Factors inuencing the total value of chronotherapeutic compliance

Single variant analysis was performed to analyse the factors inuencing the total value of chronotherapeutic compliance of different characteristic hypertensive participants. The mean of all participants compliance score, 822 was seen as a cut-off and the difference between urban and rural areas, age, education level, marital status, family member living together, occupation, monthly income of family, time of diagnosis, payment of medical care and whether intervention had statistical signicances (Table 3). All these variates were tested by multiple variants logistic regression analysis; except age, marital status, occupation and time of diagnosis, the other six factors were still statistically signicantly different (Table 4).
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Blood pressure monitoring Before 134 156 128 After 172 177 136 Difference 38 103 08 Time of taking medicine Before 111 218 108 After 147 239 121 Difference 36 107 13 Taking medicine Before 116 197 120 After 146 233 131 Difference 30 112 11 Diet Before 115 224 112 After 152 211 125 Difference 37 123 13 Exercise Before 86 188 82 After 114 227 91 Difference 28 147 09 Restriction of cigarettes and alcohol Before 130 264 137 After 141 259 142 Difference 11 109 05 Total Before 781 626 778 After 908 514 823 Difference 127 425 45

191 185 061 238 211 088 229 229 097 197 128 079 114 128 075 211 194 056 711 548 243

1256 7569 1249 2524 0065 3508 1617 2718 1396 3948 0182 0398 1218 4469

0213 0000** 0216 0016* 0948 0001** 0106 0008** 0163 0000** 0856 0693 0207 0000**

CCQH, Chronotherapeutic Compliance Questionnaire for hyperpietic. *p < 005, **p < 001.

Discussion
Through our intervention of three months, there were signicant differences between the intervention and the control groups BP, which suggested our interventions based on chronotherapeutics were effective. The reason may be as

2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 11491156

Original article

Effect on blood pressure of a continued nursing intervention using chronotherapeutics

Table 3 Single variate analysis of factors interfering total value of chronotherapeutic compliance of hypertensive patients Variable Difference (0 = rural, 1 = urban) Age Gender (0 = M, 1 = F) Nationality (0 = Han, 1 = minority) Faith (0 = no, 1 = yes) Education level Elementary Junior Senior v2 (df = 2) Marital status Widowed Single Divorced Married v2 (df = 3) Living with relatives Alone Nursery maid Children Spouse v2 (df = 3) Occupation Farmer Workman Cadre Other v2 (df = 3) Source of nance In service Pension Folks Others v2 (df = 3) Monthly income Low Middle High v2 (df = 2) Time of diagnosis Payment of medical care Own expenses Medicare Cooperative medical care Insurance v2 (df = 3) Whether intervention *p < 005, **p < 001. b 1050 0115 0628 0077 0246 0000 1091 2135 SE 0439 0063 1272 0054 0045 OR (95%CI) 233 112 188 119 109 (145, (108, (066, (046, (083, 937) 192) 2263) 214) 186) v2 5247 9657 0244 3116 0089 p 0019* 0002** 0621 0078 0766

0234 0469

100 229 (155, 736) 651 (232, 1840)

10258 15671 19052

0000** 0000** 0000**

0000 0674 0248 1669

0325 0145 0381

100 186 (081, 478) 120 (054, 329) 542 (126, 2337)

0279 1964 14405 14211

0611 0371 0000** 0003**

0000 0529 1074 2874

0246 0361 0557

100 169 (105, 274) 293 (144, 593) 617 (208, 1815)

4574 8839 10687 5612

0032* 0003** 0001** 0018*

0000 1114 1431 0622

0379 0387 0563

100 304 (145, 640) 437 (198, 831) 154 (037, 513)

8655 15244 2732 9963

0003** 0000** 0093 0002**

0000 0613 0484 0468

1484 0373 0476

100 190 (074, 491) 167 (078, 315) 175 (079, 386)

1764 1687 1954 0916

0174 0192 0135 0339

0000 1074 2315 2615 0000 1217 1063 0395 0163

0361 0533 0619

100 293 (144, 593) 1012 (356, 2879) 1366 (406, 4592) 100 243 (192, 308) 124 (082, 186) 148 (116, 189) 118 (109, 127)

8839 18830 25349 17862

0003** 0000** 0000** 0000**

0674 0784 0124 0039

4409 1859 10088 10136 17445

0038* 0173 0001** 0000** 0000**

follows: we helped participants know the risk and inducing factors for hypertension and made them realise the indication, time prone to complications and their relationship to chronobiological rhythm, etc. Therefore, they could avoid these risk factors in their daily activity and take measures in

time to prevent complications. Our psychological interventions helped participants accommodate their mood to avoid the uctuation of BP, especially when the pressure was rising according to individual BP rhythm. These interventions could help participants avoid some complications of hypertension
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X-Y Zang et al. Table 4 Multiple variants logistic regression analysis of factors interfering total value of chronotherapeutic compliance of hypertensive patients Variable Difference (0 = rural, 1 = urban) Age Education level Marital status Living with relatives Occupation Monthly income Time of diagnosis Payment of medical care Whether intervention *p < 005, **p < 001. b 1081 0674 1154 0287 1005 0583 1514 0915 1076 0485 SE 0546 0416 0349 0121 0498 0456 0529 0505 0648 0159 OR (95%CI) 295 196 317 118 273 145 450 261 298 162 (101, (078, (154, (054, (126, (054, (256, (095, (143, (119, 859) 417) 629) 191) 594) 486) 815) 451) 1035) 222) v2 3917 2697 10964 1547 6643 0853 21139 3544 6934 9345 p 0044* 0102 0001** 0231 0011* 0427 0000** 0061 0011* 0002**

and control BP effectively. Under our behaviour interventions, participants could take their medicine before BP rose to avoid its uctuation. They could also change their lifestyles such as reducing physical activities according to chronotherapeutics, and thereby control BP better. And we also found that BP of both the intervention and the control group participants were controlled steadily at the end of the rst month and the stability of intervention group was maintained while in the control group the stability faded with time and disappeared by the end of the second month. The reason may be in a short time (e.g. one month) participants would be compliant to doctors prescription and the medicine could control BP. However, after time, we could see the priority of the intervention in improving BP. The control groups compliance to BP monitoring, time of taking medicine, taking medicine and lifestyle lowered, which could explain the instability of their BP. Naylor et al. (1999) examined the effectiveness of an advanced practice nurse-centred discharge planning and home follow-up intervention for elders at risk for hospital readmissions. The intervention group patients received a comprehensive discharge planning and home follow-up protocol designed specically for elders at risk of poor outcomes after discharge and implemented by advanced practice nurses. The result showed an advanced practice nurse-centred discharge planning and home care intervention for at-risk hospitalised elders reduced readmissions, lengthened the time between discharge and readmission and decreased the costs of providing health care. Thus, the intervention demonstrated great potential in promoting positive outcomes for hospitalised elders at high risk for rehospitalisation while reducing costs. The accurate measurement of BP is the sine qua non for successful management (Chobanian et al. 2003). In recent studies, three common methods of monitoring BP, such as clinic BP, home BP and ABPM have been used. Each monitoring method has its advantages and disadvantages. Self-monitoring of BP at home and work is a practical
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approach to assess differences between ofce and out-of ofce BP prior to the consideration of ambulatory monitoring (Zhu et al. 2008). Clinic BP is often used in clinical diagnosis, but its veracity is compromised by the white-coat effect (Selenta et al. 2000, Zhu et al. 2008). ABPM provides information about BP during daily activities and sleep. BP has a reproducible circadian prole, with higher values while awake and mentally and physically active, much lower values during rest and sleep and early morning increases for three or more hours during the transition of sleep to wakefulness (Kario et al. 2003). Therefore, in our study, we combined ABPM and home BP self-monitoring not only to nd out the characteristic of each participants individual BP but to avoid the limitation of nance so as to form a monitoring system based on home self-monitoring. Therefore, this could help to make ABPM and home self-monitoring complementary and constitute a nursing programme for hypertensive patients based on individuals chronobiological rhythm. We used the mean BP of six measurements of home self-monitoring as a participants BP (Chatellier et al. 1996) to make sure this home self-monitoring was similar to ABPM. Under our intervention, participants understood the inuence of BP uctuation and the importance of home BP self-monitoring; therefore they could accept this more easily. The role of ambulatory measurement in guiding drug treatment is the subject of many researches and its role in this regard has not been fully established (OBrien et al. 2000). However, recent reviews of the clinical value of ambulatory measurement have highlighted the potential usefulness of 24-hour recordings of BP in guiding drug treatment (White 1998, Mallion et al. 1999). Furthermore, a well-controlled study showed that when ambulatory measurement rather than measurement in a clinic was used as the basis for prescribing treatment, signicantly less antihypertensive drug treatment was prescribed (Staessen et al. 1997). On the basis of chronotherapeutics, doctors could adjust the time of taking medicine according to the most effective time of medicines

2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 11491156

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Effect on blood pressure of a continued nursing intervention using chronotherapeutics

and the peak value of BP so as to control morning BP surge. Under our intervention, we made the participants aware of different effects and characteristics of different medicines and asked them to keep strictly to the time of taking medicine. The results showed the compliance to time of taking medicine of the intervention group improved while there was no difference in the control group before and after the study. After intervention, the score of compliance to taking medicine of the intervention group increased signicantly but not in the control group. Treating hypertension is a long process and the compliance to taking medicine is extremely important. In our study, we made the intervention group understand the relationship between hypertension and stroke, heart failure and renal failure, etc., let them know that compliance to doctors prescription could control BP effectively and lessen the adverse effects of the medicine and the fear feelings caused by them. Although long-effect medicines have the virtue of longer action and less times of taking, which can improve the compliance to taking medicine, they have a higher price. In developing countries, non-compliance to hypertension medication is a major problem; unaffordable drug prices appear to be the major cause (Ohene et al. 2004). In our study, we instructed the poorer participants to take the medicine of lower price on the basis of chronotherapeutic theory, which could also achieve the intention to elevate the compliance. Nursing intervention is aimed at educating people to form good habits and lifestyle and to lower or extinguish the risk factors affecting well-being. We found that many primary hypertensive patients did not know the relationship between dietary salt intake and hypertension, the relationship between nocturnal hypertension and organ damage, or, they knew they had to limit salt intake but they had no idea by how much. After intervention, the participants improved their bad habits signicantly in diet (especially in limit of salt taking) and exercise, etc., which indicated improving patients perceiving attitudes could enhance their self-care and enhance their lifestyle. However, the study showed no difference in restriction or quitting cigarettes and alcohol before and after the intervention. The reason may be that it is hard and timeconsuming for smokers and drinkers to quit or restrict their habits, which indicates we should maintain the intervention so as to change these habits and lower the complications and mortality. From our study, we could see that the difference between urban and rural areas was one of the factors affecting chronotherapeutic compliance. Therapeutic theory has only been carried out recently with the use of ABPM in China and ABPM is only applied in advanced hospitals and limited by the nancial status of the patients.

Education level was another inuencing factor; having knowledge about hypertension can offer a hypertensive patient more chances and ways to know about hypertension and care himself/herself. Patients with higher education level found it easier to understand and accept new knowledge about chronotherapeutics. Therefore, patients with lower education level should be the key population for intervention. Family member living together was also an inuencing factor. Different members living together could affect the value of compliance, which, in descending order were spouse, children, nursery maid and single. We know correct measurement is necessary for treating hypertension successfully and home BP measurement may depend on family members help and supervision. Patients living together with their spouse might nd it easier to communicate and accept the supervision than those with children or nursery maid, etc. and their chronotherapeutic compliance might be better. Therefore, we can make use of these in our future interventions to promote patients compliance. Monthly income of family and payment for medical care were also inuencing factors. Chronotherapeutic treatment and nursing rely on patients ABPM, which may be limited by patients nancial situation. The cost of ABPM was not included in hospitalisation insurance now in China. Therefore patients with worse nancial status found it difcult to accept ABPM as a means of monitoring BP.

Conclusions
On the basis of ABPM, continuous intervention on hypertensive patients guided by chronotherapeutics could effectively improve therapeutic compliance and blood-pressure control. Differences between urban and rural areas, education level, family member living together, monthly income of family, payment of medical care and whether intervention were the inuencing factors of hypertensive patients compliance to chronotherapeutics, therefore health care providers should take different measures to improve compliance according to patients different characteristics.

Limitations
In this study, we developed the seven-day recall CCQH in Chinese and its reliability and validity were only evaluated in China. In future, it could be translated into English and other languages and be tested through international cooperation.

Relevance to clinical practice

Health care providers who deal with Chinese hypertensive patients can improve patients therapeutic compliance and
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X-Y Zang et al.

BP control guided by chronotherapeutics; according to different inuencing factors on patients chronotherapeutic compliance, they should pay more attention to those whose compliance might be worse.

Acknowledgements
We thank the participants and staff for their long-time commitment to the study. The source of funding came from Scientic Fund of Tianjin Medical University.

Contributions
Study design: XYZ, YZ; data collection and analysis: XYZ, JFL, YFC and manuscript preparation: XYZ, YZ, FKYW.

Conict of interest
The authors declare that they have no conict of interests.

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