Articulating silences: experiential and biomedical constructions of hypertension symptomatology

Experience of suffering in patients with hypertension: a qualitative analysis of in-depth interview of patients in a university hospital in Seoul, Republic of Korea

OBJECTIVE

To describe the suffering experienced by patients with hypertension, not only regarding symptoms, but also suffering in a social context.

DESIGN

A qualitative analysis of semi-structured interview data. Interviews were audio-recorded and transcribed verbatim. A descriptive approach was taken by exploring patient accounts and presenting their experiences and perspectives.

SETTING

Cardiology clinic in a university hospital (Samsung Medical Center, Seoul, Republic of Korea).

PARTICIPANTS

Patients with hypertension and without serious comorbidities who had been followed-up at a cardiology clinic of a training university hospital.

RESULTS

Nineteen men and women (male:female=12:7) were interviewed. The mean age was 44 years, and the average hypertension duration was 4 years. All 19 patients reported symptoms allegedly to be associated with hypertension. Anxiety about blood pressure fluctuation and hypertension complications, dislike of antihypertensive medication and associated labelling effect, family stress and refusal to be enrolled in life insurance were commonly found among patients' interviews. Relatively younger (≤50 years of age), actively working patients experienced stigmatisation and discrimination in the workplace.

CONCLUSION

The illness experience of patients with hypertension consists of suffering associated with threatened or damaged self-identity at the individual and social level. Medical professionals should have more awareness of the suffering of these patients to improve the quality of care. An education programme with proper focus on the elements of patients' suffering may help to alleviate it.

Seasonal affective disorder and engagement in physical activities among adults in Alaska

Seasonal affective disorder (SAD) is a type of depression in which symptoms occur during a particular season. While physical activity has been shown to improve symptoms for depression in general populations, the relationships between physical activity and experiences of seasonality and SAD remain underexplored. We conducted a survey with adult members of a recreational gym in Fairbanks, Alaska. The survey collected self-report data on sociodemographics, health behaviours, and elements of the Seasonal Pattern Assessment Questionnaire (SPAQ). Results indicate that 18.68% of our study participants meet the criteria for winter-pattern SAD and 43.96% meet the criteria for subsyndromal SAD ("winter blues"). We conducted two regressions to understand experiences of SAD and predictors of seasonality more generally. Gender was a significant predictor of SAD, with women more likely than men to experience SAD (p = .04). Being social at the gym, whether going to the gym with others or participating in activities with others, was associated with higher seasonality than being independent at the gym (p = .03). Younger age was also associated with higher seasonality (p < .001). This study contributes new insights about the relationship between engagement in physical activities and experiences of seasonality among adults in a northern latitude.

Nasa dugo ('It's in the blood'): lay conceptions of hypertension in the Philippines

Introduction

Understanding explanatory models is important for hypertension, a leading risk factor for cardiovascular disease and stroke. This article aims to determine what adult patients with hypertension in the Philippines attribute their condition to, how these views might be explained and what the implications are for hypertension management.

Methods

This is a qualitative study drawing on 71 semistructured interviews (40 initial and 31 follow-up) and four focus group discussions with patients diagnosed with hypertension. The setting was urban and rural low-income communities in the Philippines.

Results

Four prominent perceived causes were identified—genetics, heat, stress and diet—for what patients refer to as ‘high blood’. We propose a ‘folk physiology’ that rests on local understandings of blood and blood flow, draws from broader cultural notions of illness causation and accounts for a dynamic, non-chronic view of hypertension that in turn informs the health behaviours of those affected.

Conclusions

By understanding that hypertension is frequently seen not as a chronic constant condition but rather as an episodic one triggered by external influences, although in those genetically predisposed to it, it may be possible to address patient’s beliefs and thus adherence to treatment.

Sociocultural Perceptions and Enablers to Seeking Mental Health Support Among Bhutanese Refugees in Western Massachusetts

This qualitative study aimed to identify cultural influences on seeking mental health support among Bhutanese refugees resettled in Western Massachusetts. Bhutanese refugees aged 18 years or older were recruited for eight focus group discussions, organized by age and gender ( N = 67, 49.3% female, mean age = 38, SD = 15.9). The PEN-3 cultural model was used as the theoretical framework to examine the roles of cultural perceptions that influence mental health-seeking behaviors. Focus group discussions were audio taped to facilitate the thematic-analysis. Younger participants (<35 years) reported experiencing stressors relating to economic hardships and difficulties in developing academic and social skills as they juggle breadwinner and care-giving responsibilities for their families. Older participants reported frustration with the difficulties in learning English and increased dependence on their children. Family members provided the initial frontline support to persons with mental health problems. If family support did not work, they consulted with their relatives and trustworthy community members for further assistance. Psychological factors such as fears of emotions, social norms, beliefs, and self-esteem associated with cultural norms and values influenced seeking mental health support. All participants expressed the need to have a culturally tailored intervention to develop acquired skills to improve their self-esteem and self-efficacy in order to integrate into their new social and cultural environment. Because family members make important decisions about seeking mental health support, involving family members in developing and delivering culturally appropriate skill development interventions could be a potential strategy to reduce their stress and increase resilience in this refugee community.

Knowledge, attitudes, and beliefs related to hypertension and hyperlipidemia self-management among African-American men living in the southeastern United States

OBJECTIVE

Perceptions of illness affect cardiovascular disease (CVD) self-management. This study explores knowledge, attitudes, and beliefs regarding hypertension and hyperlipidemia management among 34 African-American men with hypertension and/or hyperlipidemia, age 40-65, living in the Southeastern United States.

METHODS

In-person focus groups were conducted using semi-structured interview questions informed by the Health Belief Model (HBM).

RESULTS

Participants had a high level of knowledge about hypertension self-management, but less about cholesterol self-management. Perceived severity of both conditions was acknowledged, though participants perceived hypertension as more severe. Barriers to self-management included medication side effects and unhealthy dietary patterns. Facilitators included social support, positive healthcare experiences, and the value placed on family. Cultural implications highlighted the importance of food in daily life and social settings. Participants expressed how notions of masculinity affected self-management-noting the impact of feelings of vulnerability and perceived lack of control stemming from diagnosis and treatment expectations.

CONCLUSIONS

The findings highlight gaps in knowledge of hyperlipidemia versus hypertension, and the impact of cultural context and perceptions on engagement in self-management behaviors.

PRACTICE IMPLICATIONS

Public health practitioners and healthcare providers serving African-American men should address cultural factors and notions of masculinity which can hinder effective disease management among this population.

Embedded Narratives: Metabolic Disorders and Pentecostal Conversion in Samoa

Drawing from interviews and participant observation, this article explores the intersection of diagnosis of metabolic disorders and religious conversion among Pentecostal Christians in Samoa by analyzing what I call embedded narratives--conversion narratives embedded in illness narratives. Drawing from ethnographic data, I examine how using conversion narrative conventions enabled those living with metabolic disorders to narrate behavior change in a culturally and socially valorized way. By embedding their narratives, I suggest those living with metabolic disorders shifted the object of care from a disease process toward the creation of a religious life and in turn transformed the risks associated with metabolic disorders, including diet, exercise, and pharmaceutical use into moral risks associated with everyday religious life. In these cases, Pentecostal conversion created possible scripts for changing health practices, managing stress, and shifting resource use in the name of religious commitment, providing insights into how self-care can be an expression of religious practice.

"No One Ever Even Asked Me that Before": Autobiographical Power, Social Defeat, and Recovery among African Americans with Lived Experiences of Psychosis

Our article draws on ethnographic research with African American males diagnosed with a psychotic disorder in a high-poverty urban area of the northeastern United States. Our participants frequently described the ways public mental health services led them to experience a paralyzing erosion of autobiographical power, which we define as the ability to tell one's own story and be the editor of one's own life. We identified three important points when the loss of autobiographical power seemed to perpetuate social defeat or a sense of social powerlessness (Luhrmann 2007) for our participants during their interactions with public mental health care. We invite further inquiry into the loss of autobiographical power in settings of public mental health care, the sense of social defeat it seems to perpetuate, and the impact of these on mental health recovery, especially for people living in contexts of persistent social adversity.

Getting to Normal: Women's Experiences Self-Managing Their Perceived Blood Pressure Changes

BACKGROUND

In the United States, nearly 25% of all women older than 20 years have hypertension (HTN). Nearly 30% to 50% of persons with HTN experience symptoms attributed to high blood pressure (BP). Women with hypertensive symptoms may connect their symptoms to perceived BP changes and may be using their perceptions about BP changes to guide their HTN self-management. There is limited research about perceived BP changes or their use in self-management.

OBJECTIVE

The purpose of this qualitative study is to describe the experiences of women with HTN self-managing their perceived BP changes.

METHODS

van Manen's phenomenology methodology and method guided the inquiry. Women with HTN who believed they could tell when their BP changed based on their symptoms were recruited from community settings and were interviewed once with a semistructured guide. Interviews were digitally recorded and professionally transcribed. Textual data were analyzed using thematic analysis to identify major themes.

RESULTS

Seven black and 6 white women comprised the study sample. Participants were middle aged (mean [SD], 50.5 [9.62] years), were experienced in living with HTN (mean [SD],10.76 [9.50] years), had at least a high school education, and had a limited annual income (93% <$24 000). One central theme ("getting to normal") and 4 subthemes (i.e., "I can tell," "tending to it," "the wake-up call," and "doing it right") were discovered in the data. The themes depict a process of episodic symptom-driven and day-to-day actions that the participants used to get their BP to normal.

CONCLUSIONS

The study is significant as new knowledge was discovered about how women perceive their BP changes and use them to guide self-management. This study contributes to clinical practice through suggestions for improving patient assessments. Results serve as a foundation for further research of the self-management of BP changes and developing belief-based interventions with the potential to improve BP control.

Lay perspectives on hypertension and drug adherence: systematic review of qualitative research

OBJECTIVE

To synthesise the findings from individual qualitative studies on patients' understanding and experiences of hypertension and drug taking; to investigate whether views differ internationally by culture or ethnic group and whether the research could inform interventions to improve adherence.

DESIGN

Systematic review and narrative synthesis of qualitative research using the 2006 UK Economic and Social Research Council research methods programme guidance.

DATA SOURCES

Medline, Embase, the British Nursing Index, Social Policy and Practice, and PsycInfo from inception to October 2011.

STUDY SELECTION

Qualitative interviews or focus groups among people with uncomplicated hypertension (studies principally in people with diabetes, established cardiovascular disease, or pregnancy related hypertension were excluded).

RESULTS

59 papers reporting on 53 qualitative studies were included in the synthesis. These studies came from 16 countries (United States, United Kingdom, Brazil, Sweden, Canada, New Zealand, Denmark, Finland, Ghana, Iran, Israel, Netherlands, South Korea, Spain, Tanzania, and Thailand). A large proportion of participants thought hypertension was principally caused by stress and produced symptoms, particularly headache, dizziness, and sweating. Participants widely intentionally reduced or stopped treatment without consulting their doctor. Participants commonly perceived that their blood pressure improved when symptoms abated or when they were not stressed, and that treatment was not needed at these times. Participants disliked treatment and its side effects and feared addiction. These findings were consistent across countries and ethnic groups. Participants also reported various external factors that prevented adherence, including being unable to find time to take the drugs or to see the doctor; having insufficient money to pay for treatment; the cost of appointments and healthy food; a lack of health insurance; and forgetfulness.

CONCLUSIONS

Non-adherence to hypertension treatment often resulted from patients' understanding of the causes and effects of hypertension; particularly relying on the presence of stress or symptoms to determine if blood pressure was raised. These beliefs were remarkably similar across ethnic and geographical groups; calls for culturally specific education for individual ethnic groups may therefore not be justified. To improve adherence, clinicians and educational interventions must better understand and engage with patients' ideas about causality, experiences of symptoms, and concerns about drug side effects.

Chronic disease self-management and health literacy in four ethnic groups

Research from several fields has explored health literacy as a multidimensional construct. The authors' multimethod study, "The Impact of Cultural Differences on Health Literacy and Chronic Disease Outcomes," assessed health literacy and chronic disease self-management among 296 patients from four ethnic groups (Vietnamese, African American, White, Latino) at a Massachusetts community health center between 2006 and 2010. Health literacy was assessed using the short form of the Test of Functional Health Literacy in Adults (S-TOFHLA), the Rapid Estimate of Adult Literacy in Medicine (REALM), and the Short Assessment of Health Literacy for Spanish-speaking Adults (SAHLSA) measures. Qualitative research methods, including in-depth interviews (n = 34), home visits (n = 12), chronic disease diaries (n = 15), and focus groups (n = 47), were completed with a subset of participants. Qualitative interviews indicated a wide range of interpretations of S-TOFHLA questions in which participants substituted their own illness or health care experiences for the abstract examples offered in the instrument, at times leading to incorrect responses. Situating these responses in a broader social and cultural context, this article describes examples of the wide range of chronic disease self-management abilities among participants with limited education and/or low health literacy. It also discusses the culturally variable health beliefs identified among participants interviewed that may play important roles in their chronic disease self-management practices.

Understanding minority patients' beliefs about hypertension to reduce gaps in communication between patients and clinicians

The authors' objective was to gain a better understanding of minority patients' beliefs about hypertension and to use this understanding to develop a model to explain gaps in communication between patients and clinicians. Eighty-eight hypertensive black and Latino adults from 4 inner-city primary care clinics participated in focus groups to elucidate views on hypertension. Participants believed that hypertension was a serious illness in need of treatment. Participants' diverged from the medical model in their beliefs about the time-course of hypertension (believed hypertension was intermittent); causes of hypertension (believed stress, racism, pollution, and poverty were the important causes); symptoms of hypertension (believed hypertension was primarily present when symptomatic); and treatments for hypertension (preferred alternative treatments that reduced stress over prescription medications). Participants distrusted clinicians who prioritized medications that did not directly address their understanding of the causes or symptoms of hypertension. Patients' models of understanding chronic asymptomatic illnesses such as hypertension challenge the legitimacy of lifelong, pill-centered treatment. Listening to patients' beliefs about hypertension may increase trust, improve communication, and encourage better self-management of hypertension.

Deconstructing fatalism: ethnographic perspectives on women's decision making about cancer prevention and treatment

Researchers have long held that fatalism (the belief in a lack of personal power or control over destiny or fate) constitutes a major barrier to participation in positive health behaviors and, subsequently, adversely affects health outcomes. In this article, we present two in-depth, ethnographic studies of rural women's health decisions surrounding cancer treatments to illustrate the complexity and contestability of the long-established fatalism construct. Narrative analyses suggest that for these women, numerous and complex factors--including inadequate access to health services, a legacy of self-reliance, insufficient privacy, combined with a culturally acceptable idiom of fatalism--foster the use of, but not necessarily a rigid conviction in, the notion of fatalism.

Intergenerational transmission of chronic illness self-care: results from the caring for hypertension in African American families study

PURPOSE OF THE STUDY

African Americans often experience early onset of hypertension that can result in generations of adults managing high blood pressure concurrently. Using a model based on the Theory of Interdependence, this study examined whether intergenerational transmission of hypertension knowledge and self-efficacy would affect hypertension self-care of older parents and their adult children.

DESIGN AND METHODS

We recruited 95 African American older parent-adult child dyads with hypertension. We constructed separate logistic regression models for older parents and adult children with medication adherence as the outcome. Each model included individual demographic and health characteristics, the partner's knowledge, and self-efficacy to manage hypertension and dyad-related characteristics.

RESULTS

Parents were more adherent with medication than adult children (67.4% vs. 49.5%, p < .012). There were no significant factors associated with parent medication adherence. In adjusted models for adult children, medication adherence was associated with child's gender (odds ratio [OR] = 3.29, 95% confidence interval [CI] = 1.26-8.59), parent beliefs that the child had better hypertension self-care (OR = 4.36, 95% CI = 1.34-14.17), and child reports that the dyad conversed about hypertension (OR = 3.48, 95% CI = 1.18-10.29). Parental knowledge of hypertension and parent's self-efficacy were weakly associated with adult children's medication adherence (OR = 1.35, 95% CI = 0.99-1.84 and OR = 2.59, 95% CI = 0.94-7.12, respectively).

IMPLICATIONS

Interventions should consider targeting African American older adults to increase self-care knowledge and empower them as a primary influencer of hypertension self-care within the family.

The role of culture in health literacy and chronic disease screening and management

Cultural and language differences and socioeconomic status interact with and contribute to low health literacy, defined as the inability to understand or act on medical/therapeutic instructions. Health literacy is increasingly recognized as an important factor in patient compliance, cancer screening utilization, and chronic disease outcomes. Commendable efforts have been initiated by the American Medical Association and other organizations to address low health literacy among patients. Less work has been done, however, to place health literacy in the broader context of socioeconomic and cultural differences among patients and providers that hinder communication and compliance. This review examines cultural influences on health literacy, cancer screening and chronic disease outcomes. We argue that cultural beliefs around health and illness contribute to an individual's ability to understand and act on a health care provider's instructions. This paper proposes key aspects of the intersection between health literacy and culturally varying beliefs about health which merit further exploration.

Diabetes self-care among a multiethnic sample of older adults

Type 2 diabetes constitutes a leading and increasing cause of morbidity and mortality among older adults, particularly African Americans, Native Americans, Mexican Americans, and rural dwellers. To understand diabetes self-care, an essential determinant of diabetic and overall health outcomes, 80 middle aged and older adults from these four disproportionately affected racial/ethnic/residential groups engaged in in-depth interviews, focusing on approaches to and explanations for diabetes self-care. Certain self-care activities (medication-taking, diet, foot care) were performed regularly while others (blood glucose monitoring, exercise) were practiced less frequently. Despite research suggestions to the contrary, only one in four elders used unconventional diabetes therapies, and only one-third listed someone other than a health care provider as a primary information source. Few self-care differences emerged according to race/ethnicity/residence, perhaps because of the influential and common circumstance of low income. Thematic analyses suggest that inadequate resources, perceived efficacy of medication, great respect for biomedical authority, and lack of familiarity with and concerns about unconventional therapies are influential in establishing these patterns of self-care. We discuss the similarity of self-care practices and perspectives irrespective of race/ethnicity/residence and the predominance of biomedical acceptability.

Lay beliefs about hypertension: an interpretive synthesis of the qualitative research

PURPOSE

The purpose of this interpretive synthesis was to explore lay beliefs about high blood pressure and its treatment in order to develop a foundation for better partnering with clients.

DATA SOURCES

Meta-interpretation was used to analyze 11 qualitative research studies published in the United States between 2000 and 2005.

CONCLUSIONS

Professional and lay beliefs about hypertension are not congruent. Historical factors, lack of congruence between belief systems, and poor relationships with providers lead many clients, especially African Americans, to distrust providers and impede the effectiveness of treatment plans. The most problematic discrepancies were related to beliefs about (a) the presence of symptoms, (b) the need to take medications for the rest of life, and (c) race-specific treatment plans. The interactions between nurse practitioners and hypertensive clients have not been explored.

IMPLICATIONS FOR PRACTICE

Professional-client interactions based on partnership models, with specific consideration for the above-stated discrepancies in beliefs, are necessary to improve hypertension control.

Conceptions of wellness among the Yup'ik of the Yukon-Kuskokwim Delta: the vitality of social and natural connection

Focus group research was conducted to examine indigenous conceptions of wellness among the Yup'ik Eskimos of southwestern Alaska. The dialogue on wellness emphasized the importance of living a traditional lifestyle, seeking creative solutions to manage drastic cultural change, and fostering connection within the communities and the native landscape. These themes mesh well with existing characterizations of Alaska Native experiences and worldviews, and reflect substantial links between enculturation, acculturation and health. The data underscores the importance of comprehending local conceptions of wellness in order to effectively work toward promoting optimal health. This paper represents part of an ongoing dialogue in which researchers and native communities co-direct the investigation into healthy ways of being in the world.

Situating stress: lessons from lay discourses on diabetes

In response to the serious toll diabetes takes on health and resources, researchers increasingly are examining physical and psychological pathways that affect and are affected by diabetes, including stress. Although biomedical researchers and practitioners are beginning to recognize the association between stress and diabetes onset and management, laypersons have long-standing and extensive insights into the multiple ways in which stress is associated with the diabetes disease process. In this article, we examine lay perspectives on stress and diabetes among a multiethnic sample of 80 adults. Participants suggest varying arenas in which stress intersects with diabetes, including stress as implicated in the origin of diabetes, as a threat to maintaining glycemic control, as a challenge to self-management, and as a precursor to and a consequence of diabetes complications. An improved understanding of such perspectives may enhance appropriate disease management and develop a more valid conceptualization of stress in research efforts.

Complementary and alternative medicine use among a multiethnic sample of older adults with diabetes

OBJECTIVE

This study describes complementary and alternative medicine (CAM) use for diabetes self-management among a multiethnic sample with an aim of better understanding lay perspectives on CAM's utility and determining whether CAM practices undermine conventional diabetes self-management.

DESIGN

During in-depth interviews with 80 older adults, data were collected on sociodemographics, the full range of self-management practices, and attitudes toward CAM. Analysis included descriptive measures of association and line-by-line coding.

SETTING/LOCATION

Trained interviewers recruited respondents from four health or social service sites. Sites were selected because they contained a large clientele of the targeted ethnic group and had been involved successfully in previous research studies.

SUBJECTS

Twenty (20) adults age 50 and older from each of the groups most adversely affected by diabetes (African Americans, Hispanics, Native Americans, rural whites) participated in the study.

OUTCOME MEASURES

Self-management strategies (included CAM) were assessed through a semistructured interview guide. Structured instruments obtained data on sociodemographics and health history. The 15-item Summary of Diabetes Self-Care Activities Questionnaire (SDSCA) assessed the frequency of completing recommended self-management activities.

RESULTS

One in four elders reported using CAM, with respondents' cultural background associated with the CAM modality. We found no relationship between standard biomedical regimens and CAM use, supporting respondents' suggestion that CAM supplements rather than substitutes for biomedical self-management. Respondents suggested that use of CAM was limited by CAM's inaccessibility, and, underlying all, the dominance of conventional biomedical therapies that undermines belief in CAM's effectiveness.

CONCLUSION

Older adults with diabetes use a flexible configuration of diabetes-self-management techniques, including culturally specific CAM modalities. CAM use, however, occupies a limited role in diabetes self-management, largely because of the predominance of conventional biomedical regimens.