Hypertensive patients knowledge of high blood pressure

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1 ORIGINAL PAPER Hypertensive patients knowledge of high blood pressure Karin I Kjellgren, Staffan Svenssonl, Johan Ahlner and Roger SaIj6* Department of Clinical Pharmacology, Faculty of Health Sciences, Department of Communication Studies, Linkiiping University, Linkiiping, Sweden. Received June Accepted February Scand J Prim Health Care Downloaded from informahealthcare.com by on 05/20/14 Scand J Prim Health Care 1997;15: ISSN Objective - To investigate hypertensive patients understanding of the circulatory system, in particular high blood pressure. Design - Semi-structured audio-taped interviews of patients immediately after a regular follow-up appointment with their physician. Setting - A primary health care centre and a specialist clinic (hypertension unit) in southern Sweden. Pahents - 33 hypertensive patients, consecutively selected. Main outcome measure - Focus was set on the exploration of patients understandh@nowledge. Results - In spite of a long history of hypertensive care, on average ten years, patients had a less than satisfactory understanding of their condition. Most patients knew their bid pressure values, but very few were able to give an account of Hypertension is seen today as a cardiovascular risk factor, and lowering the blood pressure is considered a form of prevention (1). Preventive work requires that patients assume considerable responsibility for monitoring their health status. The understanding of hypertension is for most patients intellectual and expressed in blood pressure numbers rather than anchored in firsthand experiences of signals from their own body, as would be the case with most other chronic conditions. This will require increasing attention to the necessity of establishing informative and convincing communication with the patients about salient features of their condition (2). There are several factors that are important in medical interviews. Orth et al (3) suggested two components; patient exposition, i.e. the possibility for patients to express perceptions of their condition in their own words, and provider explanation. Low compliance with antihypertensive drug regimens is a well-documented reason for inadequate control of hypertension (4-6). Compliance is a complex function of cognitive, motivational, behavioural, and social factors. Heurtin-Roberts and Reisin (7) showed that culturally influenced health beliefs about hypertension significantly affect compliance and blood pressure control. The aim of the present exploratory study was to analyse, by means of semi-structured interviews, patients understanding of high blood pressure. Focus was set on exploring the following topics: Scad I Prim Health Care 1997; IS what high blood pressure implies in functional terms. Knowledge of high blood pressure seems mainly to be derived from sources other than the health care system, in particular from the mass media. Knowledge of the risks assodated with hypertension was quite good, as was the insight into how these risks couldbe managed. Concluswn - An assessment of patient knowledge of high blood pressure ought to be a starting point for educational strategies that aim to deepen patients understanding of their state of health. Key wordr: blood pressure, hypertension, patient knowledge, patient compliance, patient education. Karin I. KjeUgren DipL Nurse Ed, Department of Clinical Pharmacology, University Hospital, S Linkoping, Sweden - patient knowledge of the concept of high blood pressure - patient understanding of diastolic and systolic blood pressure - patient perceptions of the risks associated with having a high blood pressure and their assumptions regarding how these risks can be managed - sources from which patients had gained knowledge of hypertension - ways in which patients experience a high blood pressure. PATIENTS AND METHODS Study population The data derive from a study of 33 audio-taped interviews with hypertensive patients. The interviews were carried out immediately after a regular follow-up appointment with the physician. Half of the patients (n=16) came from a rural, primary health care centre. The other half (n=17) came from a specialist clinic (hypertension unit) in a major hospital located in a city. Both the primary health care centre and the specialist clinic provide care for the general population. The specialist clinic receives patients with increased severity of hypertension. All the patients were living in Southern Sweden. To be eligible for the study, patients had to meet the following criteria:

2 - they had to visit their physician for a regular hypertension follow-up appointment - their main diagnosis should be hypertension - they should currently be, or have been in the past, treated with at least one antihypertensive drug. A consecutive selection of patients meeting these criteria was made in the regular calling periods for followup appointments. Forty-four patients were asked to participate in the study. Four of them never came for the appointment, and a further seven did not participate, as follows: three were reluctant to be tape-recorded; one was a physician who did not consider himself representative; the remaining three gave no reason. Of the patients who were not included, six were female and five male (mean age 60 years, range 40-78). The study was approved by the Local Ethics Committee of The Faculty of Health Sciences, Linkoping University, Sweden. Data collection and analysis Semi-structured interviews (approximately 30 minutes in length) were conducted immediately after the consultation, by the first author. Initially a fairly open question was presented on each of the five topics described above. On the basis of the answers received, general follow-up questions were asked further to clarify the meaning of the answers. The sequence of questions was decided by the interviewer in the course of the interview. The intention was to explore the patients understanding of the significance of high blood pressure. All conversation between the patients and the interviewer was tape-recorded and later transcribed verbatim. The analysis was based on the audio-recordings and the transcripts. The written data consisted of 324 pages of transcripts, which were analysed using qualitative and quantitative methods: answers were categorized, and frequencies of the different types of responses cal- Hypertensive patients knowledge of high blood pressure 189 culated. The variation between patients in their conceptions of the different topics was categorized on the basis of the answers. RESULTS Study population The typical patient of the whole sample was 58 years old, had a consulting blood pressure of 152/91 mmhg and had been treated for hypertension for ten years (mean values). Some additional characteristics of the patients are given in Table 1. Patient perceptions of high blood pressure An analysis of the answers to the initial question What is high blood pressure? revealed that these could be divided into two main categories (Fig. 1). The answers in the first category (13 patients) implied an attempt to give a functional account of (high) blood pressure, i.e. they described hypertension in the context of blood circulation. In the other category (20 patients), the answers did not attempt any functional account, but instead presented some persona1 experiences of high blood pressure. Most of this second group focused on what they considered to be the consequences of hypertension, e.g. headache, dizziness, tiredness, strain on the heart, ruptures of blood-vessels, strokes and infarcts. It was not uncommon for the patients to associate the high pressure with unhealthy living. Some patients who did not suffer from any symptoms of hypertension described it straightforwardly as something that can be measured. Excerpt 1 : Patient T. (female, aged 71, hypertensive for 20 years, current blood pressure 175/85 mmhg) P: No. High blood pressure, it s a disease one doesn t directly feel. (No.) Instead, it s when they take it Table I. Characteristics of the patients. Primary health care centre (n=16) Specialist clinic (hypertension unit) (n=17) Mean SD Range Mean SD Range Age (years) (35-83) 55 9 (45-74) Blood pressure (mmhg) Systolic ( ) ( ) Diastolic 86 6 (70-95) 95 8 ( ) Duration of hypertension (years) 11 8 (1-30) 10 7 (1-23) Sex Male Female Education Up to secondary education High school Universi tv Scand J Prim Health Care 1997: 15

3 190 K. I. Kjellgren et al. L Fig.]. Patients accounts of high blood pressure. I Scand J Prim Health Care Downloaded from informahealthcare.com by on 05/20/14 with the cuff, they see where I am on the scale. (Hm) And I can t say that - well, that it s the blood pressure s fault. (No.) No. Only six of the 33 patients had an understanding of the functional mechanisms behind high blood pressure that at least to some extent corresponded to currently accepted theories on the pathophysiology of hypertension (8). The answers were not always consistent during the interviews, and a slightly different account - more or less consistent with what had previously been said - could be given in response to some other question. Where is the pressure high? The conceptual problems shown by patients when describing the blood pressure phenomenon were again demonstrated when it was found that less than half of them were aware that the blood pressure is distributed in blood vessels throughout the body. Some patients even located it to the part of the body where it is measured, i.e. the arm, or to the part from where they had experienced symptoms, e.g. the head. This mode of reasoning, in which patients accounts of high blood pressure focus on the symptoms or signs, was consistently found in the data and further illustrates the elusiveness of the condition. The blood pressure level or the headache seemed to be perceived as tangible phenomena, while the underlying physiological cause behind these symptoms and signs remained obscure. The diastolic and systolic blood pressure. When answering the question about the meaning of the systolic (the higher) blood pressure and the diastolic (the lower) blood pressure, a majority of patients thought that the two pressures reflected different physical functions (Fig. 2). Nine patients gave a scientifically correct picture. About one fifth of the patients regarded the pressures merely as something that is measured. Two of these patients also responded to the question about what high blood pressure is by saying that it is something you measure. Scand J Prim Health Care 1997; I5 Fig. 2. Patients understanding of the concepts diastolic and systolic blood pressure. In contrast to the somewhat vague conceptions of hypertension as a physiological phenomenon, it was interesting to note that the patient s knowledge of his/ her actual blood pressure level was very good. Twentyeight of the 33 respondents gave an answer that corresponded to the physician s measurement. Patients conceptions of the consequences and munagement of high blood pressure In general, patients seemed familiar with risks associated with hypertension. The ways in which hypertension can be managed and its sequelae avoided were also known. Nearly all the patients (n=29) identified drugs as a means of controlling blood pressure. Life-style factors such as exercise, diet, and stress were identified by more than one-third of the patients. There was an obvious connection between the perception of hypertension and the ability to comply with and manage risk factors. if the patient did not perceive the condition as serious, or did not understand the nature of hypertension and its consequences, hdshe was usually less inclined to agree with the need for recommended actions, as is illustrated by this excerpt: Excerpt 2: Patient P. (male, aged 51, hypertensive for 20 years, current blood pressure 170/90 mmhg) P: I havn t taken my pills for several years. (No-0) It must have been when I found out that the pills prevent damage that I began to take them properly. (Uh-huh)

4 The context in which we talk to the patients about the risk factors is also of significance for understanding and adhering to therapy. Only after the father of the patient in the excerpt above died from a stroke, having been hypertensive for many years, did the patient really understand the importance of taking the antihypertensive medication. Where do the patients get their infomation? An important source of information for patients was the immediate circle of relatives and friends. But outside these contexts, we found that those who reported having informed themselves about hypertension stated that their main source of information was the mass media (n=13). The few who had consulted some kind of medical literature had used old medical books. Twelve of the patients claimed that they had not read anything at all about high blood pressure. Personal information from the physician played an important role as a source of knowledge. Eight patients explicitly referred to the physician as a provider of information. Awareness of factors affecting blood pressure. About two-thirds of the patients had their hypertension diagnosed when consulting a physicianihealth care for some other reason. This supports the general claim made in the medical literature that hypertension is often discovered incidentally when patients are screened, visiting the clinic for some other reason. Most of these patients reported having had no symptoms, or did not relate the symptoms to the high blood pressure. Most patients in hypertension follow up care were aware that the blood pressure is influenced by various factors. The factor most frequently mentioned was stress. Other factors that were considered significant in this context were exertion, anxiety, and weight gain. We found no obvious relation between how patients understood high blood pressure and its consequences, and their age, gender, education, or years as hypertensives. DISCUSS ION We believe that the results of our study illustrate a somewhat contradictory situation. In some respects patients were well informed, in others they seemed more or less lost. Thus, in spite of a long history of hypertensive care - the average being ten years - many had no functional understanding of the physiological nature of their condition. On the other hand, almost all were wellinformed as regards certain important issues, such as their own blood pressure levels. Quite a large proportion were also able to identify risk factors, and accurately mentioned several factors likely to influence their blood pressure. There are contradictory opinions in the recent litera- Hypertensive patients knowledge of high blood pressure 19 1 ture about the significance of patients knowledge for the success of health measures in this area. Many studies support the claim that patient knowledge is an important determinant for successful treatment of hypertension (2,3,7,9). Other studies do not verify this finding (10-13). The contradictory outcomes and opinions are probably due to variations in definitions of compliance and patient knowledge, and, even more importantly, to how these factors are operationalized in research. If, for example, knowledge is measured by requiring patients simply to agree/disagree to statements in questionnaires, knowledge may appear satisfactory. This is, however, in our opinion a weak indicator of patient knowledge and it is not inconceivable that patients on many occasions score high on such passive measures in spite of considerable Iack of knowledge of the nature of their condition and its possible consequences. In our study, knowledge was assessed by asking patients to answer open questions in their own words. This is of course a more demanding test that results in what appears to be a lower level of knowledge. If compliance is seen just as obedience to health advice, the patients understanding is of less importance and their only duty will be to follow instructions. But if we are operating within a health care concept in which the goal is informed patients who actively contribute to monitoring their own health status, the patients understanding of their own condition and its physiological nature is vital. In this case, the fact that a large proportion of the patients did not have a reasonably clear functional understanding of the circulatory system and what high blood pressure implies in functional terms is a serious shortcoming. The mass media was a major source of information for many patients. The media probably addresses the patients in their life world (14) language, a language that is easy to understand and be influenced by. To provide patients with easily accessible, contemporary and reliable literature about hypertension would give them a better chance to create a more comprehensive picture of the meaning and implications of high blood pressure. There is a need for an ongoing assessment of patients understanding of high blood pressure by health care providers to assure empowerment to increase selfcare competence. ACKNOWLEDGEMENT The study was supported by a grant from the County of Ostergotland, Sweden. REFERENCES 1. Kawachi I, Wilson N. The evolution of antihypertensive therapy. SOC Sci Med 1990;31: Scand J Prim Health Care 1997; 15

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