Does the attached article support evidence based practice? If so how?
Hindawi Publishing Corporation
Volume 2013, Article ID 671691, 10 pages
A Qualitative Study of Patient Perspectives about Hypertension
Emily P. Jolles,1 Raj S. Padwal,2 Alexander M. Clark,3 and Branko Braam1
Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, AB, Canada T6G 2G3
Division of General Internal Medicine, Department of Medicine, University of Alberta, Edmonton, AB, Canada T6G 2G3
Faculty of Nursing, University of Alberta, Edmonton, AB, Canada T6G 2G3
Correspondence should be addressed to Branko Braam; email@example.com
Received 11 January 2013; Accepted 5 February 2013
Academic Editors: G. Davidai, H. Komine, and A. A. Noorbala
Copyright ? 2013 Emily P. Jolles et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
To understand hypertensive patients? perspectives regarding blood pressure and hypertension treatment, this qualitative study
applied semistructured interviews of hypertensive patients. Participants were recruited from two hypertension clinics at the
University of Alberta in Edmonton, Canada. To be eligible for inclusion, patients had to be aged 18 years or older, diagnosed
with hypertension by a healthcare provider, and currently taking an antihypertensive medication. Participants were stratified in the
analysis according to blood pressure control. Twenty-six patients (mean age 57; 62% female) were interviewed, of which 42% were
on target and 58% were not. Three underlying themes emerged from the interviews: (a) knowledge of blood pressure relating to
diagnosis and management and control of hypertension, (b) integration of hypertension management into daily routine, and (c)
feelings and beliefs of wellness. None of the above themes were associated with better control. Knowledge gaps were found, which
emphasize the need for further patient education and physician training. Feelings and beliefs of wellness, and not knowledge, were
important factors in home assessment of blood pressure. The absence of connections between control of hypertension and the
identified domains indicates that current approaches could benefit from the development of a more personalized approach for
education and communication.
Hypertension is highly prevalent, and although rates of detection and control of hypertension are improving in many
countries, uncontrolled hypertension remains common 
and medication and lifestyle adherence remains low. Nonadherence leads to substantial avoidable healthcare costs 
because of inefficiencies in care delivery, discarded medications, and expenditures related to preventable hypertensionrelated sequelae . Nonpharmacological interventions to
improve hypertensive medication adherence are usually very
complex involving both educational and behavioural interventions and data examining efficacy have not been consistent . Improved understanding of the psychology of the
hypertensive patient seems desirable.
A number of patient-related barriers to optimizing blood
pressure (BP) control have been identified. These include lack
of patient knowledge, difficulty of treating an asymptomatic
condition, personal beliefs that conflict with hypertension
treatment goals, and other patient issues such as social
economic status, cultural beliefs, access to care, psychosocial
factors, and health literacy . Additional obstacles include
a lack of communication and trust between patients and care
providers, high medication costs, high drug burden, failure to
attend follow-up appointments, and discontinuation of therapy due to drug side effects [5?10]. There is limited data available about patients? personal perspectives regarding obstacles
to hypertension control [11, 12]. We therefore performed a
qualitative study consisting of semistructured interviews to
explore hypertensive patients? views on their disease state and
issues related to optimizing BP control.
2.1. Patient Recruitment and Inclusion. Patients were recruited from two hypertension clinics at the University of Alberta
(Edmonton, Midwestern Canada). Inclusion criteria were age
over 18 years; ability to read, speak, and write English; hypertension defined as either having a BP over the desired target,
patients? BP was either <140/90 mm Hg or <130/80 mm Hg in
case of DM or CKD, or being on antihypertensive therapy;
absence of cognitive dysfunction; use of at least one hypertensive drug; agreeing to sign informed consent. Each patient
was mailed a pamphlet as part of the appointment scheduling,
and, during the appointment, recruiting physicians asked
patients whether they would be willing to participate in the
study. Written information about the study was then provided
by the study coordinator and informed consent was obtained.
Patients received a $50 reimbursement for participation in the
study for the time spent on the interview and costs of parking
and travel. Ethical approval was obtained from the University
of Alberta Health and Research Ethics Board; all participating
patients signed consent to participate in the study.
2.2. Conducting Qualitative Interviews. Patients were consented and interviewed by EPJ, and all interviews were
audio-taped and transcribed verbatim. The interviewer stated
that she was interested in patients? perspective on hypertension management and ensured confidentiality that patients?
answers would not be reported back to the referring doctor.
Interviews were conducted in a neutral, nonclinical setting.
The sample was substratified according to hypertension
control (controlled versus uncontrolled). Patients were considered ?on target? if BP was either <140/90 mm Hg or
<130/80 mm Hg in case of DM or renal impairment defined
by estimated GFR <90 mL/min/1.72 m2 as derived from the
An interview topic guide was developed using the current
literature in the field and based on expert opinion. Interviews were semistructured, 30?60 minutes in duration, and
designed to elicit patients? perspectives using open-ended
questions to trigger responses and prompts/probes as necessary for clarification purposes. Two pilot interviews were
conducted and transcribed, after which the interview guide
was refined, and then the remaining interviews were conducted. The pilot interviews were included in the analysis.
Specific interview topics were definitions of high BP, the
consequences of uncontrolled hypertension, current BP in
relation to targets, methods to lower BP, medication adverse
effects, and barriers to and facilitators of routine drug intake
2.3. Analysis. Data analysis was organized using NVIVO8
(QSR International), a computer program that organizes
repeating themes and aids in the coding of transcripts.
Themes were derived from a review of the literature and by
cataloguing reoccurring themes from the interviews .
Additionally, descriptive statistics such as lab values and
demographic variables were extracted from charts and added
to the dataset for analysis. To ensure rigour, a selection of early
transcripts was reviewed independently by 2 researchers (E. P.
Jolles and A. M. Clark). Themes emerging from the interviews
were used to create categories and subcategories for the
coding framework. Interviews were conducted until data
saturation was reached and new themes were no longer
Table 1: Baseline characteristics.
SBP, mm Hg
DBP, mm Hg
BP at or above target
Total cholesterol, mmol/L?
LDL cholesterol, mmol/L
eGFR, mL/min/1.73 m2
Diagnosis of diabetes mellitus
Diagnosis of prediabetes
Fasting glucose, mmol/L
BMI > 30 kg/m2
Framingham cardiac event score?
57 ?/? 16
134 ?/? 17
79 ?/? 11
4.9 ?/? .93
2.8 ?/? .93
93 ?/? 29
72 ?/? 23
5.8 ?/? 1.5
One patients information not available.
3.1. Patient Population. Twenty-six patients (62% female;
majority Caucasian), aged 57 ? 16 years (range 26?84), were
included in analysis. Baseline characteristics are provided in
Table 1. Sixty-five percent of the participants were prescribed
more than one drug for hypertension. The most commonly
prescribed antihypertensive drug class was inhibitors of the
renin-angiotensin system (62%). Forty-two percent of the
patients were at or below target BP levels.
3.2. Qualitative Interviews. Three underlying themes
emerged from the interviews: knowledge of BP, management
integration of hypertension management into the daily
routine, and individual patient feelings and beliefs of wellness
that impact hypertension control (Figure 1). Detailed themes
mentioned most often by patients are listed in Table 2 and
are stratified by patients on and off target.
3.3. Knowledge about Hypertension. Patients widely reported
that hypertension was a health concern to them. However,
while patients possessed some general knowledge of their
condition and hypertension, the level and sophistication of
this knowledge varied widely (Table 3). About half (54%) of
patients were able to recall that optimal BP was 120/80 mm Hg
or could identify their target BP threshold (<140/90 mm Hg
and <130/80 mm Hg for those with DM or CKD). Neither
patient sex nor achieved BP levels were related to knowledge
about targets. However, most patients (92%) were aware of
methods that could or would be likely to lower their BP. The
majority (92%) knew their current BP. Seventy-three percent
of patients could recall consequences of hypertension, such
as cardiovascular events and renal disease, but patients
struggled to define hypertension.
Table 2: Themes mentioned by patient population.
Theme and subtheme
Wishes to lower or eliminate the need for medication
Belief in the benefits of medication
Mention family history of HTN
Ways to lower BP
Recall target or optimal BP
Knowledge-seeking (internet search, books, magazines)
Salt and hypertension
Feelings and beliefs of health and wellness
Routine to aid in medication adherence
Coping with travel
Not on target
Patients indicated that healthcare providers did communicate information about hypertension; however, around half
of patients had additional questions. Some patients perceived
that their doctors were ?too busy? to answer additional
questions. Patients (69%) mentioned that other healthcare
providers, such as pharmacists and specialists, often provided
more education than physicians.
Patients stated that they were comfortable and quick to
discuss adverse effects with their doctor so that medication
could be changed. The most commonly perceived side effects
were edema (19%), dizziness (19%), increased urination
(15%), headaches (12%), dry throat/cough (8%), nausea and
vomiting (8%), loss of sexual desire (8%), feeling lethargic
(8%), heartburn (4%), hair loss (4%), and constipation (4%).
3.4. Knowledge about Antihypertensive Medication. When
asked about the function of medication, most patients did
not know the exact mechanism of action of the pills. The
consistent exception to this was diuretics, which patients
referred to as a ?water pill.? Patients described the water pill
as ?flushing the system instead of building up,? ?makes you pee
more,? and ?takes certain things out of your system like sodium
and different things out of your blood stream.? All patients
viewed their BP medication as being all quite similar (i.e., did
not believe that one was more ?powerful? or ?important? than
More than half of patients (69%) attributed health
issues to side effects from their antihypertensive medication.
3.5. Knowledge Regarding Lifestyle. Patients understood that
lifestyle modifications could decrease BP. The majority of
patients (85%) mentioned changes such as reducing salt
intake and checking for sodium content (88%), exercising
(69%), following a healthier diet (eating more fruits and
vegetables) (69%), losing weight (46%), decreasing stress
(38%), quitting smoking (12%), decreasing caffeine intake
(8%), and lowering alcohol intake (4%). While quitting smoking does not decrease BP (CHEP 2011 guidelines), smokers
did state that among ways to lower BP, quitting smoking
would be relevant. Surprisingly, few patients (12%) indicated
that incomplete adherence to lifestyle modification advice
was preventing them from decreasing medications.
Lack of time,
spending extra money
Pill dosettes, aid from spouse
time/busy, lack of
energy, lack of
motivation or routine,
lack of social support
or ways to lower blood
High knowledge; not
manifestations for "Feelings" marker for
blood pressure blood pressure control
(go to the
perceived as higher
blood pressures by
Strategies for travel,
Spouse support, use of
precut fresh foods and
salt-free foods by
reading labels, making
time, and creating a
Figure 1: Diagram depicting key patient themes.
3.6. Pragmatism and Routines: Integration of Medication
into Daily Life. The most frequently mentioned barrier to
medication adherence was a lack of a structured routine or
a change in the existing routine (88% mentioned routine)
for self-administering BP medications (Table 4). Patients
reported greatest success when they were able to seamlessly
integrate their medication into their daily life. Patients had
difficulty when schedules and routines were interrupted
unless they had coping strategies to deal with these issues
(e.g., carrying around extra pills and traveling with pill
boxes). Of the 81% of respondents that commented on missed
doses, 54% denied missing any dose and 27% reported that
they ?sometimes? missed a dose either due to forgetting or
a change in routine. When asked what would happen if a
dose was missed, respondents reported that they would take
the next scheduled dose (and by doing so, they would miss
a dose). Additionally, some stated that they may experience
some side effects (headache, BP fluctuations, and feeling
tired) from a missed dose. Monetary issues were only cited
by 8% of patients.
Facilitators of adherence included having an established
routine and using reminder tools to ensure medication is
taken on a daily basis. Almost all patients (88%) mentioned that using day-labeled pill boxes and making pills
visible, along with establishing a routine that incorporates
drug administration, ensured daily adherence. This could be
summarized by one patient: ?. . . Wash your face, brush your
teeth, and take your pills? (male, on target). Patients described
additional strategies to optimize adherence including pill
counting prior to embarking on a trip and carrying special
traveling boxes for extra pills in case that some were lost or
misplaced. Lastly, 12% of patients mentioned that spouses and
family members helped remind them to take their pills and
refill their prescriptions.
Table 3: Quotes of patients with respect to knowledge regarding blood pressure management.
Knowledge and HCP
Knowledge and HCP
Knowledge: BP medication
Knowledge: BP medication
Well it is definitely not a good thing for the body. I mean it can cause a lot of problems to kidneys and strokes
and you know make your heart work faster and therefore weaken it. You know, it is great when you exercise
and you get your heart going faster, but when your heart has to pump faster just to, kind of you know, deal
with your everyday life I mean it is not, it is not very clever at all. It is not very beneficial to you to have high
blood pressure. (female, on target)
P: Yeah I suppose I do not ask them because [?] I, I they will take the readings and they will vary. I assume
that if, if they had concerns they would ask me, and I do not want to be a hypochondriac or be a [chuckles]
asking rhetorical questions that do not really have an answer to them, so. And I sort of respect their time so
[?] and, and they might seem like silly questions so.
I: Do you get that feeling from something that they did or is that more?
P: No, just respect their time and know that [?] I just maybe think they are [?] dumb questions perhaps or
taking up the doctor?s time asking so. (male, on target)
I: Do you have a good understanding about what high blood pressure is? So if your doctor was in the room
right now would you have questions for him that you still do not really understand?
P: What causes high blood pressure? Right. Why do they put you on medication, things like that.
P: They should answer that and talk about it.
P: The only person who will do that [?] is a pharmacist. They will explain it more than the doctors. ?Cause
the doctors are in and out, they?re so busy. (male, not on target)
I: Do you have any idea of what it does for you? Or how it works or?
P: No. I do not. (male, not on target)
I can?t say as I do [know what each pill does], I know it?s supposed to lower my blood pressure. So I know that
the water pill is very helpful. Um other than that, I do not know technically what mine does. (female, on
Um, no I mean [?] if the side effects, if the sexual thing was a proven side effect [?] I would have to make a
decision because [?] I might go off it just to see if it changed much. (male, on target)
Yeah. No the other ones I was on were nasty. Like within, within four hours of taking it, I would be head over
the toilet bowl, sick, migraine [?] nasty. ? ? ? but my hair was falling out and the pharmacist said, yeah the
diuretic can do that. So I asked my doctor, please change. And he went through this whole mess of all these
other ones that we were trying that just made me deathly ill. (female, not on target)
P: Yeah, well every time I go to the doctor [?] he always goes over it and you know tells me what I should be
doing. And I guess, if I did exactly what he said, more than likely I would not have high blood pressure. (male,
not on target)
P: No I mean cognitively I know that stop smoking and lose weight and get active is the best thing you can do
for blood pressure. I am sure eating well and cutting out is probably another good thing too but I like salt so, I
mean I know what I should be doing it?s just that I am not doing it.
I: Is that what it is or what is getting in the way?
P: Nothing, but sheer apathy.
P: Or [?] laziness. I sit at work all day.
P: Maybe something happening? You?d think that two hundred over whatever it was blood pressure would
make me pick up and notice and start doing things but, I do not know, I really don?t know.
P: It is stupid, it is really stupid.
I: Not to do anything or?
P: Yes! I am sixty for God?s sake. I mean life is not getting any shorter or any longer. Do I need to be taking
care of this now. (female, on target)
P: Yeah. I think, I do not know, maybe somebody would have to tell me, if you do not stop eating so much salt,
you?re going to be dead in five years.
P: And then I?d be like oh crap,
I: So that would be your motivation?
P: Yeah. (female, not on target)
Table 4: Quotes of patients regarding routines in the management of their blood pressure.
P: I?ve never missed it. I get right panicky if I have to miss it. And I know, you know the doctors have said, if
you miss one day it?s not going to, you know, but I don?t like to miss no. I don?t miss.
I: What are you worried about if you miss?
P: Actually I can?t tell you what I worry about, I just think it?s not probably a good thing. (female, on target)
It really doesn?t happen unless [?] um if schedules are all screwed up, if we?re away somewhere or travelling
yeah. Which doesn?t happen more than you know, a couple times a year. (female, not on target)
P: Well it?s not cheap. And then you know, it?s like taking the medication right? I can?t even afford it right now.
The healthier I stay, the better, cheaper it is for me. (male, not on target)
Yes sometimes wife tell me [?] [name] take all pills! Alright told [name] are you taking all together like this?
(male, not on target)
I?m a frequent traveler so I carry my pills. Take them, take them and yeah I?m [?] very rarely might I miss a
day of taking them but most of the time I take them. (male, on target)
But it?s quite easy when you have them in your little containers. (female, not on target)
Oh I for years was really bad. I have a dosette now and I faithfully, got it all numbered the days of the month.
(male, not on target)
It?s not going to be a problem. I?ve been doing it for years, So it?s part of my ritual. It?s just the way it is. You have
high blood pressure and you take it you don?t forget. (male, on target)
Um [?] but of course really the only setback is to that is because of my lifestyle I am very busy, and you don?t
always have time to eat healthy. But that?s, you know, you know I try and eat healthy and exercise as much as I
can. I think that?s the part that stresses me out a little bit is that [?] um you know, I know I should be losing
weight and I know I should be doing it for my health, but I just have to get to I know it?s important medically.
Um [?] you know but with lifestyle it is really hard to do that. (patient 13, female, on target)
Yeah sometimes weekends aren?t the best for me [laughs] And I?m a bit worried about that if I retire ?cause I
think sometimes um [?] I eat a better diet on workdays because I have to make a lunch and take it. [?] I
think I?m just on more of a routine. (female, not on target)
P: And salt free diet, or salt reduced.
I: And how do you follow a salt free diet?
P: My wife takes care of it. (male, on target)
3.7. Integration of Exercise and Diet Routine: Barriers and
Facilitators. Barriers to maintain a healthy diet were mentioned by 58% of respondents (work schedule, too busy to
cook, frequently eating out/prepared meals, lack of routine
or motivation, and costs) and 38% mentioned facilitators
(spouse support, use of precut fresh foods and salt-free foods,
label reading, time management, and creating a routine) for
healthy eating. Exercise barriers (weather, disability/injury,
time/busy, lack of energy, lack of motivation or routine, and
lack of social support) were mentioned by 54% of patients,
while only 19% mentioned facilitators for increasing activity
levels (exercise equipment or video games in home and better
weather). Thoughts about being overweight were expressed
by 50% of the patients (63% of females and 30% of males).
3.8. Feelings and Beliefs of Wellness. Despite hypertension often being described as being ?silent? and asymptomatic, 69% of participants experienced symptoms that they
attributed to elevated BP levels (Table 5) so that personal
feelings and/or beliefs had an impact on hypertension management. Patients mentioned physical manifestations such
as headaches (38%), loss of energy, feelings of weakness/
tiredness (27%), dizziness and light-headedness (19%), water
retention (19%), and numbness (8%). Thirty-one percent of
the respondents felt that these symptoms were associated
with fluctuations in their BP levels and appeared when their
BP was not controlled. Participants used these symptoms as
an indication of whether or not a BP measurement should
be taken or a care provider seen. Others...
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