INTRODUCTION

Hypertension is one of the renowned risk factors contributing to cardiovascular disease, including stroke, arrhythmias, coronary heart disease and myocardial infarction.1 About 1.39 billion adults worldwide were diagnosed with hypertension2 in 2010 and the number is predicted to increase to 1.56 billion by year 2025.3 More than half of the hypertensive patients were unable to achieve well-controlled blood pressure level despite the recent advancement in the antihypertensive treatment.4 Poor medication adherence is one of the contributing factors that caused uncontrolled blood pressure level among hypertensive patients.5,6,7 The rate of medication adherence in many developing countries including Malaysia was reported lower when compared to developed countries.8,9,10,11

Likewise, in 2015, 30.3% of the Malaysian adults (i.e. 18 years and above) had hypertension, with 13.1% of known hypertension and 17.2% of undiagnosed hypertension.12 Of note, only 26.8% of these hypertensive patients had their blood pressure under control13 and up to 46.6% of them were reported to have poor medication adherence.14 A recent local study revealed that a total of 20,799 excessive pills were returned by hypertensive patients at a single Malaysian government hospital, with a total cost of (Malaysian Ringgit) MYR 4,362.28 (equal to USD 1037) was wasted during the 8 months of study period with an average wastage of MYR 42.35 (equal to USD 10) per patient; changing medication by the doctor and death of patients were the most common reasons accounted for the wastage.15

Low rate of adherence to antihypertensive medication has significantly increased blood pressure and was associated with higher rate of hospitalization and mortality.16 Previous studies have found that many hypertensive patients did not adhere to antihypertensive medication because they had wrong perception towards hypertension or they were unconfident with their antihypertensive medication such as concern of potential adverse effects.17,18,19 Lack of knowledge about usage of medication and various misleading perceptions of hypertension management have resulted inappropriate use of medication especially medication adherence among community-dwelling hypertensive patients.20,21 Furthermore, there is a paucity of local data about hypertensive patients’ perspective towards quality use of medication and hypertension management at the community level. Hence, this study aims to explore hypertensive patients’ perspectives on quality use of medication and issues related to hypertension management among community-dwelling hypertensive patients in Malaysia. The generated local data from this study is anticipated to yield different views from previous studies, such as poorer knowledge among local hypertensive patients towards hypertension management compare to the developed country17 and different perspective towards quality use of medication compare to the research studies from the Asia countries.18,22 The emerged findings from this study will be useful for healthcare provider and policy maker in the treatment of hypertension.

METHODS

Study Design

This study adopted qualitative methodology via focus group. This qualitative study was based on the COREQ Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups.23 Phenomenology approach was utilized in this study to develop an understanding about patients’ view on medication and hypertension management. Phenomenology approach involves the use of the meanings of living experiences and it is essentially “consciousness of” or an “experience of another”.24 Phenomenological analysts provide a close examination platform of individual experiences to capture the meaning and common features, or essences, of an experience or event.24 The content of focus group with semi-structured interview guide questionnaire was prepared based on literature reviews on patients’ hypertension management and earlier work on patients’ perceptions on quality use of medication.17,18,25,26 Three focus group discussions were carried out from August 2015 to September 2015.

In order to achieve the objectives of focus group discussion, the content of semi-structured interview was developed based on the English literatures17-19,22 which have highlighted the global hypertension management and quality use of medication issues encountered by the hypertensive patients. The participants were asked with the semi-structured questionnaires and they were encouraged to interact with each other, exchange ideas and issues based on their experiences or points of view.27 The questions were developed in English and translated into Malay language (the national language) by a professional translator from a local university. Backward translation from Malay language into English language was conducted by another independent translator who was different from the forward translator. The purpose of back translation is to maintain the quality control in step demonstrating. To ensure the inter-translation validity and similarity of conceptual during the translation, harmonization is an important process to discuss the inconsistencies and discrepancies between the source and the target language versions. The questions were prepared in an open ended format and were pre tested for content validity, face validity, and clarity by three pharmacists with vast experience in pharmacy practice research and further adjusted after pilot testing with five patients with hypertension in Penang who were not part of the study target population. The topic of discussion was then sent to an independent experienced moderator for further cleaning. The moderator ensured that topics to be discussed are up to the level of patients.

Study Sample and Setting

This study was conducted at Flat Desa Wawasan. Flat Desa Wawasan is a low cost flat which accommodates about 3000 residents in Bukit Mertajam, Penang, Malaysia. With the collaboration Penang Family Health Development Association (FHDA) Non-governmental Officer (NGO), this study could have an established relationship with the participants in order to produce a better quality focus group discussion.23 FHDA is one of the NGO with non-profit, voluntary citizens’ group which is organized on a local, national or international level. Posters invitation were put on the notice board one month prior the event and those hypertensive patients who were interested in this program contacted the researchers. Participants were recruited by using purposive sampling method. The selected participants represented variation of characteristics and the potential to provide rich, relevant, valid and generalizable information. Hence, the selection of the participant was based on age, living status and the different range of blood pressure levels. The inclusion criteria were the following: being diagnosed with hypertension by a registered medical doctor for at least six months ago, treated with antihypertensive medication for the past three months prior to the study and aged 18 years old and above. Patients with enduring mental health problems or cognitive impairment were excluded. Initially 20 participants were invited to participate in the focus group discussion, but three participants did not turn up in the discussion due to time constraint. Eventually a total of 17 participants were divided into three groups which followed the standard guideline.28,29 A focus group comprises of 4-8 people are usually recommended30 as group exceeded than eight people are difficult to control.28

The discussions were focused on the patterns and reasons of irrational use of medicines, and participants’ perception and knowledge towards hypertensive management. The focus group discussion was carried out at the multipurpose hall of Flat Desa Wawasan. Prior to the focus group discussion, participants were requested to be seated for at least 10 minutes before their blood pressures were being measured. A blood pressure monitoring apparatus (Brand: Omron® with model HEM-7080) was utilized to monitor participants’ blood pressure level.

Information sheet was explained and signed informed consent was obtained prior to the commencement of focus group discussion. The researcher with experience of a qualitative research in a previous study31, played a role as moderator and was assisted by six pharmacy students and two NGOs in the focus group discussion. The participants comprised of Malay, Chinese and Indian hypertensive patients and some of the Indian participants did not understand English and Malay languages. Moreover, some of the participants were old and weak in listening. Therefore the six Indian students assisted the Indian participants in the translation of questionnaires.

Prior to focus group discussion, moderator introduced his background and qualification to the participants. Despite of the personal introduction, moderator also briefed the participants about the study goals for this focus group discussion. The moderator encouraged all hypertensive patients to participate actively in the discussion by giving several probes. The examples of probes were: how do you get high blood pressure medications? Elaborate on the difficulties you were telling about, etc. Eventually every participant was given an opportunity to add on anything about medication and hypertension management.

In order to achieve the objective of focus group discussion, the participants were encouraged to interact with each other, exchange ideas and issues based on their experiences or points of view.27 Malaysia is a multi-racial, multi-cultural and multi-religion country which comprises of Malay, Chinese, Indian and other ethnic population. There are many languages spoken in Malaysia as they are from different ethnic background. Although Malay language as national language but some elderly could not speak well in national language (Malay language) and English because their education level only up to primary school and some of them never receive formal education. Therefore it is inevitable to use multi languages in this discussion and the pharmacy students played a vital role in translating the questionnaire to the participants. The entire questionnaire guide was read in Malay language and was translated to English, Chinese and Indian language by the moderator or assistants if requested by the participants. All the conversation and discussion were audio-recorded and field notes were utilized when necessary during focus group discussion. Three focus group discussions were carried out until saturation of the contents which ranged from 40 to 60 minutes.

Ethical Approval

Ethical approval [USM-HLWE/IEC/2014 (0003)] was obtained from Universiti Sains Malaysia–Hospital Lam Wah Ee Ethics Committee prior to the study.

Data Analysis

After the focus group discussion, all the conversation were transcribed verbatim into Malay language while listening to the audiotape by the two project assistants and the data were counterchecked by the researcher. The field notes were referred during transcribing process. The transcriptions were translated into English by two appointed translator and back translation was performed to ensure correctness and reliability in linguistic. Textual data were explored using content analysis method. Textual data were read several times by the researcher to identify themes and categories. Numerous codes were identified and relevant quotes were categorized under each code. “Open coding” procedure was carried out by writing down as many categories as necessary to address all aspects of the content. In order to reduce the number of categories, the listed categories were filtered by rearranging based on the priority to produce a new list of categories and sub-headings. At the same time, another researcher carried out the same procedure independently to generate the category system. Then the two lists of categories were compared and adjustments were made when necessary. The final list of categories and sub-headings was compared again with the original transcript to ensure all aspects of data were identified and tested for constant comparison. When there were no new themes identified, a conclusion would be made at this saturation point. In order to add validity to the study, the research findings were presented to the participants and feedback were taken to ensure the participants’ own idea and perception were represented and not curtailed by researchers’ own agenda and perspective.

RESULTS

Seventeen hypertensive patients were recruited in this study. The demographic characteristic of the participants are shown in Table 1. Most of the participants obtained their antihypertensive medication at no cost from the government hospitals.

Three major themes were developed via the thematic content analysis, including medication management in hypertension, self-management of hypertension and patients’ knowledge towards hypertension (Table 2).

Theme 1: Medication adherence among hypertensive patients

Three subthemes were further identified in the context of medication management in hypertension.

i) Medication adherence

Nine participants claimed that they never forget to take medicine. One participant has a good habit by bringing her antihypertensive medicine when she travels.

1. “I take medicine every day. Never forget”. (P1)

2. “I take medicine every day and I bring my medicine during visiting to relatives’ houses”. (P3)

However, four participants did not take medication every day. Three participants missed antihypertensive medicine for 2 to 3 days in a week. The reasons given were too busy with work, concerned about side effect of medication, bored with the medication and felt inappropriate use of their antihypertensive medication by doctor.

1. “Sometimes I forgot to take medicine. About 2-3 days in a week I forgot to take medicine”. (P4)

2. “Sometimes when I felt stress then I take medicine”. (P5)

In the context of taking antihypertensive medicine at appropriate time, eight participants took antihypertensive medicine at wrong time without differentiate whether the medication should be taken prior or after meal. The reasons were too many medications to be taken and have confused with the item to be taken with empty stomach or after food.

1. “Suppose my antihypertensive medicine should be taken after meal but sometimes I took it before meals”. (P8)

2. “I am afraid to take medicine before meal because I felt stomach empty”. (P9)

“I rarely took medicine because I have many concerns about medicine especially it would interfere with my thought and become to be less intelligent”. (P12)

To address the reasons of not motivated to consume antihypertensive medication, two participants were bored of taking antihypertensive medication and four participants were experienced side effects from antihypertensive medication.

1. “I was bored with the medicine”. (P5)

2. “I felt nausea when taking medicine”. (P16)

3. “Sometimes I feel tired and afraid of hair loss”. (P6)

Five participants were reluctant to take antihypertensive medicine regularly due to some concerns. However, these participants continue collecting their antihypertensive medicines from government hospital every month.

1. “I fear of the side effects of the drug and the consequences of causing cancer, so I will eat more fruit like apples rather to take antihypertensive medicine every day”. (P4)

2. “I think my high blood pressure medicines are not suitable to me. So I did not take it regularly. When I felt uncomfortable and backache, then I will take the medicine, otherwise I would not take it. But every month I still collect my high blood pressure medication from hospital”. (P5)

ii) Strategies to overcome barriers to adherence

Moreover in order to make sure antihypertensive medicine was taken, one of the participants has taken initiative to take all medicines at the same time.

1. “In early morning, I take all medicines at once before going to work although some of the medicines should be taken either before or after meal”. (P10)

In addition, ten participants prefer to share antihypertensive medication related problems with the NGO officer whom have attended them closely rather than their doctor and pharmacist at hospital. This is due to the close relationship and trust that they have in each other.

1. “I prefer NGO member because they know me well”. (P5)

2. “I have problem of transportation but a nurse (NGO) will help me to collect medication from hospital. I am so glad to them (NGO) and I am willing to share my problem (medication) with them (NGO)”. (P14)

Moreover, a participant has taken initiative to have a recording book in order to enhance medicine compliance.

1. “I keep in a plastic bag. I will write or record in a book when taking medicine to avoid from forgetting because I am a stroke patient”. (P9)

Theme 2: Self-management of hypertension

Three subthemes were identified and categorized under self-management of hypertension. Participants have their own way in controlling and reducing their blood pressure.

i) Personal Strategy

In the response to the action to be taken if they have elevated blood pressure causing headache, the participants have various ways to manage it. Six participants took over the counter (OTC) medications, while a few participants prefer to take a rest.

1. “I will sit and relax. Then I will eat Panadol® (Paracetamol)”. (P12)

2. “I would feel very emotional and angry when my blood pressure is high. Then I will take high blood pressure medicine and then sleeping”. (P7)

Seven participants took herbal medicine in addition to their antihypertensive medication prescribed by doctors in controlling blood pressure.

1. “I always eat traditional medication in the form of seeds to control blood pressure”. (P9)

2. “I take herbal medication in the form of small tablet”. (P13)

While a participant commented he preferred Chinese tea which will “dilute” his “concentrated” blood.

1. “I will drink Chinese tea to “wash” my blood”. (P1)

Five participants were reluctant to take herbal medicine in controlling their blood pressure. They believed medicines from hospital were good enough to control blood pressure.

1. “I have never taken herbs, herbal remedies or traditional medicine to control blood pressure”. (P5)

ii) Awareness on signs and symptoms of high blood pressure

The participants were found to have different signs and symptoms when their blood pressure levels were elevated. When their blood pressures were elevated, twelve respondents reported dizziness as the first symptom they experienced. Three participants considered sweating and headache as the alarming signs for the increased blood pressure level.

1. “I felt dizzy and headache”. (P 6)

2. “I would have a feeling of dizziness and tightness at the neck after eating beef which may have increased my blood pressure”. (P9)

A participant commented that he would not feel any symptoms until he was told by her doctor about the increased of blood pressure.

1. “I did not feel anything until I was notified by doctor that my blood pressure was not under control”. (P7)

Theme 3: Patients’ knowledge towards antihypertensive medication and hypertension

Participants have different understandings towards hypertension. The various levels of understandings have resulted in the different ways of hypertension management among the hypertensive patients.

i) Learning process

Seven participants were very interested to acquire knowledge of hypertension management. They had taken initiatives to attend educational talk. Four participants gained the knowledge of hypertension management through passive learning via mass media.

1. “I get the knowledge from education talk and health briefing”. (P8)

2. “I received a lot of information (hypertension management) from TV (television) and radio”. (P12)

In addition, three participants obtained hypertension knowledge through health care provider and NGO members.

1. “My NGO officer always shares with me the knowledge of hypertension”. (P15)

ii) Knowledge on hypertension

Most of the participants (n=13) did not know the acceptable level of normal blood pressure. The lack of knowledge pertaining to targeted blood pressure is worrying and these patients should be educated on this.

1. “Normal blood pressure level is at 190/80 mmHg”. (P9)

2. “I do not know”. (P14)

Eleven respondents did not understand the causes of high blood pressure.

1. “High blood pressure is cholesterol in the blood”. (P3)

2. “High blood pressure caused by stress and fatigue”. (P6)

Ten participants knew about the complication of hypertension, with the eight of them noted that kidney disease and stroke as the consequences of hypertension.

1. “It will cause kidney damage”. (P3)

2. “The complication of hypertension is paralyse and would cause stroke”. (P7)

iii) Knowledge on hypertensive medication

All participants did not know the name of their antihypertensive medication. However nine of them remembered the shape and colour of their antihypertensive medications.

1. “I do not know the name of my medication, but usually I will bring my own high blood pressure medication as sample when buying medication at retail pharmacy”. (P7)

2. “I do not know. I just take medication by looking at its shape and physical characteristics”. (P12)

In the context of knowledge about mechanism of action for the antihypertensive medicine, all participants did not know how their antihypertensive medications work. They just understood that antihypertensive medications were used to control blood pressure.

1. “I do not know how my high blood pressure medicine works”. (P6)

2. “I do not know about it (mechanism of action). I only follow doctor’s instruction to consume medicine”. (P11)

Ten participants commented antihypertensive medication could control their high blood pressure in order to save their lives. Two participants did not know the advantages of taking their antihypertensive medicine.

1. “I do not know the advantages of taking high blood pressure medication and I took medicine because I was instructed by doctors”. (P9)

2. “I do not know. I just knew it (the hypertensive medicine) could save my life. (P14)

In the perspective of long term effects of antihypertensive medicines, six participants reported their concerns of kidney failure as side effect of antihypertensive medicine. Additionally, a participant stated that antihypertensive medicine has affected her memory.

1. “I afraid that the high blood medication will damage my kidneys”. (P4)

2. “Kidney disease. Because my husband had suffered kidney disease”. (P5)

3. “The concern of taking too much of medicine as it may cause me easy to forget matter”. (P13)

Three respondents were not being influenced by these statements; this could be summarized by one participant:

1. “I am still taking medications continuously with no concerns although many people claim that the medicine from hospital will cause kidney failure”. (P2)

Eleven participants were concerned about medication’s expiry date. They knew expired medications were not suitable be consumed.

1. “I will check the expiry date. If I found the medications were old then I will send it to hospital”. (P6)

2. “I will not take the medicine if the colour of medications were changed”. (P8)

DISCUSSION

This study assessed hypertensive patients ‘perspective towards rational use of medication and hypertension management. The existing findings have successfully explored the different views of appropriate use of medication and hypertension management compare to the studies from western countries17,25 and Asia countries.18,19,22

In the present study, medication adherence and strategies to improve medication adherence were identified as key factors in the medication management of hypertension. Four respondents revealed that they forgot to take medication occasionally. The level of non-adherence among the participants in the present study could be skipping from one dose medication per day to the extent of skipping few weeks’ medication. This finding is in line with the earlier study about the variation of medication adherence among the chronic disease patients in Western country.32 Different reasons were given by the participants for not adhering medication. Consistent with the study findings by Holt and colleagues, the current study highlighted various natures of barrier to adherence among hypertensive patients.33 Consistent with the previous studies34,35,36,37,38, one of the medication adherence’s barrier was taking too many medication at one time. In line with the study reported by Cazorla and Rodriguez39, the present study demonstrated that eight participants did not take medication at the same time every day and a minority of them stopped medication when their blood pressure were at the optimal range. Of note, the current study has similar participants demographic (i.e. unemployed and living alone) as in Zullig’s study which studied the factors contributing to medication non-adherence.34 A key to success in management of hypertension is adherence and persistence to prescribed medicines. Poor adherence to antihypertensive medication could lead to elevated blood pressure level and contribute to high morbidity and mortality.

The current study identified second theme as self-management of hypertension which comprised of personal strategy and awareness on signs and symptoms of high blood pressure. Use of herbal and traditional therapies were perceived as one of personal strategies in controlling blood pressure instead of taking antihypertensive medication in the present study and were paralleled with the other studies from Africa, Asia and Europe countries.40,41,42,43,44 A local study revealed that high prevalence of Malaysian population used herbal and traditional therapies for chronic disease despite of prescribed medication by general practitioner.45

Consistent with the previous studies, the last theme emerged from the existing finding was the patients’ knowledge towards antihypertensive medication and hypertension.17,18 The subthemes included the learning process on how the participants acquired knowledge of hypertension, knowledge on hypertension and hypertensive medication. In the context of patients’ knowledge towards hypertension, most of the participants in this study did not know the accepted range of blood pressure. Similarly, a study conducted by Wizner reported that hypertensive patients were significantly less aware of normal blood pressure level, especially systolic blood pressure level compared to normative patients.46 The hindering of better control of blood pressure level could be due to the low awareness of normal blood pressure values among the hypertensive patients.

The present study revealed that all participants did not understanding about the actual mechanism action of antihypertensive medication when compared to a qualitative study conducted at Canada.17 In contrast to these findings, the Canadian study managed to show that the hypertensive patients in their study were able to explain the water pill (diuretic agent) as “making you pee more” and “takes certain things out of your system like sodium and different things out of your blood stream”.17 Nevertheless, six participants in this study reported to have some experienced side effects of the antihypertensive medications and they were concerned that these medications would lead to the kidney failure. Side effects such as palpitations, frequent urination, recurrent bouts of hunger, erectile dysfunction, dizziness, cough, physical exhaustion were reported in almost half of the hypertensive patients in Krethcy’s study and it also reported that patient’s non adherence were significantly related with the experienced side effects.47 In addition, a systematic review which included 53 qualitative studies reported that the side effects experienced by the hypertensive patients and the concerns about medication addiction have led to poor adherence among hypertensive patients.38

Limitation

There are few limitations in the present study. In this qualitative study, the semi structured questionnaires were designed based on the previous studies17,18,25,26, for instance the medication management by the hypertensive patients and contents from Malaysian national survey on the use of medications might influence the topic development for this study. In addition, the dominant voice from the vocal participants would override other voices in the method of focus group discussion.48 Hence the data obtained from this focus group discussion might have high possibility from those vocal participants than those inactive participants. However, these issues were resolved by encouraging inactive participant to give opinions and highlighting probes by the moderator. Besides, there might be a gap of communication in the process of translation by the pharmacy student to the participants during the focus group discussion. Moreover, the interaction among the participants could not achieve at the optimum level by using multi languages during the discussion. Lastly, the participants in the present study were from low income residential area, thus the findings obtained cannot be assuredly extrapolated to those moderate and high income people with hypertension.

CONCLUSIONS

This study explored the hypertensive patients’ perspectives on the use of medication and highlighted the issue of concerns about hypertension management. The misconception about the side effect of antihypertensive medication has led to poor adherence among the participants. The lack of knowledge towards the targeted blood pressure level was found among the participants and its consequence contributes to low level of self-monitoring of blood pressure. Health educational talk and screening program by the healthcare professional in collaboration with NGO should be advocated at the community level in addressing the above gaps.

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Notes