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

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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.

100

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

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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.

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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.

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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.

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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.