Study and participant characteristics
A total of 961 articles were retrieved and 11 were included after removing duplicates and articles that did not meet the inclusion criteria, as shown in Fig. 1. The 11 included studies involved 250 young and middle-aged hypertensive patients aged 18–64 years. Two studies included only females [20, 21], and one study included only males [22]. The included studies involved six countries, including two in Malaysia [23, 24], four in America [21, 22, 25, 26], two in China [27, 28], one in Brazil [29], one in Denmark [30] and one in Bangladesh [20]. Eight of the included studies used interviews [20,21,22,23,24, 29], two used focus groups [25, 26] and one was not specified [30].
Literature screening flow chart
Of the data analysis methods, four used thematic analysis [20,21,22, 26], two used Colaizzi’s seven-step analysis, two used content analysis [24, 25], one used descriptive-reductive-interpretive schema [23, 30], one used interpretive phenomenological analysis [25] and one used grounded theory analysis [29]. Subjects included in the study and study characteristics are shown in Table 1. We used the JBI Qualitative Research Inventory to assess the quality of the 11 included articles, and the results showed that all selected articles were of medium and high quality, as shown in Table 2.
Synthetic results
We have identified four themes with ten sub-themes: Poor disease recognition (low disease perception, fuzzy disease knowledge); Barriers to doctor-patient interactions (short communication time, unmet knowledge needs, incomplete guidance for disease management); Living in a hostile environment (heavy workload, lack of companionship, ignorance of families); Expectations for a healthy body (responsibility of family roles, witness the cruelty of illness), as shown in Table 3.
Poor disease recognition
Low disease perception
Low disease perception is mainly reflected in poor medication adherence and difficult lifestyle changes. Poor medication adherence is mainly reflected in patients’ own minimisation of the disease and resistance to taking medication. Medication was not a ‘priority’ [23]. In young and middle-aged patients, clinical symptoms were not obvious [20, 22, 25, 30], and therefore most patients in the study cited ‘busy schedules’ and ‘missing’ medication as reasons for not taking their medication regularly [22, 25, 23, 26], and believed that medication was not a ‘priority’ [23]. Some patients are so confident about their health that they believe they ‘don’t need’ medication [23, 25] or that they can ‘control’ the disease [30, 23]. The difficulty of lifestyle change is reflected in the fact that the vast majority of patients ‘know’ that a healthy lifestyle is good for the disease, but are unable to do so [20, 22, 23, 25, 27, 28]. Daily activities such as diet [20, 21, 27], exercise [27] and blood pressure measurement [20, 23] were only marginally improved when there was a change in disease or clinical symptoms. We also found that exercise was a ‘more acceptable goal’ for young and middle-aged patients compared to dietary changes [23, 25, 29]. Lifestyle changes require a long period of adherence, but most patients adhere to management only briefly at the time of diagnosis and often abandon it later due to laziness or lack of motivation, and they want to have clear goals and be monitored [20, 25, 23, 27, 28]. In addition, home blood pressure monitoring is not encouraging, as patients support the benefits of regular blood pressure monitoring for disease control, but most continue to monitor their blood pressure only when they feel ‘unwell’or have symptoms of hypertension [20, 23].
Fuzzy disease knowledge
Most young and middle-aged patients understand some basic knowledge about blood pressure management and what conditions may ‘trigger’ the disease, and will consciously avoid them in their daily life. However, due to the lack of accurate knowledge about the disease, they often follow the wrong advice or are unable to manage the disease effectively [20,21,22,23, 25,26,27,28, 30]. Some patients lack knowledge about the complications of hypertension and the medications used to treat it, leading to minimisation of the condition and resistance to the medications used to treat it [20, 25, 27,28,29, 23]. As one patient put it, ‘I don’t know the dangers of high blood pressure and targeted, individualised medication [27]’.
Barriers to doctor-patient interactions
Short communication time
Most patients want to provide their doctors with complete information about themselves and receive appropriate responses, but due to the high volume of outpatient visits, communication time is too short, resulting in inadequate access to information for patients [21,22,23,24,25, 27,28,29]. As one patient put it, ‘I don’t tell my doctors about my problems with taking my medication. They usually say something like, “OK, just take your medicine, you can go now”. It’s not even five minutes compared to the long wait [23]’.
Unmet knowledge needs
They are very concerned about the side effects of therapeutic drugs, and the side effects of drugs are one of the reasons why they are resistant to taking drugs, and they hope that their doctors can inform them about the side effects of drugs and how to deal with them when they occur, but they are rarely satisfied with the process of medical consultation [22, 24, 25, 27, 28, 23, 26, 29]. In addition, due to a lack of knowledge about antihypertensive drugs, they are very resistant to prescription drugs, especially in Asia, and most of them try to use other treatments (e.g. traditional medicines) instead of prescription drug therapy [20, 21, 23, 24, 27]. But few doctors are able to listen and offer solutions. As one patient said, ‘… As a rule of thumb, I would never tell a doctor that I use ginseng powder and herbs, which I alternate with clinic drugs. Do you know what happens? I just say “an herbalist told me that ginseng powder helps control blood pressure ……. “ Before I could finish my statement, the doctor told me to stop talking nonsense and only take the medicine he prescribed …… [24]’.
Incomplete guidance on disease management
Most patients felt that they needed detailed guidance from healthcare professionals on the day-to-day management of their condition [27, 28], but sometimes the guidance from healthcare professionals was not personalised or comprehensive, leading to confusion and mistrust of healthcare professionals. As one patient said: ‘…… The doctor told me that I have to take medication all the time and that I have to make sure that I eat with less oil and less salt, so to what extent is less oil and less salt considered less oil and less salt? I think my home and the restaurant is considered very light compared to the taste, I would like to ask again, he looked at the next patient [28]’.
Living in a hostile environment
Heavy workload
‘Lack of time’ was the main deterrent cited by the majority of patients [20, 23, 25, 27, 28]. Many patients cite a lack of time for healthy activities, or even believe that work stress is a contributing factor. As one patient said, ‘I work and work and work without sleeping. I don’t have time to rest and I feel stressed [23]’.
Lack of companionship
Through our synthesis, we found that young and middle-aged patients need mutual encouragement and supervision from their patients, and they want to find a partner to exercise with or a good role model [20, 25, 27, 23, 28].
Ignorance of families
Family members’ misconceptions about hypertension can also affect patients’ blood pressure management [20,21,22,23, 26]. Patients have a close relationship with their families, whose neglect or misunderstanding of the disease can lead to difficulties with dietary changes or inappropriate behaviours. As one patient put it: ‘My wife still cooks food high in salt and fat, even though she knows I have high blood pressure’ [23] Or: ‘All my children have advised me to try alternative medicine first because they don’t want me to become too dependent on medication [23]’.
Expectations for a healthy body
Responsibility of family roles
Derived from the responsibility of family roles, they carry out the management of the disease. They want to be with their families, raise their children and do not want to die prematurely [20,21,22,23, 30]. As one patient put it, ‘I’m thinking a lot about my little boy. What will happen to him, of course I hope he …… I’ll be around at least until he’s older …… I’ll be able to see him get on as an adult [30]’. Love for their children and family motivates them to take the disease seriously.
Witness the cruelty of illness
Hypertension is often comorbid with other serious illnesses, and it is only after witnessing or experiencing a major medical event that patients realise the seriousness of hypertension, become more aware of the condition and control their blood pressure [21, 29, 23, 30]. As one patient put it: ‘……. We found his office full of unused blood pressure medication. I think he died of something that could have been prevented. I saw my mother mourning him and how desperate she was. He knew something was wrong. He knew about his blood pressure, but he didn’t do anything about it [30]’. Other patients who experience complications from hypertension begin to change their poor lifestyle and actively manage their disease after developing anxiety. As one patient put it, ‘I had to take it seriously. That’s what the doctor said, he said, “Because you didn’t realise you’d had a stroke,” and I didn’t realise it either [21]’.
Reflection
We mapped the synthesised results (four themes ten sub-themes) into the COM-B model. C (capability) includes both physical and psychological components. We mapped the theme of disease perception to the mental component of competence. O (opportunity) refers to all factors outside the individual, including both physical and social components. We mapped the life circumstances with living in a hostile environment (heavy workload, lack of companionship, ignorance of families) and barriers to doctor-patient interactions (short communication time, unmet knowledge needs, incomplete guidance for disease management) to the opportunities section. M (motivation) refers to all the brain processes that inspire and direct behaviour. We mapped the expectations for a healthy body (responsibility of family roles, witness the cruelty of illness) to the motivation section (Table 3, Fig. 2). We mapped the results to the COM-B model and proposed clinical interventions by combining the combined results with the corresponding 9 interventions (Table 4).
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