Treatment and management of chronic diseases is a major health challenge world wide. Within the context of developing countries, self management practices for chronic diseases is an under researched area. Understanding of self management practices by patients in chronic diseases management such as hypertension will help healthcare providers more aware about their patients’ needs for better treatment outcomes.
Aims: To explore the impact of hypertension from patients’ perspective towards their daily living activities.
Method: A focus group study conducted with 19 hypertensive patients to get the insight of hypertension patients’ self management practices. The study was conducted in Sandeman Provincial Hospital at the city of Quetta, Pakistan.
Results: Analysis of the focus group discussion yielded four major themes. 1) Effect of hypertension on participants’ physical, mental and social states, 2) involvement in self management, 3) factors contributing to self management and 4) perception of participants towards antihypertensive agents. Majority of the patients admitted that they were involved in self management of hypertension but these management strategies came from social, peer or family and very little information come from the health care professionals. Exercise of self management was strongly connected to the philosophy of the patients towards drug nature and comparative advantages and disadvantages. Patients also expressed uncertainties against continuous drug usage for the management of chronic illnesses.
Conclusion: Patients suffering from chronic conditions tend to make routine decisions about their illnesses. This may include use of medications, prophylactic measures and self management. Patients seem to have more influence from peers, family members and people with past exposure, thus try to manage their condition on advises from their side. For proper implementation of self management in therapeutic plans, amalgamation of behavioral strategies to improve self-management requires a multidisciplinary team effort (physicians, pharmacists, nurses). The approach to patients should be individualized, taking into consideration their culture, economic situation, knowledge and beliefs regarding the disease and treatment, response to medication and changes in status over time.
Introduction:
Hypertension is a major global concern and is counted as one of the key factor responsible for developing cardiovascular events. It has massive disturbing impact on the population, resulting in unnecessary morbidities and mortalities. Hypertension alone is held accountable for more than 5.8% of death worldwide, loss of 11.9% year of life, adjusted life of 1.4% and decreasing life expectancy (21, 2) leading to further cardiac abnormalities such as myocardial infarction, stroke, heart failure, kidney failure and a number of other countless effects on the human body (3).
Treatment and management of hypertension follows the traditional design similar to other chronic diseases which depends upon pharmacotherapy (4) and preventive measures in shape of life style modifications, physical exercise, weight loss and reduced stress (5). Further more, it is recommended that self management programs have to be incorporated with the treatment regimen especially in the cases of chronic diseases to augment patient care and safety (6). These designs do promise a persistent control of blood pressure and decrease in the development of cardiac events but still large populations are seen with uncontrolled hypertension and thus becoming more vulnerable to cardiac abnormalities (7).
The major population burden of the world is carried by Asia thus the frequency of cardiovascular risk is also seen at the higher side (8). Very poor degree of knowledge towards hypertension is often reported when the sub continent comes into discussion (9). With in this context, there is scarcity of data about hypertension, its risk factors, management and treatment from Pakistan and especially from those areas with lower incomes, tribal residencies, no formal education and lack of access to health facilities.
To date, there is no single universally defined and accepted definition for Self management. Self management often means differently to different people thus changing actual motives of the concept. A simple statement defining self management is proposed by Creer who stated that “when the individual participates in treatment, he is engaged in self-management” (10). Alternatively, Barlow proposed self management being the ability to manage the symptoms, treatment, physical and psychosocial consequences and life style changes inherent in living with a chronic condition (11). Where as Adams in 2004 linked self management with activities that are undertaken to live well with one or more chronic conditions. These include gaining confidence to deal with medical management, role management, and emotional management (12). It is important to mention that self management is not an alternative to medical therapy but to provide a synergetic response along with the treatment.
Therefore, we aimed to explore the impact of hypertension on participants’ physical, mental and social states and whether hypertensive participants are involved in self management for their condition.
Methods
Study design
A qualitative approach was adopted because it allows a flexible and in-depth exploration of participants’ attitudes and experiences (13). Focus group study was conducted to get the insight of hypertension participants towards self management in detail. Focus group methodology was prioritized over other methods because it offer a wide extent of ideas and feelings that individuals have about certain issues, as well as revealing the differences in perspective between groups of individuals. Large data is generated in comparatively short time span and the findings of focus group interviews can be presented in straightforward ways using simple language (14). The most divergent features of focus group interviews is its group dynamics, the type and range of data generated through the social interaction of the group are often deeper and richer than those obtained from one-to-one interviews (15).
Ethical approval
As there was no human ethical committee for non-clinical, observational studies in the institution were the research was undertaken; permission for conducting the interviews was obtained from the Medical Superintendent of the hospital. Beside that, written consent was also obtained from each of the respondents.
Recruitment
The study was conducted in Sandeman Provincial Hospital at the city of Quetta, located in north-west of Balochistan province of Pakistan between June 2009 and August 2009. Hypertensive participants receiving treatment for hypertension, having ages between 18 and 60 years and having good physical and mental health to participate and ability to communicate freely in national language of Pakistan were targeted for this research. A total of 23 participants were selected purposely and 19 attended the focus group sessions. Participants were fragmented into three groups according to age and sex, with 6 participants each to two groups and 7 participants to one thus ensuring premium potential and ease of management (16). Participants with diagnosed hypertension and on antihypertensive medicines only for the last six months, with no other chronic diseases, available for study and communication capabilities were included in the study. Participants suffering from multiple chronic diseases, using medications other than antihypertensive agents, potential of absenteeism and non familiarity with language were excluded. The scheme of recruitment and characteristics of the participants is summarized in Table 1 and Figure 1.
FG* 1 (n=6)
Males 18-60yrs
(33.83±2.714)
FG 2 (n=6)
Females 18-60yrs
(31.67±3.445)
Patients attended (n = 19)
Patients recruited (n = 23)
FG 3 (n=7)
Males 18-60yrs
(35.71±4.461)
Figure 1: Focus group layout. Data is presented as mean ± standard deviation
*Focus group
Description
FG 1
FG 2
FG 3
Subjects(n)
6
6
7
Age(mean ± standard deviation)
33.83±2.714
31.67±3.445
35.71±4.461
Gender
Male
Female
6
0
0
6
7
0
Education
Primary
Secondary
Intermediate
Bachelors
Masters
0
0
3
3
0
0
1
1
3
1
0
2
2
2
1
Locality
Urban
Rural
5
1
4
2
5
2
Income
Less than Pk Rs* 10000
Pk Rs 10000- Pk Rs 20000
Pk Rs 20000 and above
0
3
3
1
4
1
2
3
2
Number of medications used
1
2
3
More than 5
0
6
0
0
0
4
2
0
0
5
2
0
Hypertension control
Adequate
Inadequate
4
2
4
2
5
2
Duration of disease
Less than 1 year
1-3 years
3-5 years
More than 5 years
0
5
1
0
1
3
2
0
0
2
4
1
Table 1: Characteristics of focus group participants
*Pakistan Rupees
Data Collection
Prior to the focus group discussions, a structured schedule of topics to be discussed was established. The topics were viewed by a group of cardiologists working at the cardiac department for the purpose of validity. The topics with little amendments were than sent to the independent experienced moderator for further cleaning. The moderator ensured that topics to be discussed are up to the level of participants. It was also confirmed that all questions are open ended. The finalized schedule was again reviewed by the research team. All focus group discussions were audio taped. Table 2 reflects the topics that were finalized and discussed in the focus group.
Schedule of topics for focus group study
How would you define hypertension?
How has hypertension affected your life?
What do you know about self management?
Are you engaged in self management of hypertension?
Does self management really help you controlling your blood pressure?
What is your current and past medication regimen?
What is your experience of antihypertensive treatment?
What is your perception towards antihypertensive medications?
What is your experience of health care and health care professionals?
What do you perceive about your past, present and future health?
Table 2: Schedule of topics for focus group study
Data Analysis
Data analysis was conducted in three stages: transcription, coding and extraction. Major themes were triangulated and sub themes were identified. Participants attending the focus groups were given a briefing about the nature of the research prior to the discussion itself. Data received from all three groups was compared and it was made assured that all topics were covered and important additional information was also extracted. As the data was reported in perfect shape, the analysis was started.
Transcription:
Transcription of the recordings was done by the principal investigator manually. The said transcriptions were reanalyzed by the research supervisor.
Coding:
Coding was done on the basis of grounded theory. Quotes related to one topic were grouped together. Major themes were identified and the quotes were added to the related themes. Sub themes were also recognized and incorporated with the themes. The four major themes that were generated are as follows: 1) effect of hypertension on participants’ physical, mental and social states 2) Involvement in self management 3) factors contributing to self management and 4) perception of participants towards antihypertensive agents.
Extraction:
The research team verified the major themes and sub themes. The said verification was supported by supervisor of the study and confirmed the results of the analysis. Data of each focus group was compared with each other to maintain homogeneity. Triangulation was done and analysis was drawn.
Theme 1: Effect of hypertension on participants’ physical, mental and social states
Reduced every day activities and mental stress was reported by almost every participant of the focus group. Participants expressed certain fears regarding impact of hypertension on their life as illustrated by the following quotes:
“I was in severe stress when I know that I suffer from hypertension. Now I will develop further heart problems and this will continue till my death” (P3, FG1)
“I know that I can not perform moderate workouts now, this will result in further problems. My routine life is destroyed and i have to give up all what I use to do before” (P4, FG3)
Socially, participants’ family members and financial status was badly affected by hypertension. Some participants have to leave their current jobs as they were unable to perform heavy works, while others stated the impact on treatment on their monthly expenditure.
“I use to work with heavy machines, now I feel tired and fatigued. I can not find a desk job too so my output at work is getting decreased and so is my progress” (P2, FG2)
“The medicines are too costly and because of my problem my family is also restricted to specific diet. With my income it is not possible to cover all expenditures. My disease has made my life problematic” (P3, FG3)
Theme 2: Involvement in self management
Majority of participants admitted that they are engaged in self management. They declared other hypertensive participants, peers and family members the source of this information. Some stated that health care professionals were responsible for this activity.
“I read that salts, oily food and smoking can increase blood pressure. If I can adopt regular exercise and stick to medication, I will have no problems. I am doing that and I feel I am ok” (P1, FG1)
“I started using garlic in my food. I am also having green tea thrice a day. I was told by my friend that I can control my blood pressure like this and it is working” (P2, FG1)
Some participants added that after diagnosis of hypertension, they tried to know more about it. It was an approach which was independent of them.
“My self management started the day I knew I had hypertension. I go through books, digests, internet, discussed with friends that what are the causes, effects and problems related with hypertension” (P5, FG1)
“Now I do not use fatty products, no outside food and try to use lots of fruits and liquids. I even bought a BP apparatus so I can check my blood pressure daily” (P1, FG3)
“I came to know that brisk walking is best for controlling hypertension. For me self management is going for a walk every day and keeping away from stress and tension” (P1, FG3)
Self management strategies employed by participants
Avoid use of fatty diets.
Less salt in take
Regular exercise
Smoking cessation
Regular monitoring of blood pressure
Avoid stress and tension
Table 3: Self management strategies
Theme 3: Factors contributing to self management
Nearly entire participants described heavy expenses in shape of physician fee, medication; diagnostic tests the major reason of self management. An interesting measure was hypertension being untreatable; participants expressed no use in consulting physicians regularly until or unless there is a severe problem faced by them.
“What is the use of going to physician when your condition is not treatable? It is wise to carry management at home and that always work” (P1, Fg1)
“I know that if I go to the doctor, he will charge me huge fee and will give me the same old medicines. May be he will add one more. So I prefer to stay at home and try to control my blood pressure myself” (P3, FG2)
I use medicines properly, but when I feel sad or I am doing some important work my blood pressure rises again. My doctor told me that if I use drugs properly I won’t feel this. It means that this condition is not treatable and what ever I do, it will keep coming back. So why should I spent my money on expensive drugs? (P7, FG3)
Whenever I move out with family, I feel relaxed and my blood pressure remains in controlled range. Even for days I do not take medicines and nothing happens. I think that it is the routine (activities) that controls my blood pressure and not the medications so I manage my routine work and have no problem. (P4, FG1)
Theme 4: perception of participants towards antihypertensive agents.
General perception of patient towards their medication drugs seemed quite unique and totally different as compared to its general pharmacology. Knowledge related to hypertension and its management was on the average level but still some participants had reservations about the treatment and management issue
“Drugs are hot (warm) in nature. They enter the stomach and increase temperature which interferes with digestion. At the same time, body temperature rises too. That is why when I feel good, I do not take medicines and try to control it by diet” (P6, FG2)
“My father had hypertension for 15 years. He was on strict diet plan and used his medication regularly. Even than his blood pressure was not controlled so as I see diet plans, walk, medication etc has no effect on hypertension. Once it develops, it is for ever and you can not do any thing” (P4, FG1)
“I use medicines properly but when I feel sad, or I am doing some important work my blood pressure rises again. My doctor told me that if I use drugs properly I won’t feel this. It means that this condition is not treatable and what ever I do, it will keep coming back. So why should I spent my money on expensive drugs?” (P5, FG3)
There were reservations regarding alternative medicine use in participants with hypertension. Some participants emphasized that use of traditional remedies give much more better results.
“I saw my parents treating me and other kids with herbs, home remedies, amulets etc. They said that natural products do not interfere with human body. I was brought up with the use of these things. Even for hypertension I try traditional products and only visit the doctor when I fell seriously ill” (P6, FG2)
“I do use medicines prescribed by my physician but at the same time I use some traditional remedies as my blood pressure was not controlled with drugs alone, but when I started traditional remedies along with the drugs, I faced no problem. It is a good combination and I even discussed this with my physician” (P2, FG3)
Discussion
The present study highlights the perception of hypertensive participants regarding self management and medication use for the management of hypertension in Pakistan which was not previously reported in the literature. The present study showed that patients with hypertension have their lives disturbed by this long term condition. Participants suffering from chronic conditions tend to make routine decisions about their illnesses and the manner to counter it. This may include use of medications, prophylactic measures and self management. Interestingly, self management strategies that are employed by participants are a decision of their own and often results in worsening of symptoms. In the present study participants tend to focus on self management but at the same time consider self management to be the total thing. The use of antihypertensive agents only when symptoms are aggregated clearly indicates that participants feel self management to be more important than pharmacotherapy. This clearly reflects the level of interaction with the physicians. More over there are merely any counseling service available for the participants that make decisions for participants even difficult. In such conditions, participants has more influence of word of mouth from peers, family members, people with past exposure and thus try to manage their condition on these advises. It is not wise to state that all these advise are wrong but there is no doubt that these advises are not from professionals and may vary from patient to patient, therefore, self management strategies that are employed by participants often results into further complications. For proper implementation of self management in therapeutic plans, amalgamation of behavioral strategies to improve self-management requires a multidisciplinary team effort (physician, pharmacist, nurse). Teaching self management is time consuming, requiring repeated contacts with health care professionals for education, self monitoring and assessment of progress. The approach to patients should be individualized, taking into consideration their culture, economic situation, knowledge and beliefs regarding the disease and treatment, response to medication and changes in status over time.
Lack of human recourses in health sector is counted as a major hurdle when it comes to delivery of optimal health care to all. Pakistan has no exception in this case and faces a severe shortage both in number of professionals and as well as health care facilities. In 2008, only 8 physicians, 1 dentist and 6 nurses and midwifery were available for 10,000 of population (17). This results in the development of medical pluralism, where the patient will use different system of healing. In the current study, it was obvious that participants focus more on Complementary and Alternative Medicine (CAM) compared to orthodox therapy. Participants made independent but similar assessments regarding the use of modern medicines. It was also observed that orthodox medication do not have such dominance over the population as it is seen in the western world (18, 19). In addition, indigenous healing systems particularly hikmat (treatment with herbs) and spiritual healing are quite prominent in the studied population. There is no legal or official acknowledgment as far as the spiritual healing is concerned; still it is the treatment of choice to the majority of the population
Another aspect of patient care revolves around Health Belief Model, which states that attitudes and beliefs of individuals can explain health behavior. Perceived benefits and barriers about the health care regimen play a vital role in achieving therapeutic success. Participants were seemed stressed with medication prescribed to them. A general ideology of medicines carrying more harmful effects flourishes in the society. It is one reason that results in non adherence to medications and development of further complications. Opportunities are available for future research and these potential areas should be addresses by social and medical research so the information can be utilized in policy and decision making by the officials and health care team.
Conclusion
In summary, the present study has given a unique approach into the experience of patients with hypertension. The findings indicate that patients are employing self management strategies but these strategies are mostly related with experiences and with little professional advice. The study has provided the key ingredient that need to be included in a disease-specific self-management program.
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