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The Experience of Living with Hypertension: Lessons from a Cohort of Older Men
By
Junjira Seesawang
A dissertation submitted in partial fulfillment of
the requirements for the degree of
Doctor of Philosophy
(Nursing)
at the
UNIVERSITY OF WISCONSIN-MADISON
2019
Date of final oral examination: 12/21/2018
The dissertation is approved by the following members of the Final Oral Committee:
Barbara J. Bowers, Professor, Nursing
Heather Johnson, Associate Professor, Medicine and Public Health
Barbara King, Associate Professor, Nursing Lisa Bratzke, Assistant Professor, Nursing
Nataporn Sansiriphun, Associate Professor, Nursing
i
ACKNOWLEDGEMENTS
There are some people that without them, completing this dissertation would have been
impossible. I am eternally grateful to them all.
First and foremost, thank you to the participants for generously giving their time, for
trusting me and allowing me into their world. Thank you to the healthcare providers for their
support and assistance in recruitment.
I owe a debt of gratitude to my advisor, Dr. Barbara Bowers, who provided timely advice
and support throughout the incredible journey of research and writing. I am forever grateful to
her for her mentoring and her enthusiastic support. A special thanks to my committee members,
Dr. Nantaporn Sansiriphun, Dr. Barbara King, Dr. Heather Johnson, and Dr. Lisa Bratzke for
helpful guidance and nurturance.
I would like to thank the Royal Thai Government and Praboromarajchanok Institute for
Health Workforce Development, for financial support during my educational journey in the U.S.,
and the University of Wisconsin Madison, School of Nursing for research funding.
Last, but not least, this dissertation would never have been completed without the
encouragement and an endless source of support of my family, gundam guy, and friends.
ii
Tables of Contents
Abstract………………………………………………………………………………...…… iii
Chapter 1: Introduction………………………………………………………………….... 1
References…………………………………………………………………………………… 12
Chapter 2: Experience of Men Living with Hypertension: An integrative Review…..... 20
Abstract……………………………………………………………………………………… 22
Introduction………………………………………………………………………………….. 23
Methods……………………………………………………………………………………… 24
Results……………………………………………………………………………………….. 26
Discussion…………………………………………………………………………………… 33
References…………………………………………………………………………………… 37
Chapter 3: Factors Influencing Ability to Self-Manage Hypertension among Older Adults in Asian Countries: A Systematic Review of Qualitative Studies…..………...…
49
Abstract……………………………………………………………………………………… 51
Introduction………………………………………………………………………………….. 52
Methods……………………………………………………………………………………… 54
Results……………………………………………………………………………………….. 57
Discussion…………………………………………………………………………………… 62
References…………………………………………………………………………………… 67
Chapter 4: Developing a Personal Sense of Risk: A grounded Theory Study of Older Rural Thai Men with Hypertension……………………………………………………….
87
Abstract……………………………………………………………………………………… 89
Introduction………………………………………………………………………………….. 91
Methods……………………………………………………………………………………… 93
Results……………………………………………………………………………………….. 99
Discussion…………………………………………………………………………………… 114
References…………………………………………………………………………………… 123
Chapter 5: Summary……………………………………………………………………..... 135
References…………………………………………………………………………………… 139
iii
Abstract
Background: Poor adherence to treatment and poorly controlled hypertension are
common in older men, especially in rural areas. Knowledge about the experience of living with
hypertension among older men is important for developing nursing practices to enhance
treatment adherence. However, little is known about the personal experiences of older men with
hypertension. This dissertation includes three papers that address the following: (1) the
experiences of men with hypertension, based on a review of literature, (2) factors influencing the
ability to self-manage hypertension among older adults in Asian countries, based on a review of
qualitative studies, and (3) grounded theory study exploring the experiences of 29 older Thai
men living with hypertension in rural areas.
Results: The first paper presents an integrative review of relevant literature on the
experiences of men living with hypertension. The second paper is a systematic review of
qualitative evidence that provides information about factors influencing the ability to self-
manage hypertension among older adults in Asian countries. The third paper addresses the
knowledge gap about experiences of older Thai men living with hypertension in rural areas,
using a grounded theory approach to develop a conceptual model called “developing a personal
sense of risk”. This conceptual model provides guidance for assessing one’s personal risk of
developing hypertension-related complications among older Thai men and can help to improve
risk communication, develop a standard tool to assess perceptions of personal risk, and also
develop storytelling interventions to motivate behavior change.
Conclusion: This dissertation study adds to our current knowledge about the experiences
of older men with hypertension. This study also proposes an innovative conceptual model for
understanding the personal sense of risk for developing hypertension-related complications
iv
among older Thai men from rural areas. Finally, this study can inform the development of
effective interventions to improve adherence to treatment and blood pressure control among
older men with hypertension who live in a rural area.
1
Chapter 1
Introduction
2
Background
Hypertension has become a serious worldwide public health problem, being most
prevalent in adults aged 60 years and older (WHO, 2013). Hypertension is the leading global
preventable risk factor for cardiovascular disease, stroke, and renal dysfunction (Bromfield &
Muntner, 2014). Thailand is currently experiencing a high prevalence of hypertension and high
rate of hypertension complications (Thawornchaisit et al., 2013; Khumtaveeporn &
Jirathummakoon, 2015). Heart disease and stroke, which are often associated with uncontrolled
hypertension, have become the leading causes of death and disability among older male patients
in Thailand, especially in rural areas (Aekplakorn et al., 2012, Suwanwela, 2014). Managing
patients with uncontrolled hypertension is challenging since the reasons for failure to control
blood pressure are complex. Promoting patients’ behavior change, including adherence to
treatment may be influenced by several factors such as habitual lifestyle behavior and
perceptions of illnesses (e.g. perception about the cause of an illness, the symptoms that are part
of the condition, the consequences of the illness, and how the illness is controlled or cured) and
its adverse outcomes (Power et al., 2008; Kausar, Awan, & Khan, 2013).
An individual’s experience is thought to play a significant role in their treatment
adherence and adoption of healthy behaviors (Allen, Purcell, & Dennison, 2010; Sheeran, Harris,
& Epton, 2014). For example, when persons experienced considerable difficulties controlling
blood sugar levels and blood pressure or the consequences of disease processes, they are more
likely to take action to manage their disease and prevent an adverse health outcome (Price et al.,
2009; McKenzie & Skelly, 2010; Tawfix & Mohamed, 2016). Poor adherence to treatments and
lifestyle changes for hypertension remains a worldwide problem, including for Thailand. Older
male patients with hypertension had low adherence to medication, exercise and dietary regimens.
3
The number of patients with inadequate blood pressure has remained constant (Mahmoud, 2012;
Vrijens et al., 2017). Thus, there is a need to discover experience of living with hypertension
among hypertensive older rural Thai men who exhibited poor adherence to recommended health
behavior and how their experience influences health-related behavior. Better understanding the
experience of older rural Thai men living with hypertension may help in promoting successful of
hypertension management including effective behavior change interventions.
Significance
Hypertension is not only the most frequent chronic health problem experienced by Thai
older people but is also a leading risk factor for stroke and coronary events (Puavilai,
Prompongsa, Srriwiwattnakul, & Srilert, 2011; Thawornchaisit et al., 2013). The most recent
government survey documented that 59.4% of total Thais over 60 years had hypertension
(Aekplakorn et al., 2012) and a statistically significant higher prevalence of hypertension in Thai
older men than women, 58.3% and 49.3%, respectively (Aekplakorn et al., 2011). In addition,
studies have reported lower control rates in rural, compared to urban, settings (Aekplakorn et al.,
2012; Chongthawonsatid, 2015; Leelacharas, Kerdonfag, Chontichachalalauk, & Sanongdej,
2015).
In Thailand, although progress has been made in prevention, detection, control, and
treatment of hypertension, there is continuing poor hypertension management among Thai older
men. Blood pressure control was lower in Thai older men (25.2%) than Thai older women
(30.5%) (Aekplakorn et al., 2012). Thanakwang and Kunnasit (2009) reported that fewer than
half of older men, were aware of and received treatment for their hypertension, or had achieved
sufficient control. Similarly, blood pressure control was lower in men than women in Korea
(7.7% vs 14%) and in Taiwan (21% vs 28.5%) (Cheung & Cheung, 2012). Moreover, among
4
men in Thailand, blood pressure control was also lower in rural areas than in urban areas (17%
versus 21%) (Sinsap & Jankra, 2017). The same trend was observed in Africa, with a prevalence
of control among treated hypertensive men much lower in rural than in urban areas (7.7% versus
52.3%) (Damasceno et al., 2009). Several studies have documented that Thai older men are at
greater risk for complications of hypertension than Thai older women. This higher risk is
reflected in the higher incidence of stroke in Thai older men than women (Aekplakorn et al.,
2012; Leelacharas et al., 2015; Nilanont et al., 2014). For example, the prevalence of ischemic
stroke across people with hypertension was 3.59% for Thai older men and 2.80% for older Thai
women (Suwanwela, 2014). Hypertension is a chronic disease that puts an individual at risk for
long-term health problems.
Research on patients’ knowledge about their hypertension suggests that patients
perceived hypertension as a chronic lifelong condition. Leelacharas at al. (2015) reported that
Thai women consider hypertension as permanent, rather than temporary. Thai women perceived
that living with hypertension for a long time increased the risk of hypertension complications
such as renal failure and stroke. Thus, they followed providers’ recommendations to take
medications and reduced salty food. Another study (Rahman et al, 2015) exploring the
perception of hypertension among men and women in Asian countries including Thailand also
found that patients perceived hypertension as a chronic lifelong condition. They realized that
hypertension could lead to severe consequences such as heart disease, stroke, and paralysis from
stroke. Most patients agreed one or both of heart attacks and strokes as the reasons to treat
hypertension and adopted healthier behaviors. In contrast, another study among older Thai
Malays men and women (older people with ethnic Malays in Thailand) reported that patients
viewed hypertension as a common illness which can be easily cured (Udompittayason,
5
Boonyasopun, & Songwathana, 2015). Patients realized a danger of hypertension only when
obvious and severe symptoms occurred such as; fatigue, palpitation, or when they were unable to
work. These experiences led them to manage their hypertension by taking medications and
changing eating behavior. However, these studies (Leelacharas at al., 2015; Rahman et al, 2015;
Udompittayason et al., 2015) did not report specific results for older men.
Beliefs and Adherence
Research focusing on beliefs of men about hypertension demonstrates that their beliefs
are often contrary to their knowledge. A study from the US (Bennett, 2013) attempted to
understand the beliefs and attitudes of men toward hypertension among 17 African American
men (ages over 45). The study found that these men had knowledge about causes, complications
and treatments of hypertension but they did not believe that hypertension was serious, so did not
seek treatment until they experienced severe symptoms and non-adherence to hypertension self-
management. Long, Ponder, and Bernard (2017) also reported that African American men who
had symptoms including dizziness, headache, and fatigue did not seek treatment until they were
severe.
Perceived Risk and Adherence
Perceived risk of disease has been related to treatment adherence (Anderson et al., 2016;
Cioe, Crawford, & Stein, 2014; Lee, 2018; Lee, Ayers, & Holden, 2016; Shreck, Gonzalez,
Cohen, & Walker, 2013). Previous research which included both older men and women found
that perceptions of risk for chronic heart disease contributed to healthier eating habits (Khayyal,
Geneidy, & Shazly, 2016). Similarly, patients who reported being at risk for uncontrolled blood
pressure adopted a healthier diet (Thongtang & Seesawang, 2014). Diabetes patients who
perceived themselves to be at risk for sexual dysfunction and immobilization modified their
6
lifestyles in order to maintain normal blood glucose levels (Sachs et al., 2017). Lower perceived
risk has been associated with poorer adherence to recommended health behaviors (Calvin et al.,
2011; Darak et al., 2014; McKenzie & Skelly, 2010; Rouyard et al, 2017; Sahile, Yared, & Kaba,
2018) and perceived being at no risk for other problems led to no change in behavior
(Bayrampour et al., 2012; Tilburt et al., 2011; Tonberg et al., 2015). Another study found that
hypertensive patients perceived themselves at some risk but not sufficiently high to bring about
very significant impact on adherence to treatment (Atulomah, Florence, & Oluwatosin, 2010).
Medication Adherence
Men living with hypertension often found medication adherence difficult, due to
medication side effect, forgetting, and the substitution of prescription medications for folk
remedies (Bennett, 2013). African American men reported discontinuing their medications
because of severe side effects. Moreover, they frequently forgot to take their medications or
skipped doses because it was inconvenient (e.g. the medication must be taken in the morning and
the patient was usually away from home early morning). They described using folk remedies
rather than medication from the doctors. They used folk remedies when they could not afford to
fill their prescription and or if they had forgotten to fill their prescription. Another reason that
made them use folk remedies was lack of trust in health care providers. This finding was
supported by Elder et al. (2012), found that African American men with higher trust in the
medical system were more likely to report better medication adherence. For lifestyle changes,
Elbur (2015) found that older patients (age more than 65 years) were less adherent with
medication compared to younger patients while patients suffering from other chronic diseases
were found to be more adherent than patients living with hypertension alone. Individual’s
7
experience of living with diseases has been revealed to help in a number of ways with decisions
about chronic illness management (Atulomah et al., 2010).
Learning about patient’s experience can inform appropriate healthcare provider actions
throughout the illness trajectory. However, as far as we know, the experience of living with
hypertension among men was not distinctly separated from women’s experience. Very few
studies have explored the experience of men living with hypertension (Bennett, 2013; Long et
al., 2017): it was found that an individual’s belief in the severity of hypertension has a greater
influence than knowledge on treatment adherence. Nevertheless, this provides only a partial
picture of living with hypertension. However, how men respond to the diagnosis, how they link
hypertension knowledge to manage their hypertension, and how they integrate hypertension into
their daily lives are missing from literature. Importantly, although previous studies in Thailand
have documented that poor treatment adherence remains an important issue in rural older men
with hypertension, nothing has been reported about the subjective experience of men living with
hypertension in Thailand. Despite the one study describing the influence of beliefs and attitudes
on medication adherence among urban men in developed countries (Bennett, 2013), the values of
Thai culture are complex, and different from those of the West. Research in the West on beliefs,
attitudes and how they affect hypertension may have limited transferability to rural Thailand.
Furthermore, differences between the urban and rural contexts such as healthcare access and
cultural beliefs limit the transferability of research to rural environments since differences in
control of hypertension have been documented between rural and urban settings. Thus, there is a
need to understand overall experience of older Thai men with hypertension.
8
Approach to the Problem
The purpose of this study is to increase our understanding of challenges to managing
hypertension in rural, older Thai men. The majority (81.1%) of Thai older people living in rural
areas have low levels of education (68%), and low incomes (80.5%) (Jitapunkul & Wivatvanit,
2009). Rurality in Thailand has also been associated with decreased awareness of hypertension,
decreased treatment rates, and decreased levels of blood pressure control. Older rural men have
been found to have lower levels of awareness (57%) compared to older urban men (69%),
making them less likely to seek treatment than urban men (Aekplakorn et al., 2008). Lack of
awareness only partially explained the lower likelihood of treatment for rural Thai men since
rural men who were aware of their hypertension were still less likely to receive treatment with
medication compared to their urban counterparts. Moreover, blood pressure control rates were
lower among rural men than urban men (11% versus 17%) (Aekplakorn et al., 2008). These
findings suggest a significant problem with hypertension management in rural Thai men.
Rural life in Thailand is simple. Lifestyles of older rural Thais are strongly influenced by
Buddhism (Leelacharas et al., 2015). For example, older, rural Thais generally believe that
illness is primarily the result of prior actions (karma) either in a past life or in the current life,
often leading to an acceptance of their illness (Lundberg & Trakul, 2011; Sanseeha et al., 2009).
Another study found that patients reporting high Buddhist values were more likely to comply
with doctor visits and medication, as well as dietary recommendations (Sowattanangoon,
Kochabhakdi, & Petrie, 2008). Moreover, Thais believe in supernatural influences; for example,
they perceive illness as a result of fate, possibly making them less likely to see the value of
medical treatment (Tanvatanakul et al., 2007). Patients performed health practices based on
supernatural beliefs; for example, they had first treatment contact with religious/supernatural
9
treatment providers (Sanseeha et al., 2009) and patients with chronic illness were non-adherent
with treatment (Tanvatanakul et al., 2007).
Thailand is a patriarchal society, with men as head of the family, responsible for
supporting the family, and expected to show strength and leadership. Most men believe that
being a good leader of the family means supporting the family financially and contributing to the
family’s emotional, spiritual, physical and mental well-being (Romanow, 2012). In rural
Thailand, older Thai men still work in agriculture, spending days in the fields and orchards. They
have to work to earn money for their families, a high priority for them (Lundberg & Thrakul,
2011). However, we do not know how these cultural norms influence experience of living with
hypertension. More importantly, many studies have not been conducted on Thai rural men with a
prior hypertension diagnosis.
This literature review illustrates that individual experiences of living with chronic
diseases is an important determinant of behavior change and adherence to treatment (Ferrer &
Klein, 2015; Liu et al., 2015; Portnoy, Ferrer, Bergman, & Klein, 2014; Power et al., 2011;
Simonds et al., 2017). However, research into the subjective personal experience of older men
living with hypertension is scanty. The current study focuses on the major knowledge gap related
to the subjective personal experience of older rural Thai men with hypertension. Therefore, the
purpose of my dissertation study was to develop a conceptual model explaining older rural Thai
men’s personal experience of living with hypertension. To gain a deeper insight into older rural
Thai mens’ experiences, this study specifically aimed to explore their overall personal
experience, what it means to live with hypertension, how older Thai men perceive their lives
after receiving a hypertension diagnosis, how they respond to the diagnosis, and whether/how
they manage and integrate hypertension into their everyday lives. The methodological approach
10
of grounded theory is used, as it allows deep understanding of social processes, while developing
a based empirically theory, from the point of view of the actors (Charmaz, 2014). Men with
hypertension are actors who give hypertension a meaning. It is possible to describe that meaning
by accessing their symbolic universe (Corbin & Strauss, 2008). Knowledge generated from this
study could provide understanding of older rural Thai men’s experiences, hopefully assisting
health care providers to develop more effective strategies for improving care and achieving
improved outcomes for rural Thai men.
The findings from this dissertation are reported in a 3-paper format. In the following
section, I provide an outline of the 3-papers. The 3-paper dissertation provides a descriptive
overview of the research/knowledge gap concerning older men with hypertension who live in
rural areas and a possible solution to address the research gap.
Overview of the Chapters
The following three chapters provide detailed information regarding the experience of
men with hypertension, information regarding factors influencing hypertension self-management
among older adults with hypertension in Asian countries, and develop an understanding of
personal experience of older rural Thai men with hypertension.
Chapter 2 provides an integrative review as it pertains to hypertension in men and
identifies experience of men living with hypertension. The purposes were to provide an overview
of what is known about experiences of men with hypertension across the world and identify
implications for future research.
Chapter 3 gives a systematic review of qualitative research studies regarding factors
influencing hypertension self-management among older adults with hypertension in Asian
11
countries. The aim was to systematically review and synthesize qualitative research of issues that
influence self-management abilities of older adults living with hypertension in Asian countries.
In Chapter 4, I present findings from the grounded theory study which was designed to
develop a conceptual model explaining experiences of older rural Thai men with hypertension.
The findings from this study were informed by semi-structured, face-to-face interviews.
Chapters 2-4 are presented in the form of publications. Each chapter has been written to
reflect the requirements of the journals to which the paper will be submitted. Chapter 2 was
submitted to the Journal of Nursing Science. Chapter 3 will be submitted to International Journal
of Nursing Practice. Chapter 4 will be submitted to International Nursing Review.
In Chapter 5, I summarize the findings from Chapters 2 to 4 and present implications for
future research.
12
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20
Chapter 2
Experiences of Men Living with Hypertension: An integrative Review
21
Title: Experiences of Men Living with Hypertension: An integrative Review
Junjira Seesawang*, MS, RN
University of Wisconsin-Madison, School of Nursing
Corresponding Author Information
Junjira Seesawang
Acknowledgments: This study was funded by Eckburg Award. The author would like to thank
Dr. Barbara Bowers for providing helpful feedback on this paper.
22
Abstract
Background: Hypertension has become increasingly prevalent in developing countries, with
men having higher rates than women of both hypertension and uncontrolled hypertension.
Purpose: To synthesize the evidence as it pertains to hypertension in men.
Design: An integrative literature review was conducted. This review included both qualitative
and quantitative studies that focused on hypertension in men. A search for relevant literature
published from 2007 to 2017 was undertaken using PubMed, CINAHL, Ovid MEDLINE,
EBSCO, and ThaiJo databases and by examining relevant bibliographies. Seven studies (n 7)
formed the basis of this review. Findings from the identified research literature were analyzed
and described using conventional content analysis.
Main findings: Five main categories emerged from the content analysis: (1)
understanding symptoms of hypertension; (2) knowledge regarding consequences of
hypertension; (3) level of adherence to a healthy lifestyle and medical treatment and
influencing factors; (4) self-management; and (5) interventions that were designed to
improve blood pressure control.
Conclusion and recommendations: Experiencing symptoms and viewing themselves as
being at risk seem to be essential for males with hypertension to manage their condition. Future
research should explore how males with hypertension develop a sense of risk, what factors can
contribute to a sense of risk, and how the sense of risk motivates this unique population to
change behavior.
Keywords: hypertension, men
23
Introduction
Hypertension is an extremely common and serious chronic disease among adults and
older people aged 60 years or older (Angeli, Rebodi, & Verdecchia, 2013). Hypertension is a
major risk factor for coronary heart disease, stroke, and chronic kidney disease (Saeed et al.,
2011). Globally, hypertension is estimated to cause 7.5 million deaths as a consequence of severe
complications and lack of adequate control (Angeli, Rebodi, & Verdecchia, 2013; Elbur, 2015).
The worldwide prevalence of hypertension was 1.39 billion persons in 2010 (Ibrahim &
Damasceno, 2012; Mills et al., 2016). The prevalence of hypertension increases with age and
occurs more frequently in men than women (Gao et al., 2013; Helelo, Gelaw, & Adane, 2014).
Among hypertensive patients, men were less aware of their condition compared with
women (Amaral et al., 2015; Rao et al., 2014; Son et al., 2012; Wang et al., 2014). Men also
generally have lower rates of treatment and control than women (Abdul-Razak et al., 2016;
Hussain et al., 2016; Muhamedhussein et al., 2016; Pereira, Lunet, Azevedo, & Barros, 2009;
Pire, Sebastiao, Langa, & Nery, 2013). Poorly controlled hypertension makes male patients more
susceptible than women to serious health outcomes, such as stroke (Kadir, Mohamed, & Yusof,
2009; Miller et al., 2016).
The greatest challenge to reducing these negative outcomes is poor treatment compliance,
the most important cause of uncontrolled blood pressure, particularly among male hypertensive
patients (Choi, Kim, & Kang, 2017; Kubo et al., 2015). Adherence to prescribed medication and
following therapeutic lifestyle changes, such as salt restrictions, would reduce the incidence of
patients with uncontrolled hypertension, resulting in reduced hypertension-related complications
(Choi, Kim, & Kang, 2017). Previous studies reported that male patients exhibited lower
adherence to hypertension treatment than female patients (Amaral et al., 2015; Hussain, Mamun,
24
Reid, & Huxley, 2016; Rao et al., 2014). Adherence with diet and medication has been reported
to be lower among men than women (Amaral et al., 2015; Mills et al., 2016).
Despite the well documented risk, the low rate of blood pressure control and adherence
with hypertension treatment among men is poorly understood. Decreasing uncontrolled
hypertension and increasing adherence to treatment among men would have a direct impact on
reducing the risk of stroke, cardiovascular disease, and kidney disease. This integrative literature
review was conducted with the aim of investigating what is known about men’s experiences with
hypertension.
Design
An integrative review was selected as it accommodates the synthesis of both qualitative and
quantitative methodologies to be synthesized; ensuring the most comprehensive inclusion of sources
related to patients’ experiences. The methodological steps for conducting this integrative review
(Whittemore & Knafl, 2005) include: (1) identifying the focus and determining the aim of the review;
(2) searching the literature; (3) evaluating the quality of the included literature; (4) analyzing data; and
(5) presenting the findings (Table 1).
Problem Identification
While low rates of adherence to treatment and blood pressure control among men have
been documented, there is less clarity about men’s experiences with hypertension in the world
and whether the research on their experiences can inform us about contributing factors of
treatment adherence.
Literature Search
Inclusion criteria for reviewed studies were: (i) recruited sample of male patients with
hypertension; (ii) published in English or Thai language; (iii) published between 2007 and 2017 in
25
a peer-reviewed journal; and (iv) qualitative, quantitative and secondary analysis. Studies that
pooled men and women were excluded unless they reported findings separately for men. Papers
published prior to 2007, opinion papers, policy documents and best practice reports also were
excluded.
A comprehensive literature search was conducted using PubMed, CINAHL, Ovid
MEDLINE, EBSCO, and ThaiJO. A search of the literature using electronic databases was
conducted using keyword combinations, including hypertension; high blood pressure;
experience; and men. The reference lists of reviewed articles were also hand-searched.
After the initial search was performed, studies were screened for eligibility. The author
and two research assistants independently screened the title and abstract of each study. The
articles that did not meet the eligibility criteria were initially excluded according to their title or
abstract. The full-text of studies that appeared to the meet the inclusion criteria were obtained for
further screening. The author and research assistants independently conducted preliminary
screens of each article, and again determined which ones met the above inclusion criteria.
Studies with any of the above exclusion criteria were removed. Next, the author and research
assistants read the full-text of each study in detail. Both author and research assistants discussed
discrepancies and came to a consensus on which studies should be included in the final count.
Data Evaluation
Four of the included studies used quantitative approaches and three used qualitative
methodologies. The 7 articles were appraised for rigor, to provide final justification for their
inclusion in the review. In this integrative review, the Critical Appraisal Skills (CASP) Program
(CASP, 1997) was used to evaluate and critically appraise the articles. The CASP verifies
trustworthiness and relevance of studies to the review being conducted by querying: is the
26
research valid?, what are the results?, and are the results useful? The CASP tools are free to
download for public use. The CASP tools provide a comprehensive checklist to enable the author
to assess the methodological quality of a paper and make a judgment about its suitability for
inclusion in the review. The CASP checklist provided the questions and the guidance on how to
assess both qualitative and quantitative studies. Thus, the author used question sets from the
checklist based on methods used in studies. Nine questions that enabled appraisal of the rigor of
the studies were used (Table 1), which were recorded as “�(yes)”, “� (no)” or “can’t tell” to the
questions.
Data Analysis
Conventional content analysis was undertaken as Whittemore & Knafl (2005) have
suggested that this strategy can be used for data analysis in integrative review. The author and
research assistants first immersed themselves in the articles to obtain a sense of the whole,
writing notes as we read through to indicate first impressions. Next, codes were developed that
were reflective of the findings. Categories were developed by grouping codes, and organizing
codes into meaningful clusters (Hsieh & Shannon, 2005). There was a high level of agreement
among reviewers in terms of codes. The author then met with research assistants to discuss and
resolve any disagreements, and final categories were determined.
Results
Search Outcome
The initial search identified 229 studies (Figure 1). After the initial search, 102 duplicates
were removed. The titles and abstracts for the remaining 127 studies were screened. A total of 12
studies met the inclusion criteria. Next, 5 studies were excluded due to not meeting inclusion
criteria for the following reasons: a) not separating men/women in the analysis (n 2); b) lacking
27
mens’ perspectives (n 2); and c) being grey literature (n 1). Ultimately, 7 studies were
included in this integrative review.
Methodological Quality of the Studies
The methodological quality of qualitative studies was presented in Table 2. The qualitative
research designs were considered as appropriate to meet the purposes of the studies. However, the
researchers did not address researcher influence on data collection. The researchers failed to
explicitly detail strategies for self-reflection, an issue related to rigor during data collection and
analysis (Long, Ponder, & Bernard, 2017). A further example was hermeneutic phenomenology
(Bennett, 2013); a methodology that explicitly requires identification of pre-understandings, which
were not addressed in this study.
Shown in Table 2, the assessment of methodological quality of the quantitative studies
included sampling and sample size. The studies using quantitative research designs were deemed
acceptable for obtaining measurable data regarding adherence to treatment. However, small sample
sizes (Fort et al., 2015) and unstated estimates of precision (Elder, 2013; Dennison, 2007; Welsh,
Duff, Campbell-Taffe, & Lindo, 2015) (e.g. confidence intervals) resulted in uncertainty over the
strength of the findings and methodological quality in a number of the studies.
Overview of Studies
Details related to Aims, study sample, methods, major findings and limitations of the
seven studies reviewed are provided in Table 3. Four of the seven studies used quantitative
methods: cross-sectional (n 3) and randomized control trial (n 1). Three studies were
qualitative in nature, using the following study designs: unspecific qualitative approach (n 2)
and phenomenology (n 1). All studies focused on at least some portion of the experience of
men with hypertension. The sample sizes varied from 17 participants to 309 participants.
28
The national context can be seen in Table 3, four of the reviewed studies were conducted
in the United States, with one study each from Saudi Arabia, Jamaica, and Mexico. Attempts to
enhance credibility through investigating different settings were noted with most researchers
studying more than one location. With regards to settings, all studies sampled men in urban
settings. Impact of context was generally discussed in relatively simple, single factor terms such
as; genetics, or country; position towards patient participation. Studies were lacking thick
descriptions (Bennett, 2013; Elder et al., 2012; Long et al., 2017; Welsh et al., 2015) about the
healthcare setting or cultural context. In term of samples, the participants across the studies
ranged in age from 21 to 89 years, with the mean being 53.1 years. The included samples were
African American, Jamaican, Saudi Arabia, and Mexican men.
Detailed Results
Five broad categories were discovered inductively in the data, namely ‘understanding the
symptoms of hypertension’, ‘knowledge regarding consequences of hypertension’, ‘level of
adherence to a healthy lifestyle and medication treatment and influencing factors’, ‘self-
management’ and ‘interventions improving blood pressure control’. These are discussed in more
detail in the following sections.
Understanding the symptoms of hypertension
Evidence in the literature suggests that headache and dizziness were reported as the main
clinical manifestations of high blood pressure by men with hypertension. For example, most
African American men with hypertension described the symptoms of hypertension including
dizziness, headache, and fatigue (Bennett, 2013). Moreover, this study found that some
participants sought care when those symptoms occurred while others with the same symptoms
did not seek treatment until they were severe. Also, some African American men with
29
hypertension identified headaches and dizziness as the symptoms of hypertension (Long et al.,
2017). Both studies (Bennett, 2013; Long et al., 2017) found that African American men were
likely to determine when their blood pressure levels were elevated based on intermittent somatic
symptoms such as headaches and dizziness. However, the studies did not provide information on
the level of blood pressure readings among male patients.
Knowledge regarding consequences of hypertension
The reviewed studies suggested that, overall; most men with hypertension are
knowledgeable about the consequences of their condition. One qualitative study (Bennett, 2013)
found that African American participants were able to describe serious health consequences
associated with hypertension, including myocardial infarction and potential for needing heart
surgery. More recently, a qualitative study (Long et al., 2017) reported that 34 hypertensive,
African American men in their sample were aware of the consequences of their condition,
including the risk of heart attack, stroke, and death. The same study found that most men
believed that hyperlipidemia was less serious than hypertension and lacked knowledge about the
consequences of hyperlipidemia. Moreover, in a quantitative study of 48 Jamaican men with
hypertension (Welsh et al, 2015), 93.7% understood that uncontrolled hypertension could lead to
stroke or death.
Level of adherence to a healthy lifestyle and medication treatment and influencing
factors
Studies from Saudi Arabia evaluated adherence to medications and lifestyle changes (e.g.
dietary changes, smoking cessation) prescribed for hypertension by health care providers (Elbur,
2015) and in Jamaica (Welsh et al., 2015). Additional studies (Elbur, 2015; Welsh et al., 2015)
measured level of adherence to therapeutic lifestyle changes including dietary changes (e.g.
30
Dietary Approaches to Stop Hypertension [DASH] diet), exercise, smoking cessation, limited
alcohol consumption, and maintaining a healthy weight among male hypertensive patients. In the
study by Welsh et al. (2015), only 20.1% of hypertensive Jamaican men reported adherence to
exercise and 11.8% to a healthy diet. Moreover, 47.9% of Jamaican men with hypertension who
attended an urban public health clinic reported adherence to maintaining a normal weight, and
29.2% to exercising; none of them used dietary approaches to manage their hypertension (e.g.
DASH diet). However, 83.3% of patients were found to adhere to smoking cessation and 79.2%
of patients were adhering to alcohol restriction. Also, the studies reported the level of adherence
to medication treatment among male patients whose compliance rates ranged roughly from
14.6%- 57.3% (Elbur, 2015; Welsh et al., 2015).
Moreover, one study of African American men assessed the relationships among trust in
the medical system, medication adherence, and hypertension control, reporting that a higher trust
in the medical system correlated with a greater likelihood of medication adherence (OR 1.06,
95% CI: 1.00 - 1.11) than those with lower trust (Elder et al., 2012). Another study (Elbur, 2013)
found that older patients (age more than 65 years) were less adherent with healthy diet compared
to younger patients. Comorbidity was a strong predictor of adherence with regular exercise,
healthy diet, and medication among male hypertensive patients in Saudi Arabia. Overall, patients
suffering from other chronic diseases were found to be more adherent than patients living with
hypertension alone. Furthermore, Bennett (2013) found that the African American males who
lived in Texas were less likely to have access to medical care, had lower levels of trust in
providers, and more likely to experience severe side effects of medication leading to high rates of
non-adherence to antihypertensive medications. In two reported studies, income level was a
significant predictor of treatment adherence. In one study (Bennett, 2013) African American
31
males with low incomes were less likely to take medications due to financial difficulties, leading
them to substitute home remedies. Furthermore, in one study (Elbur, 2015) of male hypertensive
patients in Saudi Arabia, level of monthly income was the most important predictor of adherence
to a healthy diet, linking diet adherence to financial barriers.
Self-management
Findings from the studies reviewed suggest that men with hypertension use a variety of
strategies to manage their condition. In one qualitative study, most African American men with
hypertension reported managing high blood pressure by using folk remedies, skipping, and
stopping medications, and relying on spirituality and religion (Bennett, 2013). They stopped
taking medications due to side effects. They reported unintentionally forgetting or skipping
medication doses for reasons such as forgetfulness or their memory was a reason for forgetting,
and not having a routine or job-related reasons. Some of them described using folk medicines
such as garlic or lemon to reduce high blood pressure while others did not believe folk remedies
were effective. They also described attending church services, listening to spiritual music, and
meditation. Other researchers (Welsh et al., 2015) presented similar results from a group of
Jamaican men with hypertension who reported taking alternative remedies such as garlic, lime
juice, and hibiscus flowers along with their medication whereas others used alternative remedies
as substitutes for their medications. Significantly, a healthy diet was not included in their
lifestyle. Most Jamaican men (81.2%) reported that their meals were always prepared with salt.
Only a third of the participants engaged in exercise. However, the majority described a low
alcohol consumption and little current cigarette use.
32
Interventions improving blood pressure control
Evidence exists in the literature for the success of educational/behavioral interventions
designed and implemented in hypertensive urban African American men. The researchers
(Dennison et al., 2007) conducted a 5-year randomized control trial to test the effectiveness of
educational/behavioral interventions among men aged 21 to 54 years composed of home visits,
counseling, and comprehensive hypertension care by a nurse practitioner (NP)/community health
worker (CHW)/physician (MD) team. Hypertensive urban African American men in the
intervention group were more likely to improve adherence with hypertension self-care behavior
and improve blood pressure control rates, leading to a reduction in some consequences of
hypertension, including left ventricular hypertrophy and renal insufficiency in African American
men.
A healthy lifestyle intervention was implemented among hypertensive men in urban parts
of Mexico. The researchers interviewed 9 hypertensive men, 6 family members, and 9 healthcare
providers in Mexico (Fort et al., 2015). The researchers found that most men highlighted pride
and stubbornness as barriers for not participating in a healthy lifestyle intervention. They
participated in intervention that was because their wife, son or daughter desired it, but not from
their own desire. Getting older was an important barrier as most men believed they were too old
to learn self-management skills. In addition, they were more likely to believe that routine
physician checkups were sufficient, negating the need to participate in a dedicated hypertension
intervention program.
Other barriers for not participating in intervention included conflicting work schedules,
type of work, limited nurses, and mostly being female nurses. For example, some work schedules
conflicted with the timing of the program while some types of work did not allow them to plan
33
when they would be working (e.g. contract or seasonal jobs). Men reported that they might be
more likely to attend on weekends but nurses were more limited at that time. Importantly, having
more female than male nurses was also a factor discouraging their participation since some men
reported not being comfortable talking about their worries or problems with a female nurse.
Discussion
This integrated review set out to explore the published literature on the experience of men
with hypertension in the world. There is currently little research on men with hypertension. The
articles discussed in this review dealt with understanding symptoms of hypertension, knowledge
regarding consequences of hypertension, adherence to a healthy lifestyle and medication
treatment, self-management, and intervention improving blood pressure control.
In relation to content, the literature indicates that patients had knowledge about
complications of hypertension which was related to self-management behavior and seeking
health care (Bennett, 2013; Chythra, Kamath, Shetty, & Kamath, 2014; Kamran et al., 2014).
Generally, men were more likely to perceive that seeking medical care was unnecessary as they
believed that medical problems would improve on their own (Choi et al., 2017). Moreover,
having a female nurse and not having enough nurses on weekends were reasons for not engaging
in intervention. They started to seek health care or engaged in healthy lifestyle intervention when
increasing the perceived severity of symptoms (Kadir, Mohamed, & Yusof, 2009; Pire,
Sebastiao, Langa, & Nery, 2013). Regarding knowledge, the relationship between knowledge of
hypertension and treatment adherence in these studies was not presented.
Hypertension is characterized by intermittent or absent symptoms. These studies
indicated that presence of symptoms in some cases and symptom severity in other cases
motivated men to seek treatment (Bennett, 2013; Long et al., 2017). However, research has not
34
provided any insight into how the perception to seek treatment without experiencing symptoms
or what their reasons are for not using the knowledge that they have about complications.
The important problem, of course, is patient non-adherence to treatment. The majority of
men do not follow healthcare recommendations. They are more likely to be adherent to
hypertension therapies when they trust the medical system and healthcare providers, and/or have
other comorbidities (Amaral et al., 2015; Wang et al., 2014). In addition, gender role perceptions
can influence how men respond to their condition (Fort et al., 2015). Identifying mens’ position
in society, as the breadwinner, helps us to understand that this gendered role could be competing
with behaviors associated with engaging in healthy behavior and seeking help for their condition
(Peterson, 2009; Robertson, 2006; Robertson, Sheikh, & Moore, 2010).
Implications
We have come a long way in men’s health care by promoting cardiovascular preventive
health to men; however, there is now broader recognition of the need to study health-related
problems specific to men (Elder et al., 2012). This review highlights a need for more research on
gender-sensitive and specific hypertension management research and interventions. Identifying the
gaps, like the lack of published research from developing countries that attempts to explore the
experience of men living with hypertension, will help us to understand culture, perception, and
behavior. These issues are necessary to design gender-specific and effective interventions to improve
the health outcomes of male patients. Moreover, performing studies to address how knowledge of
hypertension influences their hypertension management and treatment adherence in order to enhance
patient adherence is recommended. It is a responsibility, as a nurse, to be aware of nursing care and
engage in development strategies to support population hypertension control. The strategies that
nurses have to develop should made by men, families, and healthcare providers to better reach men
35
and to involve family members both in a role to support patients, and also as a way to increase
prevention efforts for those family members who do not already have a diagnosis.
Strengths and Limitations of the Reviewed Studies
The inclusion of only 7 research articles may be viewed as both a strength and weakness.
Although only 7 studies were included, they were the most relevant and recently available in the
English language for informing this literature review. Key limitations of the reviewed studies
involved single locations, limited sample sizes, and rigor (give examples) of the selected studies
that limited confidence and thus generalizability of the findings. While a number of the studies
demonstrated these weaknesses, their inclusion in this literature review was warranted due to the
limited research available in this field. As a result, cautious conclusions have been drawn from
this review.
Conclusion
Men perceived hypertension as a disease with intermittent symptoms. This belief links to
a delay in managing their condition until having the complications or they are already at risk for
complications even though they know about consequences of hypertension. Hypertensive men
are faced with external and internal barriers that result in poor adherence to hypertensive
treatment, poor self-management, and low participation in hypertension interventions.
These findings indicate a need for further research to understand hypertension-related
experiences of men related to their sense of risk. Exploring men’s experiences of living with
hypertension through a masculine lens will illuminate how individual men experience common
cultural themes. Moreover, missing from the literature is a description of how men successfully
negotiate hypertension management within their daily lives. Giving voice to men’s experiences
of living with hypertension will provide the basis for new strategies that promote treatment
36
adherence and health behavior for hypertension management within male populations.
Hypertension interventions that are tailored to treatment adherence, concerns and needs of men,
their families, and communities could increase treatment adherence levels and blood pressure
control rates.
Acknowledgments
The author acknowledges Dr. Barbara Bowers for providing helpful feedback on this
paper and the financial support received from 2017 Eckburg Fund Research Award by the
University of Wisconsin-Madison School of Nursing.
37
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42
Table 1
Integrative review process
Stage Application
Problem identification What is known about men’s experiences of hypertension?
Literature search Electronic databases searched: PubMed, CINAHL, Ovid
MEDLINE, EBSCO, and ThaiJo
Data evaluation Relevant CASP critical appraisal tool applied
Data analysis Qualitative content analysis to develop categories
Presentation (results) Understanding the symptoms of hypertension
Knowledge regarding consequences of hypertension
Adherence to a healthy lifestyle and medication treatment and
influencing factors
Self-management
Interventions improving blood pressure control
43
Table 2
Summary of critical appraisal
Checklist questions
Study 1
Bennett18
Study 2
Dennison
et al.22
Study 3
Elbur et
al.23
Study 4
Elder et
al.20
Study 5
Fort et
al.19
Study 6
Long et
al.17
Study 7
Welsh 21
1. Is the chosen research
method/methodology
appropriate for addressing
the aims of the study?
� � � � � � �
2. Is the achieved sample
size sufficient for the study
aims and to warrant
conclusions drawn?
� � � � � � �
3. Are the chosen data
collection strategies
appropriate for the research
question?
� � � � � � �
4. How adequate is the
description of the data
analysis?
� � � � � � �
5. Is there comprehensive
evidence that ethical issues
have been taken into
consideration?
� � � � � � �
6. Does the study clearly
demonstrate external and
internal validity/ rigour?
� � � � � � �
7. Is there a clear statement
of the study findings?
� � � � � � �
8. Are the limitations or
weaknesses of the study
acknowledged?
� � � � � � �
9. Is the research valuable
(makes valuable
contribution/addresses
clinical implications)?
� � � � � � �
44
Table 3
Summary of reviewed studies
Study Purpose Sample,
setting
Research
design/analysis
Major result
Bennett18
USA
To explore
beliefs and
attitudes
that
influenced
medication
adherence
in African
American
men
- 17 males
- Aged over
45 years
- Setting:
hospital in a
city of Texas
- Hermeneutic
phenomenological
- Narrative
analysis
The data revealed 3 primary themes:
1. Feeling no symptoms: it can’t be
serious because I feel okay, ignoring
or failing to recognize symptoms.
2. Becoming aware of serious
complications: heading for something
bad, opening up communication with
loved ones, watching loved ones die,
taking responsibility for my health.
3. Managing HT: affording medicines
when I’m poor, tiding myself over
until I get my medicine, forgetting,
skipping and stopping (severe side
effect), and coping with spirituality
and religion.
Dennison,
et al. 22
USA
To describe
changes in
hypertension
care
utilization,
behavioral
factors,
physiologic
outcomes,
and mortality
- 309
hypertensive
African
American
men
- Aged 21-
54 years
Mean age 41
+/- years
- Setting:
- Randomized
clinical trial
(Educational/behav
ioral intervention
by nurse
practitioners,
community health
worker, and
physician)
- t-test, Chi-square,
The annual proportion of men with
controlled BP ranged from 17% to
44% in the more intensive group and
21% to 36% in the less intensive
group. At 5 years the more intensive
group had less LVH than the intensive
group and 17% of them were
decreased primarily due to narcotic or
alcohol intoxication (36%) and
cardiovascular causes (19%).
45
Study Purpose Sample,
setting
Research
design/analysis
Major result
during 5
years
hospitals
inner-city
Baltimore
regression
Elbur, et
al.23
Saudi
Arabia
Measure
adherence to
diet, exercise
and
medications
among
hypertensive
patients and
to identify
determinants
of adherence
- 144
patients from
hospitals age
<65 - >65
- Setting:
two hospitals
in Kingdom
of Saudi
Arabia
- A cross-sectional
study
- Descriptive
statistics
Rates of adherence to exercise, a
healthy diet and medications were
20.1%, 11.8%, and 34.7%
respectively. The level of monthly
income was found to be strongly
associated with adherence to both a
healthy diet. Patients aged 65 years
were found to be more adherent to a
healthy diet, comparing to elderly
ones. Only 4.2% (6 patients) were
found to be adherent to all studied
domains. Adherence to all domains
increased significantly with
educational level.
Elder, et
al.20
USA
To assess the
relationship
between trust
in the
medical,
medication
adherence and
hypertension
control among
Southern
African
American
- 235 men
with HT
- More than
80% of the
men were
aged 45
years and
older
- Setting:
hospitals in
the city of
Birmingham
- A cross-sectional
- Descriptive
statistic and
regression
African American men with higher
general trust in the medical system
were more
likely to report better medication
adherence (odds ratio [OR] 1.06),
and those with higher self-efficacy
were more likely to report better
medication adherence and
hypertension control.
46
Study Purpose Sample,
setting
Research
design/analysis
Major result
men
Fort, et
al.19
Mexico
To identify
barriers and
strategies to
involve men
and engage
family
members in
disease
management
and risk
reduction
- 9 men with
HT and/or
diabetes, 6
families, 9
health care
providers
- Setting:
primary care
health
centers in
urban areas
of Mexico
- A qualitative
study with semi-
structured
interviews
-Thematic analysis
- Internal and external factors which
influence men to make a decision to
take part in the activities: time, gender
roles, age, perception of chronic
condition, work, and healthcare
services and staffs
- Families relationships with disease:
different roles, within the family and
types of support.
Long, et
al.17
USA
To explore
knowledge,
attitudes,
and beliefs
regarding
hypertension
and
hyperlipide
mia
management
- 34 African-
American
men with
HT and/or
hyperlipide
mia,
- Aged 40-
65 years
- Setting:
two
countries in
the
southeastern
- Focus groups
- Content analysis
- Patients had a high level of
knowledge about hypertension self-
management, but less about
cholesterol self-management.
- 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. Notions of masculinity
affected self-management such as
feeling less athletic and less in control
of their bodies because of their
47
Study Purpose Sample,
setting
Research
design/analysis
Major result
diagnosis and medication use affected
their sexual functioning.
Welsh, et
al.21
Jamaica
To
determine
the extent to
which the
lifestyles of
Jamaican
men with
hypertensio
n met the
JNC7
- 48 men
with HT at a
health center
in Jamaica
- Aged 35-89
years (mean
65.2)
- Setting:
health center
in the urban
area of
Jamaica
- A descriptive
cross-sectional
design
- Descriptive
statistics
Men with 33% having blood
pressure controlled to 130/80 mmHg.
The number of men who met the
guidelines were normal weight 23
(47.9%), DASH diet zero, medication 7
(14.6%), exercise 14 (29.2%), alcohol
restriction 38 (79.2%), and smoking
cessation 40 (83.3%).
Note: BP, Blood Pressure; DASH, Dietary Approaches to Stop Hypertension; HT, Hypertension;
LVH, Left Ventricular Hypertrophy
49
Chapter 3
Factors Influencing Ability to Self-Manage Hypertension among Older Adults in Asian
Countries: A Systematic Review of Qualitative Studies
50
Title: Factors Influencing Ability to Self-Manage Hypertension among Older Adults in Asian
Countries: A Systematic Review of Qualitative Studies
Intended to submit to: International Journal of Nursing Practice
Authors: Junjira Seesawang, MS, RN
University of Wisconsin-Madison, School of Nursing
Corresponding Author:
Junjira Seesawang
51
Abstract Background: Hypertension is one of the most common chronic conditions among older adults in
Asian countries and is associated with high morbidity and mortality. Reducing morbidity and
mortality would require individual patients to engage in effective self-management strategies.
Understanding the process involved in and the factors affecting ability to self-manage is
fundamental to decreasing the complications of this long-term condition.
Aim: Present a systematic review and synthesis of qualitative research related to factors
influencing self-management abilities of older adults living with hypertension in Asian countries.
Methods: A qualitative systematic review was performed. An electronic search from databases
was conducted. Conventional content analysis was used to analyze and synthesize findings from
qualitative studies.
Results: Ten qualitative studies are included in this review. Findings cover the factors found to
influence self-management among older adults in Asian countries including: a) patient-level
influences and hypertension self-management, b) organizational-level influences and
hypertension self-management, and c) community-level influences and hypertension self-
management, and the facilitators and barriers within each of these categories.
Conclusion: Understanding factors that influence hypertension self-management may improve
assessment of self-management among older adults with hypertension in Asian countries and
also may inform intervention development to individual’s needs and to improve self-
management behaviors and health outcomes among older adults in Asian countries.
Keywords: hypertension, older adults, self-management
52
Introduction
Hypertension is very common among older adults in many Asian countries (Cheung &
Cheung, 2012; Jin et al., 2013). For example, the prevalence of hypertension in Chinese older
adults (aged ≥ 65 years) is 66.18% compared to 44.02% of middle-aged (aged≥ 45 years) (You et
al., 2018). The prevalence of hypertension and uncontrolled hypertension contribute to the
present pandemic of morbidity and disability, mortality, high economic costs, and loss of
quality of life for patients and families (Briasoulis et al., 2014; Cheong et al., 2015; Lee et al.,
2011; Malhotra et al., 2010; Park, Kario, & Wang, 2015; Seijak et al., 2013). The success of
hypertension management depends on the patient’s ability to perform hypertension self-
management which involves a complex and multifactorial process (Flynn et al., 2013).
Hypertension self-management has been identified as a critical component in
hypertension management (Flynn et al., 2013). Successful management requires patients to
engage in a range of activities including: (1) medication adherence, (2) self-blood pressure
monitoring, and (3) lifestyle modifications involving diet, exercise, limiting alcohol
consumption, and tobacco cessation (Glynn et al., 2010). Preventing the serious complications of
hypertension requires patients to incorporate these lifestyle changes into their daily routines
along with a high level of adherence (Eugene & Bourne, 2013; Hallberg, Ranerup, & Kjellgren,
2016; Kaambwa et al., 2014Motlagh et al., 2016; Zimbudzi et al., 2015).
Previous studies documented that hypertension self-management is suboptimal among
older adults with hypertension in Asian countries. High levels of poor adherence to hypertension
self-management such as dietary changes and blood pressure self-monitoring have been reported
in this population (Jin et al., 2013; Lee & park, 2017; Thongtang & Seesawang, 2018; Tu et al.,
2018). Moreover, most of them did not adhere to medication regimen; for example, they
53
purposely skipped or forgot medications (Thongtang & Seesawang, 2018). The reasons for this
are not well understood, suggesting a critical need to identify factors influencing hypertension
self-management behaviors and to develop interventions that will effectively target such factors.
Quantitative studies have previously reported facilitators and barriers to hypertension self-
management in Asian older adults (Hu, Li, & Arao, 2014; Irwan et al., 2016; Motlagh et al.,
2016; Shima, Farizah, & Majid, 2014; Truong, Jullamate, & Piphatvanitcha, 2013). However,
there is a lack of knowledge about how these factors influence self-management as experienced
by older adults in Asian countries, and how these factors operate in the daily lives of older adults
in Asian countries. To answer these questions regarding personal experience of the factors
affecting hypertension self-management in their everyday lives, qualitative research is the most
appropriate method (Butler, Hall, & Copnell, 2016). Qualitative research can help researchers to
better understand older adults’ experiences in Asian countries that contribute to their ability to
self-manage hypertension.
To address these gaps in knowledge, it is important to capture and synthesize how older
adults in Asian countries experienced the factors that influenced their self-management behavior,
which can only be done with qualitative methods. Consequently, this paper reports on a
systematic review of qualitative research (Butler et al., 2016) focusing on experiences affecting
hypertension self-management in older adults within Asian countries. We synthesized our
knowledge about the factors influencing hypertension self-management by applying a systematic
review of qualitative research to: i) broaden the clinical communities’ understanding of patients’
needs to achieve hypertension control, ii) how we can more effectively support hypertension
self-management, and iii) develop tailored self-management interventions for older adults with
hypertension in Asian countries.
54
Aim
This systematic review was undertaken to synthesize qualitative research evidence on
factors influencing older adults’ ability to self-mange hypertension in Asian countries.
Methods
Design
This systematic literature review and synthesis of qualitative studies was conducted using
the method proposed by Butler et al. (2016). This method was developed to guide researchers
conducting qualitative systematic reviews that aim to present a comprehensive understanding of
individual experiences and perceptions, rather than to evaluate the effectiveness of an
intervention (Butler et al., 2016).
Eligibility Criteria
Based on Butler’s methodology (Butler et al., 2016), the author set inclusion criteria for
studies. All searches were restricted by (see Table 1): period of publication (2008-2018) to
ensure the review examined current knowledge of the individual with hypertension, language
(English), type of journal (academic or peer-reviewed), research subject (human), and age (60
years or older).
Search Strategy
The electronic databases CINAHL, PsycInfo, PubMed, Medline, and Google Scholar
were searched using Medical Subject Headings (MeSH) key words including: ‘hypertension’,
‘high blood pressure’, ‘self-management’, ‘self-care’, and ‘qualitative research’. The literature
search was undertaken between June 2018 and August 2018.
55
Search Outcome
The Preferred Reporting Items for Systematic Reviews and Meta- Analyses (PRISMA)
guidelines (Moher, Liberati,Tetzlaff, & Altman, 2009) were used to report the selection and
exclusion of studies. A flow diagram describing the selection of studies is shown in Figure 1.
The initial search identified 1,510 studies; 419 duplicates were subsequently removed. The
author and a research assistant independently screened titles and abstracts for the remaining
1,091 studies. After screening, 1,051 studies were excluded due to not meeting criteria as they
were conducted outside Asian countries (n 645) or were quantitative studies (n 406) which
cannot answer or address knowledge gap about older adults in Asian countries’ experience of
factors influencing hypertension self-management. Forty studies met inclusion criteria and were
reviewed in full. Next, during the preliminary review of the full-text of each study, 30 studies
were excluded due to not meeting inclusion criteria for the following reasons: a) being a
quantitative study (n 8); b) lacking focus on self-management (n 10); and c) being grey
literature which was composed of knowledge artifacts that are not the product of peer-review
processes characterizing publication in scientific journals (n 12). The final set of 10 studies,
including two generated from hand searching, varied in terms of design, population, aims, and
findings as they focused on different things (Table 2).
Study Selection
After obtaining all of the studies resulting from searching the electronic databases,
duplicates were removed. The author and a research assistant independently screened the title
and abstract of each study. The author and research assistant also discussed whether to include
each study, and came to an agreement about any differences. The full-text studies that appeared
to meet the inclusion criteria were obtained for further screening. The author and research
56
assistant independently conducted preliminary screens of each article, and determined which
studies met the above inclusion criteria. Then, the author and research assistant read the full-text
of each study in detail. Reference lists from each study were hand-searched for additional
relevant studies, resulting in an additional two studies.
Data Extraction
The authors read each study and extracted: a) authors; b) year of publication; c) country;
d) study design; e) study purpose; f) participants; g) setting; h) data collection and analysis
techniques; and i) findings relevant to the review. The author and research assistant entered this
information into a table to allow for comparison across articles (Table 2).
Quality Appraisal
The author and research assistant reviewed and critiqued the quality of each study using
the QualSyst Tool for Qualitative Studies (Kmet, Lee, & Cok, 2004). The ten items include (1)
sufficient description of question/objective, (2) evident and appropriate study design, (3) context
for the study clearly described, (4) connection to a theoretical framework or wider body of
knowledge, (5) sampling strategy described, relevant and justified, (6) data collection methods
systematic and clearly described , (7) data analysis systematic and clearly described , (8)
verification procedure(s) used to establish credibility, (9) conclusions supported by the results,
and (10) evidence of researcher reflexivity. These 10 questions were scored depending on the
degree to which the specific criteria were met (no 0, partial 1, yes 2).
The author added all the scores for all items to obtain a total score, dividing this by the
total possible score to obtain the summary score (Table 3). For each study, a maximum total
score of 20 and a maximum summary score of 1 was possible. Studies that failed to meet the
minimum summary score of 0.55 (Kmet et al., 2004) were not included. The cut-point of 0.55 is
57
the minimum recommended threshold for inclusion for qualitative studies (Kmet et al., 2004).
All studies met this minimum level. Overall score ranged from 0.70 to 1.00. Our review is
therefore grounded on findings of an overall ‘good’ methodological quality. Common
weaknesses within the 10 included studies were primarily i) a lack of a clear description of
analysis and ii) limited contextual information about participants.
Data Synthesis
Data synthesis was performed using conventional content analysis, an approach that is
particularly appropriate when little is known about a phenomenon (Hsieh & Shanon, 2005) and
this method is consistent with Butler’s guideline. The authors initially read and immersed
themselves in the manuscripts to obtain a sense of the whole and recorded first impressions.
Next, codes reflecting categories and concepts reported in the ten studies were developed.
Categories were inductively developed by grouping codes based on similarities and differences,
and organizing codes into meaningful clusters (Erlingsson & Brysiewicz, 2017; Hsieh &
Shannon, 2005). For instance, category “patient-level influence” demonstrated factors at
individual levels that influenced hypertension self-management. Table 4 provides coding and
synthesized categories.
Results
Overview of Studies
Methodologies used in reviewed studies included; narrative approach (n 2),
conventional content analysis (n 3), directed content analysis (n 4), and ethnography (n 1). In
terms of location, 5 were from Thailand, 2 were from China, 2 were from Iran, and one was from
South Korea. Three studies were conducted in rural areas, 6 studies in urban areas and only one
58
study was conducted both in urban and rural areas of Asian countries. The sample sizes varied
from 9 to 44 and included both male and female patients in each study.
Detailed Results
The results of this review include a synthesis of the factors that were found to influence
self-management among older adults with hypertension in Asian countries. In each of the
included studies, Asian older adults were interviewed using open-ended questions such as “how
do you manage your hypertension?” “What is your view of the factors that support you to
manage your hypertension?” “What do you think the obstacles might be when managing
hypertension?” Study results focused on perceptions of hypertension, knowledge about
hypertension and its treatments, reasons for poor treatment adherence, self-management
approaches, and the factors influencing Asian older adult’s self-management. In this review, no
studies contributed to all categories. The most common categories addressed were patient-level
influences, organizational-level influences and community-level influences on hypertension self-
management as identified in the ten studies (Table 5).
Patient-level influences and hypertension self-management. Patient level influences
were associated with individual lifestyle and beliefs that affected their ability to self-manage.
Sub-categories included ‘personal beliefs’, ‘understanding of symptoms’, ‘perceptions of
physical health’, ‘sense of responsibility’, ‘sense of control,’ and ‘financial concerns’.
Personal beliefs. Three studies contributed to the cultural, social and spiritual beliefs that
influenced hypertension self-management. One study in Thailand, identified that most older
adults diagnosed with hypertension, expressed a belief that the imbalance between Leard (blood)
and Lom (wind) caused hypertension, and was related to inappropriate behavior such as having
hot and cold body temperature (Udompittayason et al., 2012). They believed that exposure to
59
extreme weather (cold or hot weather) caused the imbalanced circulation. Moreover, cultural
belief led most of them to use traditional medicines as they believed that traditional medicines
can improve the imbalance of circulation. These behaviors were not consistent with hypertension
management recommendations. Another study by Nayeri et al. (2015) found that some older
adults with hypertension in Iran commonly viewed diet as an integral part of social gatherings,
finding that it was difficult to maintain their dietary restrictions during social gatherings when
others were eating and drinking food not recommended for people with hypertension. Spiritual
beliefs about illness were also found to influence self-management behavior. For example,
Iranian older adults were likely to believe that the outcome of hypertension was in ‘God’s hands’
and their body was a loan from God (Nayeri et al., 2015). Thus, the idea of self- management, of
personal control, was not an option to them.
Studies in Thailand and Iran (Nayeri et al., 2015; Woodham et al., 2018) found that some
older adults did not engage in self-management behavior because they believed that western
medications had more problems than benefits and that taking medications would cause other
serious health problems. Thus, they decided not to take medications to decrease their high blood
pressure.
Understanding of symptoms. The studies of Udompittayason et al. (2012) and Woodham
et al. (2018) in Thailand, reported that older adults with hypertension were more likely to stop
medication and decided not to change their lifestyle behaviors because they had no symptoms.
They only took hypertension medication when experiencing clinical symptoms such as headache
or dizziness because they did associate this with hypertension (Udompittayason et al., 2012).
Similarly, older adults with no symptoms were more likely to believe that there was no reason to
continue taking medication, change their lifestyle, or adopt preventive behaviors such as exercise
60
(Woodham et al., 2018). This was the difference in initiation versus maintenance of
hypertension-related behavior.
Perceptions of physical health. One study conducted in Thailand found that perceptions
of poor physical heath interfered with motivation to make changes related to hypertension
management (Sutipan & Intarakamhang, 2017). Hypertensive older adults who perceived their
physical health to be poor were less likely than others to engage in physical activities. They
perceived their physical health to be poor when they cannot work as usual or when they had
muscle pain or fatigue. Perceptions of poor physical health made them want to stay at home, to
engage only in sedentary activities, and not exercise.
Sense of responsibility. Findings from the Zhang et al. (2014) study in China, suggested
that older adults with hypertension who believed they had a responsibility to take care of
themselves were more likely than others to view self-management as important to achieving a
good quality of life. In addition to feeling responsible for themselves, they believed that taking
care of themselves would prevent them from adding burden to their country.
Other studies in Thailand (Kitreerawutiwo et al., 2015) and China (Long & Li, 2016)
found that some older adults with hypertension reported focusing on their family responsibility,
such as earning an income or caring for small children. These older adults expressed a lack of
interest in managing their disease as it would redirect their focus and interfere with their ability
to engage in these other responsibilities, especially older men. This was the explanation some
older adults gave for failing to take medications.
Sense of control. In a study by Khezri et al. (2016) among Iranian older adults, an
individual sense of control over their illness was associated with greater trust in their ability to
successfully engage in self-management behavior, compared to those with a poor sense of
61
control over their illness. Those with greater sense of control were also more likely to have
stronger confidence in their ability to manage their hypertension.
Financial concern. One study in China (Long & Li, 2016) reported financial concerns,
as a factor influencing the ability to self-manage hypertension. Insufficient income limited older
adults’ ability to purchase healthy food, medications, and transportation to healthcare provider
appointments, especially among older adults who lived in rural areas.
Organizational-level influences and hypertension self-management. Only two studies
addressed organizational-level issues including provider time management and healthcare
provider-patient communication as factors influencing an individual’s hypertension self-
management ability (Kang et al., 2014; Khezri et al., 2016).
Provider time management. One study conducted in Iran (Nayeri et al., 2015) found that
many older adults with hypertension experienced insufficient time to consult with providers
about their concerns due to short visits (Nayeri et al., 2015). Thus, they reported rarely having a
chance to discuss or learn about self-management strategies to support home blood pressure
management.
Healthcare-provider communication. One study conducted in South Korea (Kang et al.,
2014) found that older adults with hypertension reported receiving inadequate attention from
healthcare providers. Some of them perceived that doctors did not listen to them. Sometimes,
they experienced lack of response when talking about having difficulty with self-management.
Moreover, they reported that their doctors did not discuss some hypertension lifestyle
management strategies such as regular exercise; but only mentioned avoiding salty food, taking
medications.
62
Community-level influences and hypertension self-management. Community-level
influences included two sub-categories: a) community resources and b) social support facilitating
or inhibiting self-management efforts.
Community resources. One study in Thailand (Sutipan & Intarakamhang, 2017) reported
inadequate community resources affecting self-management among some older adults with
hypertension such as lacking access to places for participating in physical activities. Some
abandoned the idea of exercising due to lack of safe or affordable places to exercise.
Social support. Three studies conducted in Thailand (Kitreerawutiwo et al., 2015;
Sutipan & Intarakamhang, 2017; Thongtang & Seesawang, 2018) and one study conducted in
Iran (Nayeri et al., 2015) found that social support influenced self-management. Some older
adults with hypertension reported that receiving support from others encouraged them to self-
manage and assisted them in making and maintaining lifestyle changes, especially support from
families. Older adults often shared their hypertension management strategies with family
members who could provide assistance with daily self-management tasks such as reminding to
taking medications, preparing appropriate food, and attending appointments. Families also
provided emotional support that could motivate older adults to engage with self-management
(Nayeri et al., 2015; Sutipan & Intarakamhang, 2017; Thongtang & Seesawang, 2018). In
addition to family support, peer provided emotional support and suggestions about reducing salt
or taking medications which increased their confidence to engage in self-management activities
(Kitreerawutiwo et al., 2015).
Discussion
The purpose of this systematic review was to synthesize evidence on the issues found to
influence ability of older adults in Asian countries to self-manage hypertension. Older adults
63
were found to face several issues that affected their ability to engage effectively in managing
their own health care. Findings showed that patient-level (e.g. personal belief, perceptions of
symptoms and sense of responsibilities), organizational-level influences (e.g. time management),
and community-level influences (e.g. social support) can influence ability to self-manage among
older adults with hypertension in Asian countries.
The three main categories that characterized the literature on issues influencing ability to
self-manage among older adults were patient-level, organizational-level, and community-level.
These findings are congruent with factors influencing self-management in patients with chronic
obstructive pulmonary disease (Disler, Gallagher, & Davidson, 2012) and in adult patients with
diabetes (Wilkinson, Whitehead, & Ritchie, 2014) that have been reported by others. For
example, an integrative review of factors influencing self-management of chronic obstructive
pulmonary disease showed that the presence of symptoms (e.g. dyspnea and functional
impairment) and existential determinants (e.g. meaning of life and religiosity) as most influential
on self-management (Disler et al., 2012).
However, comparing to self-management in different illnesses, systematic review on
experience of self-management among diabetic patients found different influencing factors. For
example, communication with healthcare providers and consistent, understandable and specific
education to facilitate self-management was found to affect self-management behaviors
(Wilkinson et al., 2014). Another systematic review found that only personal factors, including
health beliefs, perceived susceptibility, perceived barriers, and self-efficacy were associated with
diabetes self-management behaviors (Luo et al., 2015).
Personal beliefs are an important influence on individual’s ability to self-manage their
hypertension which is congruent with other studies. In a qualitative study of self-manage in
64
diabetes, Reyes et al. (2017) documented the influence of personal beliefs on eating behavior
changes and taking medication as prescribed. Those who believed in their ability to control
diabetes, had a positive outlook about their quality of life, and were willing to make changes in
their lifestyle were more likely to change eating habit and exercise. Moreover, Mosnier-Pudar et
al. (2010) reported that patients who believed that playing an active role in their own care could
alter the disease course were more able to maintain lifestyle changes while those who believed
that family history and genetics were the only causes of diabetes were unlikely to take an active
role in their disease management. Korpershoek et al. (2016) found that patients who believed
their symptoms would resolve on their own postponed appointments with their healthcare
providers.
Social support also played an important role in hypertension self-management. In this
review, social support from family and peers was reported to improve hypertension self-
management behavior that was consistent with other illnesses such as diabetes and chronic
obstructive pulmonary disease (Disler et al., 2012; Wilkinson et al., 2014). Social support can
promote patients to engage in healthy diet, physical activities, and decision to contact healthcare
providers (Irwan et al., 2016; Korpershoek et al., 2016; Motlagh et al., 2016). Pertaining to
support from healthcare providers, this review found that older adults with hypertension often
experienced what they viewed as insufficient consultation time from their healthcare providers.
Even though the review includes studies from different countries, there are still many
unanswered questions about self-management in hypertension that are important to explore if
effective interventions are to be developed. In this review, the participants of included studies
were mixed between older men and women. Our search did not yield any studies that focused on
differences between populations. Better distinctions in the experiences of these subgroups were
65
not generally visible. Thus, it should be taken into account when interpreting the obtained
results. There is a possibility that the generalizability of our findings may be limited as no data
were found around how perceptions and factors influencing ability to self-manage may vary
between and within different social groups. Moreover, research approach for data collection, the
researchers tended to ask open-ended questions that focused on barriers and facilitators to self-
management. However, the researcher did not ask questions on how older dealt with all obstacles
to self-manage.
To provide a foundation for research on factors influencing ability to self-manage, this
review took a broad perspective among older adults in Asian countries. Nevertheless, this
systematic review does not provide a complete profile of what may help or impede self-
management in hypertension. Moreover, our sample included older adults with other chronic
diseases such as diabetes and heart disease. Studies did not identify factors both common among
and specific to self-management of different chronic illness that may differ across the illness
trajectory.
Implications for Practice, Policy, and Research
Healthcare providers should provide more attention to individual by giving more chances
for individual to discuss their concerns and discussion needs to be sensitive to the social, cultural
or financial distinctions. Length of appointment with healthcare provider is an important aspect
for supporting an individual to effectively self-manage and facilitate the needs of older adults
with hypertension and their confidence in managing their condition. To promote the individual
incorporate hypertension self-management into their daily life, exercise and dietary
recommendations should align with the individual’s social circumstances and cultural beliefs. In
addition, convening support groups that peers led to facilitate the sharing of ideas should be
66
provided to promote learning self-management strategies through other experiences. Innovative
programs and initiatives that address these barriers warrant attention.
Hypertension self-management should be considered a national focus in Asian countries,
strengthening services to assist older adults in managing their hypertension. Health policy to
support national programs for improving hypertension self-management and better hypertension
control based on local culture, financial characteristics, healthcare systems, and available
resources in Asian countries is needed.
Future research in the area of self-management should focus on identifying and targeting
factors that increase risk of poor self-management practices. In addition, future research and
intervention studies should focus on how best to tailor interventions to improve self-management
and evaluate the short- and long-term outcomes of interventions.
Conclusion
Hypertension is a chronic condition that requires self-management behaviors which
involves a shift from being controlled by hypertension to an ability to limit the impact of the
condition. This review has found some evidence that a diverse range of patient-level influences,
organizational-level influences, and community-level influences are associated with the
individual’s ability to self-manage among older adults living with hypertension in Asian
countries. Synthesizing qualitative evidence suggests that healthcare providers working with
older adults who have hypertension have to consider those factors that influence ability to self-
manage. In order to facilitate further development of theory for older adults with hypertension in
Asian countries, future studies should attempt replication among those with different
backgrounds.
67
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75
Table 1
Inclusion and exclusion criteria
Criteria Justification
Relates to the factors
influencing hypertension
self-management of older
adults aged more than 60
years in a rural and urban
setting in Asian countries
Self-management is required for older adults with hypertension
who live in both urban and rural areas in Asian countries. Any
studies which focused on hypertension self-management in older
adults outside Asian countries were excluded, because of the
difference in the context.
Examines older adult
experiences, perspectives,
attitude or feelings as a
primary aim
Older adult experiences, perspectives, attitude or feelings
surrounding hypertension self-management must be a primary
aim of each study. Studies that did not relate to self-manage
hypertension or healthcare providers’ perspective were excluded,
owing to the expansive number of reviews on each topic.
Original qualitative data The review focused on the experiences, attitude, feelings or
perspectives of older adults, which was most appropriately
answered through qualitative research. Qualitative data from a
mixed methods study was included. Any study which utilized
survey data or statistical reporting of results and grey literature
(e.g., dissertation studies, books, published abstracts, conference
proceedings, etc.) were excluded.
76
Table 2
Overview of studies
Author,
Year,
County
Study
Design
Purpose Participants/
Setting
Data
Collection/
Data
Analysis
Findings relevant to
factor influencing self-
manage
Udompitta
yason et al.
(2012)
Thailand
Ethnographi
c study
Explore
the
perception
on
hypertensi
on
11 Thai-
Melayu
older adults
Rural
village in
Southern
Data
collection:
In-depth
interview,
observation
and focus
group
Data
analysis:
Thematic
analysis
Patients stopped taking
medication and not
change their lifestyle
due to the absence of
symptom. They only
took medication when
they had clinical
symptom such as
headache.
Patients believed that
the cause of
hypertension is the
imbalance of Leard
(blood) and Lom
(wind), leading them
not to change their
behavior.
Sutipan and
Intarakamh
ang (2017)
Thailand
Qualitative
focus group
study
Explore
barriers
and
facilitators
associated
with
healthy
10 older
adults
Urban area
in Northern
Data
collection:
Focus group
Data
analysis:
Content
analysis
Patients described that a
lack of motivation
regarding lifestyle
modification due to
perceived poor physical
health as the barriers for
adopting healthy
77
Author,
Year,
County
Study
Design
Purpose Participants/
Setting
Data
Collection/
Data
Analysis
Findings relevant to
factor influencing self-
manage
lifestyle
behavior
lifestyle behavior.
There was a lack of safe
or affordable places to
exercise.
Patients reported that
family members
motivated them in
hypertension
management such as
taking medications.
Thongtang
and
Seesawang
(2018)
Thailand
Convention
al content
analysis
approach
Explore
self-care
among
Thai older
adults
with
hypertensi
on
30 Thai
older adults
F 20, M
10
Urban area
in Western
Data
collection:
in-depth
interview
Data
analysis:
conventional
content
analysis
Patients received
support from family to
manage their
hypertension, such as
taking medication,
eating habit, and
exercise.
Woodham
et al.
(2018)
Thailand
Directed
content
analysis
approach
Gain
better
understan
ding of
perspectiv
e on living
with
hypertensi
30 older
adults
F 17, M 13
Rural areas
Content
analysis
Patients perceived that
taking medications
would cause other
serious health problems.
Patients with no sign
and symptoms believed
that there was no reason
to continue taking
78
Author,
Year,
County
Study
Design
Purpose Participants/
Setting
Data
Collection/
Data
Analysis
Findings relevant to
factor influencing self-
manage
on and
how they
manage
medicatio
n at home
among
elderly
hypertensi
on
medication.
Kitreerawut
iwo et al.
(2015)
Thailand
Qualitative
approach
using in-
depth
interviews
and focus
group
Explore
factors
affecting
health
behavior
and health
needs in
the elderly
40
participants
Rural
area
Data
collection:
In-depth
interview
and focus
group
Data
analysis:
content
analysis
Patients received
support from family and
group in motivating
them to change eating
behavior and do
exercise.
Patients used their time
to take care small
children and did not
have time to take care
themselves, such as
forgot to take
medication.
Zhang et al.
(2014)
China
A
qualitative
descriptive
design
Investigat
e the
meaning
of life and
health
11 older
adults
F 6, M 5
Urban areas
Data
collection:
In-depth
interview
Data
Patients expressed that
they must care for
themselves and they
have the power and
responsibility to take
79
Author,
Year,
County
Study
Design
Purpose Participants/
Setting
Data
Collection/
Data
Analysis
Findings relevant to
factor influencing self-
manage
experienc
e of
Chinese
elderly
with
chronic
illness
analysis:
Thematic
analysis
care of themselves such
as exercising.
Long and
Li (2016)
China
A
qualitative
narrative
design
Explore
health-
seeking
behaviors
through
which
elders
manage
diagnoses,
treatment,
and health
care.
24 Chinese
elders and
24
caregivers
F 12, M 12
Urban and
rural areas
Data
collection:
semi-
structured
interview
Data
analysis: an
abductive
approach
Patients concentrated on
fulfilling their
responsibility as
members of their
households. Thus, they
were not interested in
learning to manage their
disease and
complications.
Patients in rural area
with insufficient income
impacted on ability to
acquire food and
medication.
Nayeri et
al. (2015)
Iran
Convention
al content
analysis
approach
Explore
patients,
their
families,
and
healthcare
10 patients
F 5, M 5
Urban areas
Data
collection:
semi-
structured
interview
Data
Patients had a negative
attitude toward the
disease, treatment,
doctor, and medication,
for example, they
believed that their body
80
Author,
Year,
County
Study
Design
Purpose Participants/
Setting
Data
Collection/
Data
Analysis
Findings relevant to
factor influencing self-
manage
providers’
experienc
es about
hypertensi
on
treatment
adherence
analysis:
conventional
content
analysis
had ability to recover
itself and did not want
to use medication.
They believed that their
body is a loan from God
and they paid attention
to what they ate and
how to care of this loan.
Patients found that it
was difficult to resist
when their relatives or
friend offer them
unhealthy food.
Patients experienced a
positive impact of
supportive family
atmosphere on adhering
to treatment regimen
including eating safe
foods, exercising,
recalling medication
usage, and following
appointment.
Patients complained that
health offices were
often crowded and there
was little time to consult
81
Author,
Year,
County
Study
Design
Purpose Participants/
Setting
Data
Collection/
Data
Analysis
Findings relevant to
factor influencing self-
manage
physician.
Khezri et
al. (2016)
Iran
Directed
content
analysis
approach
Explore
the
challenges
in self-
managem
ent
empower
ment
9
hypertensio
n patients
Urban areas
Data
collection:
semi-
structured
interviews
Data
analysis:
directed
content
analysis
Patients perceived that
even they were old; they
were able to control
their disease by
complying with
medication regimen and
exercising.
Kang et al.
(2014)
South
Korea
A
qualitative
narrative
design
Explore
how older
Korean
adults
perceive
and cope
with their
chronic
illness
13
participants
Urban areas
Data
collection:
focus group
Data
analysis:
content
analysis
Patients experienced not
being heard or
considered by doctors.
82
Table 3
Quality assessment for qualitative studies with QualSyst Tool
Studies Quality Assessment Criteria for Qualitative Studies
1 2 3 4 5 6 7 8 9 10 Total
Score
Summary
score
1.Udompittayason
(2012)
2 2 2 1 2 2 2 2 2 2 19 19/20 0.95
2. Sutipan
(2017)
2 2 1 2 2 2 2 0 2 1 16 16/20 0.80
3. Thongtang
(2018)
2 2 2 2 2 2 1 2 2 1 18 18/20 0.90
4. Woodham
(2018)
2 2 2 2 2 1 1 2 2 1 17 17/20 0.85
5. Kitreerawutiwo
(2015)
2 2 1 1 2 2 1 1 1 1 14 14/20 0.70
6. Zhang
(2014)
2 2 2 2 2 2 2 2 2 1 19 19/20 0.95
7. Long
(2016)
2 2 2 2 2 2 2 0 2 1 17 17/20 0.85
8. Nayeri
(2015)
2 1 2 2 2 2 2 2 2 2 19 19/20 0.95
9. Khezri
(2016)
2 2 1 2 2 1 2 1 2 1 16 16/20 0.80
10. Kang
(2014)
2 2 1 2 2 2 1 0 2 0 14 14/20 0.70
Note. The QualSyst tool for qualitative studies: 1. Question / objective sufficiently described?; 2. Study design
evident and appropriate?; 3. Context for the study clear?; 4. Connection to a theoretical framework / wider body of
knowledge?; 5. Sampling strategy described, relevant and justified?; 6. Data collection methods clearly described
and systematic?; 7. Data analysis clearly described and systematic?; 8. Use of verification procedure(s) to establish
credibility?; 9. Conclusions supported by the results?; 10. Reflexivity of the account? (2 = Yes, 1= Partial, No = 0)
83
Table 4
Categories of factors affecting self-management and associated codes
Categories Sub-categories Codes
Patient-level influences on
hypertension self-
management
Personal beliefs � Perception of cause of
hypertension
� Self-manage is
inconvenient
� Cultural
belief/value/practice (e.g.
food and traditional
medicine)
� Spiritual belief in God
� Negative attitude towards
Western medicine (e.g.
adverse effect)
Understanding of
symptoms
� Appearance of symptoms
� Absence of symptoms
Perceptions of physical
health
� Perceptions of poor
physical health
Sense of responsibility � The responsibility of the
healthy
� Focusing on family work
� Time constraints of family
work affect time to self-
manage
Sense of control � Self-perceived control of
own health
Financial concerns � Insufficient income to self-
manage (e.g. buying
healthy food)
84
Categories Sub-categories Codes
Organizational-level
influences on hypertension
self-management
Provider time
management
Healthcare provider-
patient communication
� Lack of time for
consultation
� Longer waiting time
� Lack of active discussion
� Perceive doctors do not
listen to patients
Community-level influences
on hypertension self-
management
Community resources � Exercise environment
� Lack of public place for
exercise
Social support � Perceived support (family,
peer)
� Participation in peer
support
85
Table 5
Overview of categories and sub-categories
Theme/sub-theme Udompit
tayason
(2012)
Sutipan
(2017)
Thongta
ng
(2018)
Woodh
am
(2018)
Kitreera
wutiwo
(2015)
Zhang
(2014)
Long
(2016)
Nayeri
(2015)
Khezri
(2016)
Kang
(2014)
Patient-level influences
on hypertension self-
management
� Personal beliefs � � �
� Understanding of
symptoms
� �
� Perceptions of
physical health
�
� Sense of
responsibility
� � �
� Sense of control �
� Financial concern �
Organizational-level
influences on
hypertension self-
management
� Provider time
management
�
� Healthcare
provider-patient
communication
�
86
Theme/sub-theme Udompit
tayason
(2012)
Sutipan
(2017)
Thongta
ng
(2018)
Woodh
am
(2018)
Kitreera
wutiwo
(2015)
Zhang
(2014)
Long
(2016)
Nayeri
(2015)
Khezri
(2016)
Kang
(2014)
Community-level
influences on
hypertension self-
management
� Community
resources
�
� Social support � � � �
87
Chapter 4
Developing a Personal Sense of Risk: A Grounded Theory Study of Older Rural Thai Men
with Hypertension
88
Title: Developing a Personal Sense of Risk: A Grounded Theory Study of Older Rural Thai Men
with Hypertension
Intended to submit to: International Nursing Review
Author: Junjira Seesawang, MS, RN
Doctoral Candidate
University of Wisconsin-Madison
School of Nursing
Barbara Bowers, RN, FAAN, PhD
Associated Dean for Research and Professor
School of Nursing, University of Wisconsin-Madison
Nantaporn Sansiriphun, RN, PhD
Associate Professor
Faculty of Nursing, Chiang Mai University
Corresponding Author: Junjira Seesawang, MS, RN
Funding: This research was funded by Eckburg Dissertation Research Award, School of
Nursing, University of Wisconsin-Madison.
Acknowledgements: Thank you to dissertation committee members, staff at the participating
recruitment locations, and all participants. Authorship contributions: Study design: JS, PW, NS
Data collection: JS
Data analysis: JS, BW
Study supervision: BW, NS
Manuscript writing: JS
Critical revisions for important intellectual content: JS
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Abstract
Background: Hypertension is a public health problem conferring an increased risk of
cardiovascular, cerebrovascular, and kidney disease. However, non-adherence to treatment is
common in older men who living in rural areas. Knowledge about patients’ experience of living
with hypertension is important for promoting treatment adherence.
Aim: To develop a conceptual model of the experience of older rural Thai men living with
hypertension.
Methods: A grounded theory approach was adopted. Semi-structured, face-to-face interviews,
with 29 hypertensive older Thai men were conducted in Thailand using purposive and theoretical
sampling methods. Data were analyzed according to the constructivist grounded theory analytical
method that included initial and focused coding, and constant comparison.
Findings: ‘Developing a personal sense of risk’ emerged as the core category, which
incorporated the related four sub-processes: comparing healthcare provider information with
stories, comparing one’s own situation with stories, changing personal sense of risk, and
changing risk-related behavior. Despite awareness of multiple negative clinical outcomes, older
men focused on one particular clinical outcome, using only the selected outcome (stroke, heart
disease, kidney failure) to monitor their risk. Over time, new information in the form of stories
about people they knew influenced their sense of risk and likelihood of engaging in risk reducing
activities. Conclusion and implications for nursing: This investigation provides a conceptual model for
healthcare providers to understand older men’s perceptions of personal risk for complications of
hypertension. A personal sense of risk influences risk-related behavior change.
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Implications for nursing and health policy: The findings suggest that personal sense of risk as
a factor contributing to more effective self-management thus the development a tool for
assessing a personal sense of risk in older men with hypertension is required. As stories have
power, effective storytelling interventions should be developed to improve self-management.
Hypertension care policy needs to be developed for individualized approaches.
Keywords: Grounded theory, Hypertension, Older men, Risk determination, Risk perception,
Thailand
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Introduction
Hypertension is an important global public health threat; it is a leading risk factor for
cardiovascular, cerebrovascular, and kidney disease (Bromfield & Muntner 2014; Cate et al.
2015; WHO 2018; Yang et al. 2017). Poorly controlled hypertension can lead to a host of
hypertension complications such as stroke, heart disease and impaired kidney function
(Forouzanfar 2017; Lee 2018; Leelacharas 2015; Simonds et al. 2017). The prevalence of
hypertension varies in different regions of the world (Mills et al. 2016). In Thailand, older men
(≥60 years old) face a significantly higher likelihood of developing hypertension and its
complications than older women (Chongthawonsatid 2015). For example, the number of men
and women with stroke in 2011 was 319 and 117, respectively (Bandasak et al. 2011).
Hypertension is one of the leading causes of death and disability in Thailand and other
developing countries (Mohsen 2018; Tibazarwa & Damasceno 2014). In Thailand, adherence to
hypertension treatment regimens is lower among rural men compared to men in urban settings,
leading to greater disparities in hypertension control across geographic regions (Aekplakorn et
al. 2012). An important contributing factor to treatment non-adherence is the failure to perceive
hypertension as a serious disease (Suthipan & Intarakamhang 2017; Udompittayason,
Boonyasopun, & Songwathana 2015).
Although there is no clear explanation for the high level of treatment non-adherence
among older rural men in Thailand, studies in other countries have identified socio-cultural
influences such as limited access to healthcare, religious beliefs, culture, lack of trust in
providers or in the medical system, and income level (Bennett 2013; Elbur 2015; Long et al.
2017). Studies have found a gender difference in treatment adherence as men were less likely to
adhere to treatments and were less sensitive to knowledge about negative outcomes than women
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(Amuta et al. 2016; Khayyal et al. 2016; Macaden & Clarke 2014; Mohd Azahar et al. 2017;
Saver et al. 2014; Renier et al. 2016).
Having knowledge about hypertension, hypertension-related complications, and
perception of one’s own risk for hypertension co-morbidities, positively affected behavior and
contributed to medication adherence among African American men (Long et al. 2017). However,
another study found that knowledge alone is often insufficient for behavior change and treatment
adherence (Bennett 2013). Bennett (2013) found that having knowledge about complications of
hypertension was not sufficient to change behavior, as urban African American men did not seek
treatment or engage in self-management until they experienced severe complications. This also
suggests that knowledge about risk does not always translate to behavior change.
Based on the findings of the current review, it is unclear how knowledge operates among
older Thai men, why knowledge about risk for negative outcomes does not lead to changing
behavior, how older men respond to the diagnosis, how they integrate hypertension into their
daily lives, how/whether sense of risk lead to behavior changes, and how sense of risk develop.
Due to this complexity, it’s no wonder that there is currently a lack of model to explain
experience of older men with hypertension (Bennett 2013). Thus, current hypertension
management strategies designed to increase self-management may not be sensitive to, address or
reflect the translation of knowledge to change in behavior, the role of personal perception of risk,
or how that perception develops among older rural Thai men, which in turn may affect their
behavioral change.
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Purpose
The aim of this study was to develop a conceptual model explaining the experience of
older rural Thai men living with hypertension and how they respond to recommendations for
self-management.
Methods
Research Design
This study utilized the grounded theory methodology (Charmaz 2014; Strauss & Corbin
1998). Grounded theory seeks to understand how individuals create and construct social realities
and how those realities influence their actions. It allows for an in-depth understanding of a social
process (Blumer 1969) which in this case explicates the experience and the response of older
rural Thai men diagnosed with hypertension. Grounded theory seeks to generate a conceptual
explanation, eventually a theory or conceptual model, focusing on the social processes (Charmaz
2014; Strauss & Corbin 1998) by which the response to hypertension diagnosis is created that is
grounded in participants’ perspectives and explanations.
Participants and Setting
Participants were older male patients with hypertension living in rural communities in
western Thailand. They were invited to participate via public health nurses working in their
region. Interested men were then contacted by the researcher who explained the study. A
purposive sampling method was initially used to recruit suitable participants based on the
inclusion criteria. Participant-specific inclusion criteria included; (a) male, aged 60 years or
older, and currently a patient in the local community health center (b) diagnosed with
hypertension, (c) ability to understand and speak Thai, and communicate sufficiently, and (d)
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willing to participate in the study. Next, theoretical sampling was employed in response to
ongoing analysis. Theoretical sampling occurs as the data collection progresses to find specific
information to add depth to conceptual model which can be done by either finding specific
people to interview who have had a specific experience, or by altering interview questions
(Strauss & Corbin, 1998). In this study, after data analysis, theoretical sampling was used by
modifying interview questions or generating new questions to gain specific information
regarding emerging concept or categories.
Recruitment ended when data saturation on selected categories was reached, defined here
as the time when the researcher cannot discover new dimension in data being collected (Strauss
& Corbin 1998). In this study, saturation occurred particular around how personal sense of risk
change. Twenty-nine older men with hypertension took part in the study. The age of men
participating in the study was between 60 and 80 years (mean 68.77). The participants’
characteristics are presented in Table 1.
Data Collection
Data were collected from September 2017 to July 2018. All interviews took place in
participants’ homes. Interviews lasted between 20 and 60 minutes (average 45 minutes). Initial
interviews lasted 50 minutes. Five interviews only lasted 20 minutes, were these repeated
interviews for clarifying some information. All interviews were digitally recorded in Thai and all
audio data files were transcribed verbatim by the first author after listening to each one several
times. Initially I translated the entire 10 interviews and then when data collection progresses, I
translated quotation, codes, categories, conditions, and dimensions from Thai to English for data
analysis with major advisor.
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Initial questions were non-directive and open-ended such as “Please tell me about what
things have been like for you living with hypertension?” This question was intentionally non-
directive so that older men could lead us in the direction that was most relevant to them. I asked
open question because I would like to invite them to share their experience from their
perspectives. When I asked this question, I listened to what older men said and what they
omitted. These would suggest areas to explore in greater depth. Then, I followed participants’
data that they talked about their experience from their perspective when living with hypertension.
Next, I talked to new or previous participants by asking new questions. The new questions were
determined when we found the new concept reflected in emerging categories or when we would
like to identify the dimension or properties of the categories.
For example, after asking question, “Please tell me about what things have been like for
you when living with hypertension?” older men started talking about ‘not thinking they really
needed the medications or behavior change.’ They thought they would probably not have a
stroke because they did not have any symptoms or their blood pressure was not too high. They
told me about stories of other people. They heard or saw that other people had headache or
dizziness and then got stroke. Moreover, they talked to me that they compared themselves to
others that they heard or saw, if they had symptoms like people who had stroke, they thought
they were at risk for stroke. From their explanations, I got to a personal sense of risk. Therefore,
during subsequent interviews, topics discussed with older men included sources of information
about complications of hypertension, their experience of sense of risk, and sense of risk’s
influence on older men.
As data collection and data analysis occurred iteratively, interview guides were revised
according to memos that the researcher wrote after analyzing each interview. Once data analysis
96
had commenced and categories began to emerge, theoretical sampling was used to more fully
explore the emerging categories, identify dimensions and relevant conditions, identify interaction
among categories, and develop the emerging conceptual model (Charmaz 2014; Strauss &
Corbin 1998). The questions were changed as the study progressed to become more focused on
the emerging categories. For example, from the analysis, it seemed like risk perception
influenced their actions. Then, I thought I need to explore how do they think about risk of
hypertension and how does the perceived risk influence their hypertension self-management.
Thus I added these questions to my interview guide, to identify relevant conditions, and the
consequences: ‘What are some of the possible hypertension complications that you know of that
some people might have? Have you ever seen someone suffering from these complications?
Would you consider yourself at risk for developing hypertension complications and what makes
you think so? How does that affect how you take care of your hypertension?’ While collecting
data, probing questions were used such as ‘Could you tell me more about that? Could you tell me
why you felt that?’ encouraging the participants to clarify their experiences and describe them in
greater detail.
A total of 34 interviews were conducted with 29 older men as some individuals were
interviewed on more than one occasion, which allowed probing and clarification of issues that
were raised. Before the second interviews, the questions were modified for sufficient data and
coding. Thus, theoretical sampling was achieved through revision of interview questions to
explore directions indicated by participants (Charmaz 2014).
Ethical Considerations
This study was approved by the ethics committee of the University of Wisconsin-
Madison (number 2017-0740) and Phetchaburi Provincial Public Health Office (number
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013/2560). Older men who met the inclusion criteria were invited to participate and were further
introduced to the purposes and method of the study. The interview was one-on-one and was
conducted via one to two interviews per participant. Participants were guaranteed that they could
withdraw, without penalty, from the interview at any time and for any reason. Written informed
consent was obtained, and privacy and confidentiality were assured. All interview transcripts
were kept confidential, using reference numbers instead of real names. No link was made
between the consent form and the interviews so no identifying information was included on the
transcripts and no key was created. They were informed that the results would be presented in a
way that assured the participant’s confidentiality by using the number instead of a specific name
of participants.
Data Analysis
Data collection and analysis occurred iteratively. All interviews were transcribed
verbatim for the entire recording. Data were analyzed according to the tenets of grounded theory
to conduct data analysis, specifically procedures outlined by Charmaz (2014) which include
initial and focused coding. In the initial coding stage, the first author conducted line-by-line
coding. For example, an older man stated,
I was like my father…because our blood pressure was too high and we liked to eat salty
food…and also my friend as I heard from him about his eating. (P#7: a 60-year-old man
with 2 months of hypertension)
This quote was coded as (a) seeing oneself as being like others, (b) comparing blood
pressure to others, and (c) comparing eating behavior to others. After initial coding, incidents or
data were compared to other incidents or data. The codes and categories were compared across
interview, within interviews and with research literature to find points of similarities and
98
differences as the basis for category development (Charmaz 2014; Strauss & Corbin 1998). For
example, I used the code “seeing oneself as being like others” to compare with other interview
data and extant literature about risk perception. Then I recoded and modified the categories
based on relationship described by participants and observed by the researcher (Charmaz 2014).
After that, the research team reviewed the initial codes and gradually moved on to a more
abstract and interpretive stage of focused coding. During focused coding the most significant or
frequent initial codes were sorted, synthesized, integrated, and organized (Charmaz 2014).
Focused coding was performed after the research team met to discuss which initial codes made
the most analytic sense to categorize the data incisively. For instance, focused coding was used
to distinguish between the approaches that older men used to develop a personal sense of risk
into four main categories: “comparing provider information with stories,” “comparing one’s own
situation with stories,” “changing sense of personal risk,” and “changing risk-related behavior.”
Focused coding developed the relationships between categories (Charmaz 2014). The
relationship between categories was made clear creating visual representations or diagrams of
categories and their relationships. Constant comparison and memoing were used throughout
analysis process to condense and categorize codes and categories to facilitate theoretical
development (Charmaz 2014). Through this phase, constant comparison was used, for example,
interview statements and incidents were compared within and across interviews. Data were
compared and analyzed iteratively, constantly modifying categories and subcategories. As
saturation was approached, categories were organized into a logical, coherent emerging
conceptual model of developing a personal sense of risk. Out of four emerging categories, the
core category was selected based on its capability to capture the studies phenomena at a more
conceptual level and its interlinking with all remaining categories.
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Trustworthiness of the Study
To enhance rigor, the author used multiple strategies based on the evaluation criteria
outlined by Charmaz (2014). Credibility was satisfied by collaborative discussion among the
research team members regarding initial codes, emerging categories, and the evolving conceptual
model. An audit trail for documenting and reflecting on memos was used throughout the study
process. Quotes from multiple older men were reviewed. Member checking was used by the first
author during data collection and analysis to determine whether participants’ experiences were
accurately described by showing them components of the evolving conceptual model and asking
them whether their experience was represented, missing, or could be better described than what
was reflected in the model. Their feedback was used to both elaborate on and confirm the
conceptual model (Charmaz 2014). Concerning originality, we elected to focus on categories that
would offer new insights about developing personal sense of risk and provide a new conceptual
rendering example of the choice (Charmaz 2014). Finally, regarding usefulness, the data
provided critical information for health care providers to create nursing management strategies
that are sensitive to and reflect risk perception of older male patients.
Results
The analysis revealed ‘developing a personal sense of risk’ as a basic social process
engaged in by older Thai men following diagnosis of hypertension. Developing a personal sense
of risk was described as how older men perceived themselves to be at risk for complications of
hypertension. They perceived themselves to be at risk for complications of hypertension when
their situations aligned with stories of others who experienced a negative health outcome such as
stroke or renal failure.
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Developing a personal sense of risk, which emerged as the core category, can be
described as an ongoing process which was related to four sub-processes: comparing provider
information with stories, comparing one’s own situation with stories, changing sense of personal
risk, and changing risk-related behavior (Fig.1). The most important outcome gain achieved from
this developing a personal sense of risk was that older men changed their risk-related behavior.
Older men selected one particular risk outcome, used the selected risk outcome (stroke, heart
disease, kidney failure) to monitor their risk. In other words, risk outcome focus was the factor
that influenced how they determined their own risk. Older men’s sense of personal risk can
change over time by a number of factors including visible markers (e.g., subsequent cholesterol
levels), symptoms (e.g., diminishing symptom), and new stories.
The factor that acted at all sub-processes was the stories. The process of developing a
personal sense of risk can be influenced by stories that older men heard along the way. Older
men listened to stories that were from people they knew and about people they know or may not
know; for example, they heard from their friend about someone in another village who had
hypertension and stroke. Sometimes, they have accidentally heard stories and sometimes they
intentionally listened to stories about/from people with hypertension. The content of the stories
varied from the experiences of others who had already had a negative health outcome, to what
happened to others before getting bad outcomes, to the strategies that people used to manage
their hypertension. The stories were applied to their own, individual situation, because the older
men compared their personal situation with stories they heard. The stories they heard evolved
based on their personal risk outcome focus.
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Comparing Provider Information with Stories
At the time of diagnosis, all older men acknowledged receiving information about the
possible complications of hypertension from their health care providers. Older men were
reminded of complications at subsequent appointments. Based on what providers communicated
during these visits, older men had knowledge about and understood the risks related to
complications of hypertension.
Stories confirming or disconfirming provider information. At the time of diagnosis,
all older men recalled stories they had heard or seen about people with hypertension including
people who had experienced complications of hypertension. Every older man described a
process, beginning at the time of diagnosis, of engaging in comparisons between stories they had
previously heard or seen about people with hypertension and what providers told them. When
stories they heard were consistent or inconsistent with what providers were saying, they
described the stories as confirming or disconfirming information from providers. Comparisons
were particularly used to identify the risk of serious complications. Components in stories that
were most prominent in older men’ accounts included; the relationship of symptoms to
likelihood of complications, the importance of risk behaviors, and the importance of lab tests and
blood pressure reading.
The relationship of symptoms to likelihood of complications. When the stories they
recalled about other people who experienced bad outcomes/hypertensive complications, all
included presence of prior symptoms, the men discounted providers’ claims that symptoms were
not a necessary precursor of bad outcomes. This coupling of bad outcomes and symptoms even
suggested to some men that symptoms actually caused the bad outcomes.
102
The nurse told me about symptoms that we might not have symptoms…But I
thought severe headaches caused strokes…because I saw people with
hypertension who had strokes and they always had headaches…I thought
symptoms must happen before we had other problems. (P#13: a 62-year-old man
with 19 years of hypertension)
In contrast, provider information could be confirmed when stories they heard or saw
about people with bad outcomes included descriptions about bad outcomes without symptoms.
The nurse told me that it was not necessary to have symptoms. It was true
…because I saw my neighbor who had a stroke but he did not have any
symptoms before... (P#16: a 77-year-old man with 10 years of hypertension)
Risk behavior and complications. Pertaining to personal risk behavior, some older men
linked behaviors including eating salty or fatty food or not taking medication correctly with bad
outcomes when stories confirmed what providers said.
I listened to the nurse that if we ate excess salty and fatty food, bad
things came. I also heard this from my neighbor who ate too much salty
food and then he got “Rok Tai” (renal failure). (P#4: a 78-year-old man
with 5 years of hypertension)
103
However, in some cases, the relationship of behaviors to risk was a disconfirming story.
The nurse told me to quit smoking as it caused heart problems…But I saw my
friend who smoked; bad things did not happen to him. (P#6: a 72-year-old man
with 8 months of hypertension)
Lab tests, blood pressure measurements and complications. Others linked abnormal lab
tests (e.g. high cholesterol, abnormal renal function) and high blood pressure readings to bad
outcomes. They perceived that abnormal lab tests and high blood pressure reading caused the
bad outcomes when stories of other people with hypertension confirmed what their providers
said.
The doctor talked to me about high cholesterol and stroke. I knew…I also heard
someone had high cholesterol and then he had a stroke. I thought it made him
have a stroke. (P#9: a 70-year-old man with 7 years of hypertension)
Comparing One’s Own Situation with Stories
In this process, older men compared their own situation to the stories they heard or saw
about people with bad outcomes of hypertension, which informed the development of their
personal sense of risk. They selected the risk outcome focus before comparing their own
situation to others. Then, they compared their circumstances with stories they listened to,
104
particularly in relation to the bad outcome that they focused on. For example, they focused on a
stroke thus they compared their cholesterol to other patients who had had a stroke.
Determining risk outcome focus. Stories about other people they knew provided the
lens through which older men determined which complications they should be worried about or
what they feared the most. Stories were the condition that affected the determination of risk
outcome focus. Despite hearing about the range of possible outcomes from their providers, they
frequently focused on a single outcome, for example, they feared and worried about a stroke
after seeing someone who was paralyzed from a stroke, often largely ignoring the other possible
outcomes such as renal failure or heart disease.
I heard that someone with hypertension had renal failure. But I saw a man in my
village; he had hypertension and then had a stroke. He had paralysis and cannot
walk. I thought the stroke seemed more awful than renal failure because if I was
paralyzed by a stroke, I would not be able to walk, like him…I feared and needed
to be careful not to have a stroke. (P#7: a 60-year-old man with 2
months of hypertension)
A few, who knew someone with renal failure or heart disease, and saw what they went
through, tended to focus on those outcomes.
105
Someone in my village had kidney failure. I saw he needed dialysis. It seemed
awful to me…I didn’t want to be like him...I was concerned about
this problem (P#5:a 80-year-old man with 5 years of hypertension)
All older men focused on only one risk outcome, not multiple risk outcomes at the same
time. Most of them focused on a particular outcome over time. However, some older men shifted
outcome focus due to lab test results and/or hearing new stories.
Initially, I was concerned about stokes because I saw my neighbor had one and he
cannot walk. But when my blood (kidney function) was abnormal I thought
about my kidneys….I heard that it can make me have “Rok Tai”
(kidney failure). (P#19: a 79-year-old man with 8 years of hypertension)
Determining personal risk. Based on the outcome focus, older men started to determine
their own risk by using a risk comparison strategy and monitoring the particular risk they were
focused on. Components in their own situation that they used as basis for comparison of self to
others and determining their personal risk included; visible markers (blood pressure readings, lab
tests), symptoms, and involvement in personal risk behaviors. These were the conditions that
influenced the determination of personal risk.
The personal risk for stroke. Regarding the personal risk for stroke, most men compared
the blood pressure readings and cholesterol levels of the person who had experienced the bad
outcome, if they knew it, to their own blood pressure or cholesterol levels. Some participants
106
used presence or magnitude of symptoms as the basis for comparison and determination of their
own risk. In some cases, they compared behaviors, such as forgetting to take medication and
eating fatty food, between themselves and people they knew who had experienced bad outcomes.
When their experiences were aligned with others who experienced a stroke, their sense of risk
increased.
When I knew I had high cholesterol, I worried about a stroke. Someone I knew
had high cholesterol, dizziness and then had a stroke…I also had dizziness.
(P#12: a 73-year-old man with 6 years of hypertension)
He always forgot to take medication and then he had a stroke…I forgot to take
medication when traveling…when I did not take medication, blood pressure
would increase. It made me fear having a stroke. (P#17: a 60-year-old man with
2 years of hypertension)
The personal risk for heart problems. Older men who focused on heart problems tended
to monitor their cholesterol and blood pressure. They only saw themselves at greater risk for
heart disease if their cholesterol level and blood pressure aligned with stories about people they
knew with bad outcomes.
I worried about getting heart disease and my cholesterol and blood pressure
were high. My neighbor told me that others had heart disease due to high
cholesterol and high blood pressure…I checked my blood pressure every month
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and my cholesterol every year and compare to previous values…sometimes I
compared with my friend. (P#20: a 61-year-old man with 4 years of hypertension)
The personal risk for kidney problems. Concerning their risk for kidney problems, older
men who focused on kidney problems monitored lab tests for kidney function. When the lab
value aligned with a person they knew who had a bad outcome, they determined themselves as
being at risk for kidney failure.
My blood test was not good. Someone had abnormal kidney function and then he
had renal failure with dialysis. I was afraid as it might happen to me …I
rechecked it every year… (P#14: a 77-year-old man with 5 years of hypertension)
Changing Sense of Personal Risk
The process of changing sense of personal risk for major complications occurred as the
participants listened to, and integrated, new stories they heard over time with their own
experience and as they were told about lab tests. Most men described either listening more
deliberately to stories about/from people with hypertension, or seeking out stories deliberately as
they continued to develop their personal sense of risk. In most cases, sense of personal risk often
evolved over time, sometimes increasing and sometimes decreasing.
Conditions that impact change in sense of personal risk
Change in sense of personal risk depended on a number of conditions impacted, including
visible markers (lab values), symptoms, and new stories.
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Increasing sense of risk. Older men’ personal sense of risk can increase by monitoring
lab values connected to outcome focus and developing a new symptom which correspond with
stories, or hearing a new story.
Lab values. Older men’ sense of risk increased when their subsequent lab tests including
cholesterol levels and kidney function results were abnormal or higher than the previous results,
regardless of whether stories they heard had included any descriptions of lab values.
…Last year my cholesterol was higher than in the past. This made me worried
about it… because now I thought I had a higher risk than in the past. (P#27: a 67-
year-old man with 5 years of hypertension)
Developing new symptoms. Sometimes a personal sense of risk increased as a result of
developing new symptoms or experiencing an increase in the severity of symptoms.
Previously, I just had a headache. It was not severe…I could do my work and
felt better after taking medication. But I was very worried when I also
had severe dizziness, I feared to have a stroke. (P#15: a 65-year-old man with 2
years of hypertension)
Hearing a new story. When older men saw or heard stories along the way, they
reassessed their own risk, particularly when the stories aligned with their personal experiences.
Some older men became anxious when hearing other people’s experiences, especially when the
109
story paralleled their own experiences and resulted in a negative health outcome. For example,
after hearing a new story about someone who did not have prior symptoms, the individual would
reassess the relationship between presence or absence of symptoms and potential negative health
outcome.
I went to the hospital, I heard other patients talking about high cholesterol and
strokes…My cholesterol was high…I asked my friend who just recovered from a
stroke about his cholesterol. He had high cholesterol. It made me worry.
(P#22: a 77-year-old man with 10 years of hypertension)
Decreasing sense of risk. Decreasing sense of personal risk can also be influenced by
labs results, diminishing symptoms, and new stories.
Lab values. Older men experienced a diminished sense of risk when their subsequent
cholesterol levels or kidney function tests improved to within or near normal range after being
abnormal.
First time, my kidney function was not good. Then, last 3 years ago, It was better
... It made me think my risk for having kidney failure decreased. (P#28: a 70-
year-old man with 6 years of hypertension)
Diminishing symptoms. Reducing the severity of symptoms or having an absence of
symptoms can lower the sense of risk.
110
Previously, I worried about my dizziness. Sometimes it happened once a month
and I cannot go to my farm. After taking medicine from the doctor, I felt
better and I thought my chance to get bad outcome decreased. (P#29: a 68-year-
old man with 3 years of hypertension)
Hearing a new story. As older men heard or saw new stories about bad outcomes that did
not align with their situation, their sense of risk decreased, even though these new stories might
contradict earlier stories.
I saw my neighbor who drank alcohol had a stroke, I worried about a stroke.
Later, I heard my friend who drank but nothing bad happened to him. This made
me think it (stroke) might not happen to me, like him. So, I did not worry any
more. (P#24: a 75-year-old man with 3 years of hypertension)
Factoring in provider information. When new stories about bad outcomes aligned with
personal experience, increasing sense of personal risk, older Thai men in this study sometimes
reconsidered information from providers that they had previously dismissed. When this occurred,
the credibility of provider information increased and some began to reconsider information from
the provider, taking it more seriously and becoming more interested in risk behavior changes.
111
In the past, I never got dizzy… But later I started getting dizzy. I remembered that
the nurse told me but at that time I was not concerned. Also, my friend told me
that he had dizziness. It made me try to reduce salty food. (P#26: a 66-year-old
man with 3 years of hypertension)
When personal experience, stories from other people and provider information all
aligned, participants’ personal sense of risk increased significantly, often leading to new or
increased engagement in risk reducing behaviors.
Changing Risk-Related Behavior
All older men who personalized risk engaged in some behavior change to reduce their
risk. They often did this by using information from stories but using information from providers
only when stories and personal situation aligned with provider information. The strategies to
minimize their risks included: taking medication more reliably, making lifestyle changes, and
integrating traditional Thai and modern medicine.
Taking medication more reliably. Most men shared that they falsely reported taking
their blood pressure medication as prescribed when asked at medical visits; they usually reported
that they took medication every day, but in fact they did not take it as prescribed. However, when
older men’s sense of risk increased, they often started to take medication as prescribed. Some
older men described changing their behavior, for example, from forgetting medication due to
work schedule to carefully taking their medication as prescribed. Some who previously did not
believe their medical providers about the importance of taking medications as directed became
much more concerned about adherence.
112
Previously, I only took medications some days because I didn’t have any
symptoms. But in the last 6 months I fainted and I had very high cholesterol. I
heard my friend had high cholesterol and then he had a stroke. Then I started to
take it every morning. (P#11: a 65-year-old man with 4 years of hypertension)
Making lifestyle changes. After aligning their situations with stories, some older men
started eliminating salt and fat, exercising, quitting smoking, and reducing alcohol consumption.
Eliminating salt and fat. Older men who perceived themselves to be at risk especially,
when their symptoms and lab tests aligned with stories about bad outcomes talked about more
severely restricting salt and fat from their meals. They tended to determine their success at
following a restricted diet by comparing current to past eating habits.
Firstly, I did not reduce it because my blood pressure was not too high, no
symptoms…Until I fainted last 2 months and my cholesterol was high. I
feared having a stroke. I tried to reduce fatty diet and now I am not eating it.
(P#12: a 73-year-old man with 6 years of hypertension)
Exercising. Some older men felt that lack of exercise might put them at higher risk and
that too much exercise could lead to greater risk of a bad outcome, as they heard from stories that
someone died after too much exercise. Thus, the stories informed not only their level of risk but
also how they decided to manage their risk.
113
My blood pressure was too high. Then, I started cycling every morning. Since I
started exercising, my blood pressure decreased. I never did it over an hour
because I heard someone ran and he died and the nurse told me that didn’t
overdo it. (P#28: a 70-year-old man with 6 years of hypertension)
Quitting smoking and reducing alcohol consumption. Others who drank and smoked
perceived themselves to be at risk for stroke as they heard stories that these activities led to bad
outcomes. This prompted them to reduce or stop smoking and drinking.
My blood pressure was still high. First, I can only reduce it. But, I worried when
compared to my friend…He had a stroke. I tried and now I can stop it. (P#23: a
60-year-old man with 2 years of hypertension)
Integrating traditional Thai and modern medicine. Older men started with modern
medicine and took their medications at least some of the time. But when their blood pressure was
still high and they had some symptoms such as headache; a heightened sense of risk led them to
combine traditional Thai medicine with ‘western’ medicines. They combined traditional Thai
medicine with western medicine as they believed that traditional herbal remedies were natural
products, safe and free from any side effects and can help to reduce their blood pressure. Belief
in traditional medicines was influenced by traditional beliefs as they heard and learned from
older people in the village. Some older men thought that using only modern medicines might not
114
help to reduce their blood pressure. After using traditional medicines, most participants
rechecked their blood pressure, but others solely monitored symptoms as criteria to evaluate the
outcomes of remedies. They went to the community health center to obtain follow-up blood
pressure measurements because traditional healers cannot take blood pressures; they compared
blood pressure measurements between visits. Evaluating outcomes including blood pressure
measurement and symptoms monitoring was undertaken after they had been taking traditional
herbal medicine within a few months. Failure to achieve a good result encouraged participants to
try other traditional herbs until they achieved the desired outcome.
I took medication from the doctor. I used both… I used herb because it didn’t
have side effects and might reduce my blood pressure. My friends used it and his
blood pressure decreased. He told me to try. (P#21: a 66-year-old man with 1
year of hypertension)
Discussion
This grounded theory study highlights the process of ‘developing a personal sense of
risk.’ In this study, older men’s personal sense of risk is created by aligning their circumstances
with both stories and provider information about risk, which in turn influences their risk-related
behavior. Overall, the older men focused on a single health risk at a time, monitoring an increase
or decrease in their personal risk, leading to an increase or decrease in their sense of risk over
time.
115
Hearing and understanding the risks of hypertension from providers, did not translate into
personal sense of risk. This finding is consistent with Patil et al. (2013), who concluded that risk
awareness cannot predict risk perception; in their study, healthcare workers were aware of
hepatitis B infection but they did not perceive to have an occupational risk for hepatitis B virus
infection. The experience of our participants indicated that they knew the risks of hypertension
but did not perceive themselves to be at risk until their situation aligned with the stories they
heard from people they knew. However, a study by Vahasarja et al. (2015) found that patients
with type 2 diabetes did not believe they were at risk for coronary heart disease unless they were
told specifically by their primary health care provider that they actually had heart disease.
The findings of our study highlight the importance of stories. For older Thai men with
hypertension, these stories are substantially more powerful than medical provider information as
determine their personal risk for major complications of hypertension. Older men compared their
circumstances thoughtfully to those of other people they knew, especially to those who had
negative health outcomes. When their situation did not align with others or they considered their
disease not as severe, they perceived themselves as have low or no risk of hypertension
complications. Vicarious experience not only plays an important role in risk awareness, but they
also facilitate perception of personal risks (Wiethoelter et al. 2017). Notably, the current study
suggests that the stories older Thai men heard over time can diminish or heighten their
perception of personal risk.
In agreement with existing literature (Clay et al. 2016; Frich et al. 2006) findings from
this study suggested that other people’s experiences of hypertension-related complications
influenced personal risk. Knowing how such complications affected the other person’s work and
family life could add potency in raising older men’ awareness and perception of the risks
116
involved. Therefore, utilizing storytelling intervention is important because stories seem to be the
thing that has the most powerful in term of changing behavior and improving self-management
behavior. Previous studies reported that implementation of storytelling interventions such as
digital storytelling interventions improve self-efficacy, motivation for self-management, and
health behavior change among patients with chronic illness (LeBron et al. 2014; Njeru et al.
2015; Wieland et al. 2017). Through sharing of personal stories, persons attempt to give meaning
to their illness (Gucciardi et al. 2016) which could change the way they view their illness. Also,
it may yield changes in their approach to managing their condition and their health-related
behaviors. Existing studies recommended that before developing storytelling intervention, the
assessment of attitudes, knowledge, and behavior among patients as well as the identification of
champion storytellers (LeBron et al. 2014; Njeru et al. 2015). Moreover, the findings from this
study suggest that the assessment of individuals’ personal sense of risk should be considered.
According to the results, older men focused on one possible health outcome while
ignoring the others. Older men perceived their own risk based upon stories they heard about
specific risk factors and perceived themselves to be at risk for one risk outcome. However, Lee et
al. (2016) found that an individual’s perception of risk was influenced by an underlying process
of prioritizing threats. Participants perceived their degree of risk by considering all potential risks
and prioritizing them. They considered themselves to be at high-risk, or at little or no risk for
each potential risk.
Interestingly, in the current study, older men used a particular risk outcome to determine
and monitor their own risk, and decreased or continued to engage in risky behavior throughout
the hypertension journey. Perception of their personal risk for hypertension-related
complications differed among older men. For example, some older men believed that abnormal
117
blood tests actually led to bad outcomes while others focused on symptom presence. They
perceived that the presence of symptoms such as headaches or fainting would occur before a
serious complication such as stroke; this perception led them to alter their risk-related behavior.
These findings are consistent with a previous study which demonstrated that experiencing
symptoms contributed to self-management (Bennett 2013). Moreover, our study revealed that
older men acknowledged paying attention when experiencing symptoms that aligned with stories
about negative health outcomes.
Older men in this study believed that abnormal blood tests would give them time to
change behaviors. They actually started to manage their condition after experiencing abnormal
blood tests. It has been shown that cardiovascular and kidney failure risk perceptions were
significantly associated with reducing risk-related behavior among older men (Mohd Azahar et al
2017). This suggests that perception of personal risk turns out to be the key motivational drive to
support behavior change (Corneli et al 2014; Ferrer et al. 2018; Hein 2017; Liu 2014; Tonberg et
al. 2015; Wagener et al. 2014).
High personal risk perception appeared to be a motivator for changing behavior resulting
in a more cautious approach, such as eliminating salt and fat from their meals. This is consistent
with previous studies which found that risk perceptions is thought to play a key role in the
behavioral change as it appears to have encouraged individuals to engage in the protective
behavior (Clay et al. 2016; Lima et al. 2018; Saver et al. 2014). Low or wrong risk perception is
a major barrier to the adoption of self-management behaviors and, as a result, an additional risk
for the occurrence of other complications (Rouyard et al. 2017; Sachs et al. 2017). In addition,
findings from this study that risk behavior change followed personal sense of risk is consistent
with Protection Motivation Theory (PMT) which postulates that people are more likely to protect
118
themselves when anticipate negative consequences and have the desire to avoid them (Becker &
Maiman 1975).
A large body of literature on risk perception strongly suggests that when people feel they
are at greater risk, they tend to engage in self-management behavior or behavior changes (Clay et
al. 2016; Lima et al. 2018; Rouyard et al. 2017; Sachs et al. 2017; Saver et al. 2014). However,
previous studies did not look at how those risk perception involve and in response to risk
perception. Thus, findings from this study provides insight into how risk perception actually
develops and changes overtime.
Our results reveal that risk information from providers is unlikely to help older men
manage their hypertension-related risks. Consistent with previous findings, quantitative risk
information did not help patients with type 2 diabetes mellitus adopt and maintain healthy
behaviors (Saver et al. 2014).One noted contributor from the prior study is difficulty
understanding risk information; however, it is unclear how health information is delivered.
Interestingly, our study gives insight on how older men use risk information they receive from
providers to determine their perception of risk. They were concerned about provider information
only when it was confirmed by community stories or when their own experience aligned with
provider information. Provider information was used in reducing risk-related behavior based on a
particular risk outcome that they perceived themselves to be at risk. Thus, risk perception
overpowered information from providers.
From the finding of this study, it seems like information is sought out and passed on orally.
In other words, oral tradition is a source of information as older men rely on oral community to
get information about hypertension related-complication from other people. In Thai culture,
especially among older adults and someone unfamiliar with technologies or illiterate (e.g.,
119
people who live in rural communities), they learn orally through participation in story-telling and
ritual (Boonyiam 2015; Ketkowit et al. 2000). Previous studies suggested that Thai people,
traditionally, in order to seek information and treatment for their health problems have relied on
their family members, friends and neighbors (Pansuwan et al. 2014; Rattanawarang 2015;
Seesawang & Thongtang 2018; Udompittayason et al. 2015; Upatum 2016). They were less
likely to seek information from social media (Upatum 2016). In addition, they decided to seek
information from healthcare providers only when they experienced severe problems or
symptoms (Pansuwan et al. 2014).
Limitations
This study was conducted at only three community health centers in Phetchaburi,
Thailand. Findings from this study are representative of a small group of older Thai men with
hypertension who are living in rural communities. Therefore findings should be generalized with
caution. Additionally, further research is needed in other groups, across different cultures and
societies.
Future Research
The findings of this study describe the theoretical possibilities of developing a personal
sense of risk. More research is needed to examine how a personal sense of risk affects long-term
risk-related behavioral change. As stories seemed to have power, researchers could further
investigate characteristics of story tellers and whether it mattered in terms of weight of the story
and impact on older men’s personal sense of risk. Researchers could develop and investigate the
effects of storytelling intervention on appropriateness of perception of personal risk, attitude, and
behavior change. Other researchers may wish to develop a tool to assess a personal sense of risk
120
which includes perceived risk. In addition, future research could explore why information about
complications of hypertension from healthcare providers has less power than the information
from stories. Finally, there is also a need for research to further explore what about family
influence and personal sense of risk.
Conclusion and Implications for Nursing Practice
The core category, developing a personal sense of risk, explains how older men with
hypertension obtain a sense of risk and achieve risk-reduction behavior. The most important
motivation for increasing sense of risk and adhering to risk-reduction behavior is the alignment
of their own situation with community stories about negative health outcome and provider
information. To determine and monitor personal risk over time, older men tend to focus on a
particular outcome. Healthcare providers can play an influential role in perception of risk for
complications of hypertension among older men with hypertension. It is important to the nurses
to understand what risk outcome they focus on and why they focus on that risk outcome. Nurses
should assess personal sense of risk by using a standard tool because this information can be
useful in encouraging behavior change. Also, providers should individualize the delivery of
medical information about hypertension complications, by initially addressing the medical
outcome most concerning to the patient; this will facilitate the desired behavioral change. The
information might help to improve older men’s understanding of hypertension-related
complications, which would enable them to reassess their own risk and make informed choices
about their hypertension care. Since stories are very powerful, the nurses should assess the
stories that older men have heard or seen, so they can design and test effective storytelling
interventions to promote treatment adherence.
121
Implications for Nursing Policy
Our findings can be used as baseline data to raise awareness for healthcare professionals.
Healthcare professionals should include these older men in their plans when designing and
developing hypertension care management programs. Health policy nurses, nursing educators,
managers and researchers should work together to develop a measurement tool to assess
individual’s personal sense of risk for hypertension-related complications to be implemented in
Thai community health centers. The policy for hypertension care is required to develop as an
individualized policy by considering individual’s perceived risk, powerful story, and the nature
of the disease, and these factors should be added in hypertension care model in Thailand.
Hypertension care policy needs to be updated in order to achieve the goals of the national and the
WHO-CDC Global Hearts Initiative for decreasing the burden of cardiovascular disease. Nursing
education should incorporate the concepts and process of risk perception in curricula at both
undergraduate and post-graduate programs in Thailand in the future, in order to prepare nurses at
different level to understand and provide male-focused gender-specific care.
Acknowledgements
Special thanks to all dissertation committee members. The primary author also wishes to
thank the University of Wisconsin-Madison School of Nursing, for the Eckburg Research
Award, and all participants who kindly gave their time to participate in this study.
Conflict of Interest
The authors declared no potential conflicts of interest.
122
Author Contributions
Study design: JS, BW, NS; data collection: JS; data analysis: JS, BW; study supervision:
BW, NS; manuscript writing: JS and critical revisions for important intellectual content: JS.
123
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Table 1. Baseline Participant Characteristics (Total sample: n 29)
Characteristic Number of participants (%) Age range (years) 60-69 16 (55.17)
70-79 12 (41.38)
80-89 1(3.45)
Religion Buddhism 29 (100)
Marital status Single 2 (6.90)
Married 21 (72.40)
Widow 4 (13.80)
Divorced 2 (6.90)
Education level Primary school 24 (82.76)
Secondary school 3 (10.34)
College graduate 2 (6.90)
Employment status Agriculture 10 (34.48)
House work 19 (65.52)
Time with Hypertension Diagnosis Less than 1 year 3 (10.34)
1-5 years 17 (58.62)
6-10 years 6 (20.69)
11-15 years 1 (3.45)
16-20 years 2 (6.90)
Comorbidity
Diabetes mellitus 5 (17.24)
Dyslipidemia 4 (13.79)
Ischemic heart disease 1 (3.45)
None 19 (65.52)
Health service mostly used Primary care unit 26 (89.65)
Community hospital 2 (6.90)
Private clinic 1 (3.45)
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Figure 1. Developing a Personal Sense of Risk.
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Chapter 5
Summary
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This dissertation study has made significant contributions to the field of perception of
risk of chronic disease among older male patients. This dissertation study fulfills the aim of
gaining a deeper understanding of the experiences of older men living with hypertension. This
study provides valuable insights into how older men view their risk of developing hypertension-
related complications and the resulting degree to which they cope with hypertension in daily life.
Understanding the experience of individuals living with hypertension can help healthcare
providers develop and improve a holistic approach to caring for such patients.
Summary of Findings
Based on an integrative literature review (paper 1), I learned that men with hypertension
who experience symptoms and had other diseases such as diabetes were more likely to adhere to
treatment as they perceived their health was at risk. However, how older male patients with
hypertension develop a personal sense of risk has not been studied. As shown in this integrative
review, there is a large body of existing research focusing on risk awareness among men with
hypertension, and all studies were conducted in urban areas of developed countries. The research
findings showed that even though most men had knowledge about complications of hypertension
they still were unlikely to adhere. Thus, we were left with three important unanswered questions:
(1) Why does having knowledge about one’s risk of hypertension not always lead to treatment
adherence? (2) How do older men living in rural areas develop a personal sense of risk for
developing major complications of hypertension and what factors contribute to this
development? (3) How does this sense of risk motivate older male patients living with
hypertension in rural areas to change their behavior? These questions derive from a lack of
research about the development of a sense of risk among older men living with hypertension in
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rural areas. As such, this integrative review provided evidence for the importance of this
dissertation.
From the systematic review of qualitative studies (paper 2), I learned that hypertension
self-management is a multifaceted challenge for people with hypertension. Moreover, I learned
that an individual’s ability to self-manage is influenced by personal, community and
organizational-related factors. Nevertheless, there is little knowledge about what factors
contribute to the self-management of hypertension among older male patients. In this systematic
review, none of the qualitative research studies separated male and female results or specifically
investigated the factors that influence self-management capabilities in male patients. Also, I
learned that older patients in rural communities, especially men, self-manage their hypertension
less well than older patients in urban communities. However, prior studies have not been
reported experience of men in rural area and factors influencing their hypertension self-
management behavior. Therefore, there are some questions that need to be answered: (1) What
factors contribute to the ability to self-manage hypertension among older men? and (2) How do
these factors affect the ability of older male patients living in rural areas to cope with
hypertension and change their behavior or how these factors operate in their daily lives? Thus,
this systematic review revealed gaps in current knowledge for this dissertation study.
Developed using a grounded theory approach, an innovative conceptual model labeled
‘developing a personal sense of risk’ fosters an understanding of this sense of personal risk for
developing major complications of hypertension among older Thai men living with hypertension
in rural areas. Based on the analysis, ‘developing a personal sense of risk’ emerged as a basic
social process engaged by older Thai men with hypertension living in rural areas. This process
comprises four sub-processes. When an individual received a diagnosis of hypertension, they
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listened to risk information from providers, which led them to ‘compare information to the
stories’ they had heard from other people, ‘compare one’s own situation with stories,’ ‘change
one’s personal sense of risk,’ and ‘change risk-related behavior.’ Although they were aware of
the multiple negative potential outcomes, each one focused on one particular outcome, such as
stroke or renal failure. They used this outcome to determine and monitor their personal risk over
time by comparing their own circumstances with those of others. Their sense of risk increased
when their personal situation aligned with stories that reported negative health outcomes. More
active engagement in behavior changes occurred when their personal situation, the stories, and
provider information all aligned.
Based on this study, personal sense of risk appears to be a partial solution for addressing
the challenges of treatment adherence. We knew from the previous studies that perception of risk
influences one’s ability to self-manage hypertension (Bennett, 2013; Elbur, 2015; Long, Ponder,
& Bernard, 2017; Welsh, Duff, Campbell-Taffe, & Lindo, 2015), but we did not understand how
they develop a personal sense of risk and how one’s personal sense of risk influences the ways
older men manage their hypertension. Thus, this study contributes to filling these knowledge
gaps. In addition, findings from this study suggest that stories are so powerful in developing a
personal sense of risk and risk-reduction behavior. Therefore, another solution for non-adherence
could be the creation of storytelling interventions that convey a person’s narrative and
experiences. The use of storytelling interventions is premised on the fact that each individual has
his or her own unique experiences living with and managing a disease (Gucciardi, Jean-Pierre,
Karam, & Sidani, 2016). Thus individuals’ accounts are a valuable information source to both
themselves and others. Listening to the stories can assist persons to reflect on their own
experiences and recognize others may be experiencing similar struggles and circumstances. This
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enables pertinent information to be disseminated on how to deal with or manage their condition.
Therefore, this dissertation study contributes to understanding the development and influence of
perception of personal risk on hypertension management in daily life among older men.
Implications
The findings from this study highlight the importance of assessing a personal sense of
risk, as it affects the specific behaviors of older men. Thus, a reliable tool for measuring the
personal sense of risk needs to be designed, developed, and standardized. Since a personal sense
of risk changes longitudinally among older men, a personal sense of risk assessment should be
performed at various times such as with changes in lab tests or symptoms.
Additionally, the finding that older Thai men focus on one particular risk outcome or bad
outcome suggests that they ignore other bad outcomes. Therefore, to address this situation, risk
communication approaches should be developed aiming to improve older Thai men’s
understanding of hypertension-related complications, which would enable them to reassess their
own risk and make informed choices about their hypertension care. A personalized hypertension
risk communication method should be developed to promote treatment adherence and healthy
lifestyle behavior among older Thai men. From this study, older Thai men also perceived that
their symptoms cause bad outcomes. Thus, older men’s sense of their personal risk for
developing hypertension complications needs to be assessed or measured to see whether it is
incorrect or correct. Healthcare providers should provide simple and clear information on the
cause of complications, consequences of complications, and on what actions can be done to
reduce the risks of developing complications.
This study suggests it is important to develop a storytelling intervention because the
stories of other hypertensive patients influence older men’s personal sense of risk and
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hypertension management. Therefore, there is a major need for story-based interventions to
support disease self-management among older men living with hypertension. Listening to
personal stories about hypertension can assist individuals to reflect on their own experiences and
connect with others who experience similar struggles and circumstances, supporting self-
management (Gucciardi et al.2016).
Future Direction for Research
This study provides a foundation for future research about men living with hypertension.
Based on the findings of this study, a personal sense of risk influences risk-related behavior
change among older men with hypertension. Thus, future research can examine how a personal
sense of risk affects long-term risk-related behavioral change.
Based on the findings, older men listen to the stories of other hypertension patients, and
those stories have the power to influence risk outcome focus, personal risk perception, and risk-
related behavior changes. Therefore, future hypertension studies should investigate interventions
that integrate storytelling to foster and maintain behavioral changes to lower blood pressure and
reduce and prevent complications of hypertension among older men. In addition, researchers
could investigate the effects of storytelling intervention on accuracy of perception of personal
risk for developing complications of hypertension, attitude and behavior change in men with
hypertension.
There is also a need to further explore why information about risk of hypertension from
healthcare providers has less influence on older men living with hypertension than the
information from stories. In this study, I did not explore this phenomenon; thus, it is unclear
what older men think about the risk information received from their healthcare providers.
Moreover, researchers could explore healthcare providers’ experiences with and strategies used
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for risk communication with older men with hypertension. Additional future directions include
investigating the family’s influence on one’s personal sense of risk
The ‘developing a personal sense of risk’ model also can be used to develop hypotheses
and hypothesis testing regarding the relationship between a personal sense of risk and behavior
change, which could then be replicated in other rural populations or with other chronic illnesses.
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