SPECIAL FEATURES: METHODS

Predictive Factors of the

Nursing Diagnosis Sedentary Lifestyle
in People with High Blood Pressure
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ABSTRACT Objectives: To verify the reproducibility of dening the characteristics and related factors
in order to identify a sedentary lifestyle in patients with high blood pressure. Design and Sample: A cross-
sectional study. 310 patients diagnosed with high blood pressure. Measures: Socio-demographics and
variables related to dening the characteristics and related factors of a sedentary lifestyle. The coefcient
Kappa was utilized to analyze the reproducibility. The sensitivity, specicity, and predictive value of the
dening characteristics were also analyzed. Logistic regression was applied in the analysis of possible
predictors. Results: The dening characteristic with the greatest sensitivity was demonstrates physical
deconditioning (98.92%). The characteristics chooses a daily routine lacking physical exercise and verbalizes
preference for activities low in physical activity presented higher values of specicity (99.21% and 95.97%,
respectively). Conclusions: The following indicators were identied as powerful predictors (85.2%) for the
identication of a sedentary lifestyle: demonstrates physical deconditioning, verbalizes preference for activities
low in physical activity, and lack of training for accomplishment of physical exercise.
Key words: blood pressure, cardiovascular diseases, lifestyle, measurement, statistics.
The term clinical indicator has been used as a
synonym of dening characteristics, clinical evidence,
and signs and symptoms (Chang et al., 1998). Identi-
fying clinical indicators with a good predictive value
for a specic nursing diagnosis can contribute to
increasing diagnostic accuracy and to improving the
reliability of the diagnostic inference process (Parker
& Lunney, 1998).
Dening characteristics are understood as a group
of signs and symptoms that indicate the presence of a
particular diagnosis. They constitute clinical evidence
that needs to be studied with regard to their represen-
tation in practice. This also includes related factors that
can predict a diagnosis, such as etiological agents
(NANDA International [NANDA-I], 2009).
Accurate diagnostic inferences increase the effec-
tiveness of care by permitting nurses to choose specic
actions oriented toward the resolution and control of
identied problems. Conversely, interpretations of low
accuracy can lead to neglect of real or potential prob-
lems and cause damage to the patient (Lunney, 2001).
Background
The validation of diagnostic categories in populations
and diverse clinical situations is important. Most
likely, there will be language problems because these
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193
Public Health Nursing Vol. 28 No. 2, pp. 193200
0737-1209/r2010 Wiley Periodicals, Inc.
doi: 10.1111/j.1525-1446.2010.00902.x
categories have been developed in other cultures;
consequently, there is a need to reconstruct these
categories to include a cross-cultural approach. The
sensitivity, specicity, and predictive value of clinical
indicators are factors that can contribute to the vali-
dation of this process.
Concerned with growing global sedentarism,
NANDA-I realized the need for adding a diagnosis
that could better represent insufcient physical activity.
Existing diagnostic categories, such as intolerance of
activity, fatigue, impaired physical mobility,
and self-care decit, were all based on individuals
with various levels of physical injury (Damewood
& Carlson-Catalano, 2000). Some researchers have
proposed decit of physical activity as a diagnostic
category related to a sedentary lifestyle, with its own
dening characteristics and related factors.
Sedentarismhas also been suggested as a diagnostic
label and a content validation by Fehrings method
showed a global content validation index of .84 for the
same (Guirao-Goris, Pina, & Campo, 2000). A comple-
mentary study identied two different related factors,
expression of laziness and low performance of activ-
ities of daily living, that are similar to two dening
characteristics proposed by the NANDA-I taxonomy.
The high index of the diagnostic content validation
among specialized nurses has also been highlighted
(Guirao-Goris & Duarte-Climents, 2007).
Interest in validating the nursing diagnosis
sedentary lifestyle in the NANDA-I arose due to a lack
of diagnostic labels and prior taxonomies dealing with
human behavioral responses related to insufcient
physical activity. The diagnosis was recognized by
the NANDA-I in 2004; it was dened as, reports
a habit of life that is characterized by a low physical
activity level. The dening characteristics include the
following: chooses a daily routine lacking physical
exercise, demonstrates physical deconditioning, and
verbalizes preference for activities low in physical
activity. The related factors are decient knowledge
of health benets of physical exercise, lack of
training for accomplishment of physical exercise,
lack of resources (time, money, companionship,
facilities), lack of motivation, and lack of interest
(NANDA-I, 2009).
Because of the recent inclusion of these elements
in the NANDA-I taxonomy, the number of studies
dealing with sedentary lifestyle as a nursing diagnosis
is low. However, there are global concerns about
this lifestyle because it constitutes a health risk
capable of having severe consequences for the lives of
individuals, families, and communities. Therefore,
the dening characteristics and related factors of
sedentary lifestyle need analysis with regard to their
representation in clinical practice. Patients with high
blood pressure can serve as an example population
here. Adequate assessment of individuals with high
blood pressure and sedentary lifestyles is essential for
improved quality of care because it directs assistance
toward the specic needs of these individuals.
Research questions
This is a study to evaluate the predictors of sedentary
lifestyle in people with high blood pressure. The
research questions for this study were as follows:
(1) what is the reproducibility of the dening char-
acteristics and related factors of the sedentary lifestyle
diagnosis in patients with high blood pressure; (2)
what are the sensitivity, specicity, and predictive
value of the dening characteristics; and (3) what
are the possible predictors of the nursing diagnosis
sedentary lifestyle in patients with high blood pressure?
Methods
Design and sample
A cross-sectional study was conducted among 310 indi-
viduals (ranging in age from 18 to 69 years) with
conrmed high blood pressure and who were followed
up in the hypertension program. Any medical contrain-
dications for physical activity mentioned by individuals
were criteria for exclusion, as were cognitive problems
that rendered data collection of pertinent information
impossible. Ethical approval was obtained from the
internal committee of the institute.
Patients were consecutively selected and the sample
size was dened based on the indicated formula for
cross-sectional studies with nite populations using the
following parameters: condence coefcient of 95%and
sample error of 5%; population size of 6,042 patients
with high blood pressure registered in the program;
and sedentarism prevalence of 70% (Murphy et al.,
2005). It was not possible to use prevalence of the
diagnosis as a reference in the study because this value
was not found in the literature related to patients with
high blood pressure.
Measures
Primary data were collected on a questionnaire admin-
istered to individuals on entry into the study during
194 Public Health Nursing Volume 28 Number 2 March/April 2011
a clinical consultation for follow-up of hypertension.
The questionnaire included variables related to the
assessment of dening characteristics and related
factors of the sedentary lifestyle diagnosis. The study
considered either the presence or the absence of the
diagnosis sedentary lifestyle as an outcome variable.
The long form of the International Physical
Activity Questionnaire (IPAQ) was used in this study
(IPAQ, 2005; Benedetti et al., 2007). The question-
naire was divided into four parts. The rst part was
designed to obtain personal and socio-demographic
data. The second part recorded behavior that related
to the habitual practice of physical activity, which
enabled the collection of data related to the dening
characteristics chooses a daily routine lacking physical
exercise and verbalizes preference for activities low in
physical activity.
The third part of the questionnaire assessed physical
conditioning by means of an instrument proposed
by the Cooperative Project-World Organization of
National Colleges and Academies (COOP/WONCA).
This instrument was validated for use in assessing
short-term physical conditioning processes and had
a Spearman correlation coefcient ranging from .66
to .81 (Tudela & Ferrer, 2002).
The fourth part of the questionnaire permitted
the collection of information concerning related factors
of the nursing diagnosis sedentary lifestyle. The instru-
ment facilitated gathering data related to possible
obstacles to practicing and understanding the relevance
of physical activities. In order to identify these barriers,
we used an instrument measuring the perception of the
difculty of practicing physical activity. Testing showed
that the proposed questionnaire was satisfactory in its
applicability and clarity. It also permitted an acceptable
index of response reproducibility, with Pearson corre-
lation values ranging between .67 and .97 (Martins &
Petroski, 2000).
Specic knowledge about the importance of physical
activities was evaluated by calculating the number of
correct answers in 12 questions about physical activities
related to health that were proposed by InteliHealth
s
Inc. (InteliHealth, 2007). The information on the
Web site has been revised and approved by health
care professionals, the editors of InteliHealth, and
academic partners from Harvard Medical School and
the Columbia University College of Dental Medicine.
The questionnaire as a whole was subjected to
a pretest to verify its adequacy for measuring the
established objectives in the study and to inves-
tigate its ease of use. The resulting observations were
incorporated and the nal questionnaire was
composed. The 14 individuals who participated in the
pretest were excluded from the nal analysis.
Analytic strategy
Studies of diagnostic tests usually include two analy-
tical approaches: reproducibility and accuracy analyses.
The rst approach seeks to determine whether a mea-
surement or a technique allows for the repeated identi-
cation of a specic clinical condition. In studies of
clinical indicators for nursing diagnoses, the opinion of
specialist nurses is used as a way to assess the repro-
ducibility of each indicator to characterize a diagnosis.
For the purpose of making diagnostic inferences, data
collected from each patient during the interview and
the list of dening characteristics and related factors
from the sedentary lifestyle nursing diagnosis were
evaluated by three experts (A, B, and C) selected by the
Fehring criteria. At this stage, it is important to assess
agreement among the experts to minimize misclassi-
fying subjects with either the presence or the absence of
the diagnosis. In this study, using the Kappa coefcient,
concordance among experts was tested in the reproduc-
ibility analysis regarding the presence or the absence of
the nursing diagnosis of a sedentary lifestyle and its
clinical indicators.
In nursing diagnosis research, the accuracy
analysis is related to the condence that a nurse has
regarding the accuracy that a specic indicator will
determine whether a patient truly has or lacks a
particular diagnosis. Unfortunately, there are no
measures or techniques to serve as a gold standard
for the identication of nursing diagnoses. Thus, after
verifying the classication and an agreement among
experts, we decided to use agreement among experts
as the gold standard for identifying the presence of a
sedentary lifestyle. This strategy was used to minimize
bias on behalf of an experts individual opinion.
During this stage, the sensitivity, specicity, and
predictive values were dened for each characteristic.
For the analysis of the possible predictors of the
nursing diagnosis sedentary lifestyle, variables were
analyzed using a t test with an assumption of equal
variances for the numerical variables. Assumptions of
normality and homoskedasticity were veried before
performing the t tests. Pearsons w
2
test was used to an-
alyze the categorical variables. The variables analyzed
included age, sex, birthplace, religion, marital status,
occupation, educational level, income per capita, body
Guedes et al.: Predictors of Sedentary Lifestyle 195
mass index (BMI) classication, BMI value, time of
high blood pressure diagnosis, presence of diabetes,
dening characteristics, and related factors.
In the logistic regression the following were
included: variables that demonstrated statistical
signicance lower than .2: age; presence of diabetes;
the three dening characteristics demonstrates
physical deconditioning, chooses a daily routine
lacking physical exercise, and verbalizes preference
for activities low in physical activity; and the four
related factors lack of training for accomplishment
of physical exercise, lack of resources, lack of
motivation, and lack of interest.
From this selection, the variables were tested
to verify their overall association in order to clarify
the occurrence of the nursing diagnosis in question.
The Wald test was applied to verify the signicance
of the coefcients that encompassed the logistic
equation. The Omnibus test veried the signicance
of the developed model. The Hosmer-Lemeshow test
evaluated the difference between the observed and
the expected frequencies and the Nagelkerke R
2
test
estimated the determined capacity of the model.
In addition to these statistics, the nal denition
of the predictors considered the reduction of the
logarithm of the maximum likelihood ratio ( 2log).
Results
The age, education level, and per capita income were
nonnormally distributed. The median education was
9 years, the median per capita income was US$124.79
monthly, and the median age was 56 years. The
majority of individuals were female (65.5%), from
the capital Fortaleza (86.1%), Catholic (74.5%), and
married (64.5%).
With regard to concordance among the experts,
the dening characteristic demonstrates physical
deconditioning presented the lowest indices. The
other dening characteristics presented indices of
moderate concordance. With regard to related factors,
decient knowledge of health benets of physical
exercise and lack of motivation presented the lowest
indices of concordance. The related factors lack of
training for accomplishment of physical exercise and
lack of resources demonstrated small variations
among the experts. Lack of interest was the related
factor of greatest concordance. Moderate levels of con-
cordance among the experts were observed in refer-
ence to the presence of the nursing diagnosis (Table 1).
The dening characteristic with the greatest sen-
sitivity was demonstrates physical deconditioning
(98.92%), which had a negative predictive value of
95.74%. Furthermore, chooses a daily routine lacking
physical exercise and verbalizes preference for activ-
ities low in physical activity presented greater values
of specicity (99.21% and 95.97%, respectively) and
high positive predictive values (99.24% and 97.09%,
respectively) (Table 2).
The variables that presented statistical signi-
cance values below .2 for the nursing diagnosis of a
sedentary lifestyle were age (p5.044); presence of
diabetes (p5.048); and the related factors or dening
characteristics chooses a daily routine lacking physical
exercise (po.001), demonstrates physical decondi-
tioning (po.001), verbalizes preference for activities
TABLE1. Distribution of Concordance of the Experts (A, B, and C) Regarding the Presence or Absence of the Nursing Diagnosis
Sedentary Lifestyle, Dening Characteristics, and Related Factors
Variable/experts
AB AC BC
Kappa Sig Kappa Sig Kappa Sig
1. Dening characteristics (DCs)
Chooses a daily routine lacking physical exercise .508 .000 .564 .000 .231 .000
Demonstrates physical deconditioning .041 .011 .169 .000 .215 .000
Verbalizes preference for activities low in physical activity .531 .000 .307 .000 .574 .000
2. Related Factors
Decient knowledge of health benets of physical exercise .118 .000 .430 .000 .224 .000
Lack of training for accomplishment of physical exercise .230 .000 .689 .000 .295 .000
Lack of resources (time, money, exercise companion or facilities) .300 .000 .342 .000 .743 .000
Lack of motivation .112 .002 .127 .001 .736 .000
Lack of Interest .727 .000 .728 .000 .923 .000
3. Presence of Nursing Diagnosis .411 .000 .414 .000 .730 .000
196 Public Health Nursing Volume 28 Number 2 March/April 2011
low in physical activity (po.001), lack of training for
accomplishment of physical exercise (po.001), lack of
resources (po.001), lack of motivation (po.001), and
lack of interest (po.001).
Among these variables, demonstrates physical
deconditioning, verbalizes preference for activities
low in physical activity, and lack of training for
accomplishment of physical exercise were identied
as signicant predictive indicators. The logistic model
developed was statistically signicant according to
the Omnibus test (po.001), and it enabled the iden-
tication of the presence of the diagnosis from
these three variables of the model. No signicant
differences were identied among the observed and
expected frequencies in the nal model (p5.202).
The coefcients of each variable included in the model
demonstrated statistical signicance according to the
Wald test (po.05). The determination coefcient
of the model was .852; this coefcient implied that
the variables included in the model explained 85.2%
of the occurrence of the nursing diagnosis of a seden-
tary lifestyle in patients with high blood pressure. This
fact was conrmed through the reduction of the
maximum likelihood ratio ( 2 log) (Table 3).
Discussion
Studies have shown that the problem of physical
inactivity is a worldwide concern and indicated that a
large segment of the population does not follow current
recommendations regarding the practice of physical
activities (Altieri et al., 2004; Bernstein et al., 2001).
Worldwide inactivity justies the creation and use
of the dening characteristic chooses a daily routine
lacking physical exercise (Hallal et al., 2005). Con-
versely, a previous study has demonstrated that regular
physical exercise was associated with a signicant
reduction in cardiovascular morbidity and mortality
as well as an improvement in the cardiac illness reha-
bilitation process (Lee & Skerrett, 2001).
A study comparing active and sedentary bankers
found a relationship between the dening character-
istics chooses a daily routine lacking physical
exercise and verbalizes preference for activities low
in physical activity. In the study, the active group
perceived regular physical exercise as a source of
pleasure because it afforded them the opportunity
to forget work-related problems. Conversely, those
who were considered sedentary verbally reported
preferring activities with little physical exercise due
to a lack of motivation. Instead, they opted for activ-
ities that were calming and less physically strenuous
(Andrade et al., 2005).
The fact that the dening characteristic demon-
strates physical deconditioning was the greatest
sensitivity measure for the sedentary lifestyle diagno-
sis is likely due to the simplicity and clarity of the
individual self-evaluation tool. The ndings should be
viewed with caution because effective physical tness
depends on the thorough execution of well-planned
TABLE2. Sensitivity Value (SE), Specicity Value (SP), Positive Predictive Value (PPV), and Negative Predictive Value (NPV)
for the Dening Characteristics of the Sedentary Lifestyle
Defining characteristics SE (%) SP (%) PPV (%) NPV (%)
Chooses a daily routine lacking physical exercise 69.35 99.21 99.24 68.51
Demonstrates physical deconditioning 98.92 36.29 69.96 95.74
Verbalizes preference for activities low in physical activity 89.78 95.97 97.09 86.23
TABLE 3. Logistic Regression for the Predictive Factors of the Presence of the Nursing Diagnosis of a Sedentary Lifestyle
Predictors OMN HL R
2
2 log Wald
o.001 .202 .852 219.511
Demonstrates physical deconditioning .007
Verbalizes preference for activities low in physical activity o.001
Lack of training for accomplishment of physical exercise o.001
Constant o.001
Note. OMN5Omnibus test; HL5Hosmer and Lemeshow test; R
2
5Nagelkerke R
2
; 2 log 5Logarithm of likelihood ratio;
Wald5Wald test.
Guedes et al.: Predictors of Sedentary Lifestyle 197
activities and is inuenced by the initial level of cardio-
vascular tness of the individual as well as the type,
velocity, frequency, duration, and intensity of the
tness session (Mcardle et al., 2006). In the present
study, a demonstrates physical deconditioning den-
ing characteristic was tied to a chooses a daily routine
lacking physical exercise characteristic, which may
result in an individuals preference for activities with
little physical exertion.
Despite the lowindices of concordance for decient
knowledge of health benets of physical exercise
among the experts, the literature highlights the fact that
a knowledge decit about exercising, the purpose of
exercise, the limitations of some populations (as well as
distorted perceptions), and the benets of movement is
one reason why individuals have sedentary lifestyles.
Conversely, increasing knowledge about physical
activity can prevent an increase in sedentarism
(Domingues & Araujo, 2004). Patients knowledge
about their health conditions, therapeutic treatments,
and prevention can facilitate adherence to regimens
and to maintenance of or improvement in well-being.
Additionally, patients can avoid changes in overall
health due to uncontrollable blood pressure levels.
Finally, lack of knowledge, motivation, and interest
in physical activity were also considered important
elements in understanding the adherence of high
blood pressure patients to physical activity programs
(Chummun, 2009).
Another topic that merits discussion is a related
factor: lack of training for the accomplishment of
physical exercise. This variable is an important etiologic
factor when considering the diagnosis of a sedentary
lifestyle in patients with high blood pressure. After a
period of training, patients with slight-to-moderately
high blood pressure who regularly perform dynamic
exercise can achieve a signicant decrease in their
diastolic and systolic pressures during periods of both
rest and stress (Chobanian et al., 2003; Pitt et al., 2003).
These data may suggest the promotion of activities that
do not require training, such as walking.
In addition, regular training programs also pro-
vide better physical tness for individuals and create
sustainable mechanisms for maintaining daily physi-
cal exercise routines (thereby increasing activity).
This relationship was demonstrated in this study,
in that the characteristics or factors chooses a daily
routine lacking physical exercise, demonstrates
physical deconditioning, and lack of training for
accomplishment of physical exercise increased the
probability that patients with high blood pressure
would develop a sedentary lifestyle.
With regard to the related factor lack of resources,
the ndings demonstrated that interference from
family, friends, health care professionals, climate,
structure, time availability, and nancial resources
inuenced adherence to physical tness regimens.
Stimulation of patients with high blood pressure to
develop a more active lifestyle represents a valuable
tool for improving health standards. To become more
active, patients need to be educated and receive
adequate information and motivators. They also need
to belong to physical tness groups and have access to
favorable conditions (e.g., nancial resources, free time,
and nearby tness locations). In the present study, the
factor lack of resources was not predictive, but it is
important in clinical practice. In the institution where
the study was developed, patients received all medi-
cations and had free access to all services; this may have
inuenced our results.
In addition, analyses of the sensitivity and speci-
city of the dening characteristics in this investigation
indicated that demonstrates physical deconditioning
was the most sensitive variable; in contrast, chooses a
daily routine lacking physical exercise and verbalizes
preference for activities low in physical activity were
the most specic variables for the nursing diagnosis
under study.
Of the proposed characteristics for the diagnosis
of sedentarism, a previous study demonstrated that
verbal expression of the family of having a sedentary
lifestyle and verbalizing a preference for activities
with low or no physical activity yielded scores with a
diagnostic content validation superior than or equal
to 80; these scores were considered critical or specic
(Guirao-Goris et al., 2000). Conversely, the charac-
teristics realizes exclusively operational activities
of daily living and diminished capacity to execute
physical activity: poor physical conditioning (COOP/
WONCA score ! 3) had scores lower than 80 and
were classied as minor dening characteristics.
In a similar investigation by Guirao-Goris
and Duarte-Climents (2007), no characteristic had a
diagnostic content validation greater than 80. In
contrast, the characteristics verbal expression from
the family and/or a person of having a sedentary
lifestyle, verbalizes preference for activities with low
or no physical activity, and the presence of a COOP/
WONCA score ! 3 received higher scores of 70, 74,
and 73, respectively.
198 Public Health Nursing Volume 28 Number 2 March/April 2011
Consequently, we believe that the differences
between specicity and sensitivity, which are inuenced
by the diagnostic prevalence, directly depend on the
characteristics of the studied population. There is a
need to further investigate this hypothesis in diverse
population contexts to better clarify this question. For
Tanner and Hugles (1984), the relationship between
the clinical indicators and diagnosis could only be
validated after repeated and systematic observations
that required the development of new research with
additional subjects.
Although the classication of the physical activity
level by the IPAQ has the advantage of offering
an evaluation of physical activity in diverse contexts,
it is necessary to consider the potential recall bias
of the participants. Because of the length and detail
of the questionnaire with regard to the number and
period of executed activities, we concluded that
participants at times only estimated these values. This
estimation made it difcult to capture reliable infor-
mation fundamental for the development of the study.
Regarding the validity and reliability of these mea-
sures, we used standard techniques and calibrated
instruments for our clinical assessment. Moreover,
observation and evaluation biases are usually present
in studies of this nature. These biases can be associated
with different levels of experience and knowledge, the
omission of clinical data, lack of attention, and prema-
ture inferences. Despite the experience and selection
criteria used, one cannot guarantee that bias will not
be present. In addition, it is necessary explain that
cross-sectional studies cannot show direction or cause.
Thus, the results should be considered in the context of
their limitations.
Unfortunately, data related to levels of hyperten-
sion and the use of medications were not investigated
because the study institution primarily serves indi-
viduals with severe hypertension (SBP4179 and/or
DBP4109). This limitation should be considered when
generalizing the results, and further studies investi-
gating the relationship between a sedentary lifestyle
with these variables are encouraged.
Another point to consider is the lack of studies
regarding the nursing diagnosis sedentary lifestyle.
This dearth made it difcult to compare and discuss
ndings relevant to this research. This fact increases
the importance of developing new studies that involve
this nursing diagnosis.
The dening characteristic with greatest sensitivity
for the sedentary lifestyle diagnosis was demonstrates
physical deconditioning. The characteristics chooses a
daily routine lacking physical exercise and verbalizes
preference for activities low in physical activity
showed the greatest specicity values. The indicators
identied as predictors of sedentary lifestyle were
demonstrates physical deconditioning, verbalizes pref-
erence for activities low in physical activity, and lack
of training for accomplishment of physical exercise.
This study serves as a guide for the diagnostic
efciency of clinical indicators for the sedentary
lifestyle diagnosis and contributes to improving diag-
nostic accuracy by determining sensitivity, specicity,
and positive and negative predictive factors. We call
attention to the fact that the accuracy in question has
not been sufciently investigated in studies regarding
nursing diagnoses. We recognize the need to develop
studies examining the sedentary lifestyle diagnosis.
Such studies are fundamental in order to better delin-
eate the dening characteristics, develop more accurate
measurement instruments, and conduct clinical vali-
dation in other contexts.
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