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Answered: - Does this article support evidence base nursing? If so how

Does this article support evidence base nursing? If so?how?

Hindawi Publishing Corporation


ISRN Hypertension


Volume 2013, Article ID 671691, 10 pages



Research Article


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;


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.



1. Introduction


Hypertension is highly prevalent, and although rates of detection and control of hypertension are improving in many


countries, uncontrolled hypertension remains common [1]


and medication and lifestyle adherence remains low. Nonadherence leads to substantial avoidable healthcare costs [2]


because of inefficiencies in care delivery, discarded medications, and expenditures related to preventable hypertensionrelated sequelae [3]. 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 [4]. 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 [5]. 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. Methods


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


MDRD equation.


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


and adherence.


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 [13].


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





ISRN Hypertension


Table 1: Baseline characteristics.


Risk factor


Female (%)


Age, years


SBP, mm Hg


DBP, mm Hg


BP at or above target


Total cholesterol, mmol/L?


LDL cholesterol, mmol/L


Creatinine, mmol/L


eGFR, mL/min/1.73 m2


Diagnosis of diabetes mellitus


Diagnosis of prediabetes


Fasting glucose, mmol/L


BMI > 30 kg/m2


Smoking: never/past/current


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. Results


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.



ISRN Hypertension





Table 2: Themes mentioned by patient population.



Theme and subtheme





Wishes to lower or eliminate the need for medication


Holistic approach


Belief in the benefits of medication


Mention family history of HTN




BP consequences


Home monitoring


Current BP


Ways to lower BP


Side effects


Recall target or optimal BP


Knowledge-seeking (internet search, books, magazines)












Salt and hypertension






Feelings and beliefs of health and wellness


Physical manifestations


Integration: routine


Routine to aid in medication adherence


Coping with travel


Healthcare providers












On target





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.






ISRN Hypertension



Management of

























and target














Lack of time,


motivation, routine,


spending extra money



Pill dosettes, aid from spouse








time/busy, lack of


energy, lack of


motivation or routine,


lack of social support



Define consequences


or ways to lower blood









Low knowledge





Exception: diuretic







High knowledge; not


always implemented









Medium knowledge



High knowledge





and beliefs




manifestations for "Feelings" marker for


blood pressure blood pressure control


Cue to












(go to the





Negative effects


experiences of


hypertension were


perceived as higher


blood pressures by


some patients



Strategies for travel,


forgetting pills







Spouse support, use of


precut fresh foods and


salt-free foods by


reading labels, making


time, and creating a






Home exercise


equipment, better


weather, video


exercise games



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.



ISRN Hypertension






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


Side effects



Side effects














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.


I: Right.


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.


I: Okay.


P: And then I?d be like oh crap,


I: So that would be your motivation?


P: Yeah. (female, not on target)






ISRN Hypertension


Table 4: Quotes of patients regarding routines in the management of their blood pressure.










Monetary issues


















Dietary adherence-spousal







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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