Qualitative Research a. Read the posted article below. b. Respond to the questions below by reviewing the article and identifying

Tan CS, Hassali MA, Neoh CF, Saleem F. A qualitative exploration of hypertensive patients’ perception towards quality use of medication and hypertension management at the community level. Pharmacy Practice 2017 Oct-Dec;15(4):1074.

https://doi.org/10.18549/PharmPract.2017.04.1074

www.pharmacypractice.org (eISSN: 1886-3655 ISSN: 1885-642X) 1

Abstract Objective: This study aimed to explore hypertensive patients’ perspectives on quality use of medication and issues related to hypertension management at the community level in Malaysia. Methods: Focus groups discussion was employed in this qualitative study. A total of 17 hypertensive patients were purposively recruited. Three focus group discussions with semi-structured interview were carried out at Flat Desa Wawasan, Penang. All the conversations were audio recorded, transcribed verbatim and thematically analysed. Results: Three major themes were developed, including medication adherence among hypertensive patients, self-management of hypertension and patients’ knowledge towards hypertension. Poor medication adherence was found and different strategies were taken to overcome the barriers towards adherence. Use of herbal and traditional therapies was perceived as alternative method in controlling blood pressure instead of taking antihypertensive medication. The participants were found to have poor knowledge on side effect and mechanism of action of hypertensive medication. Conclusions: The misconception about the side effect of antihypertensive medication has led to poor adherence among the participants. Lack of knowledge on targeted blood pressure level has led to poor blood pressure monitoring among the participants. Health awareness program and counselling from health care professional should be advocated among the hypertensive patients in addressing the above gaps.

Keywords Hypertension; Medication Adherence; Patient Medication Knowledge; Health Knowledge, Attitudes, Practice; Focus Groups; Qualitative Research; Malaysia

INTRODUCTION

Hypertension is one of the renowned risk factors contributing to cardiovascular disease, including stroke, arrhythmias, coronary heart disease and myocardial infarction.

1 About 1.39 billion adults worldwide were

diagnosed with hypertension 2 in 2010 and the number is

predicted to increase to 1.56 billion by year 2025. 3 More

than half of the hypertensive patients were unable to achieve well-controlled blood pressure level despite the recent advancement in the antihypertensive treatment.

4

Poor medication adherence is one of the contributing factors that caused uncontrolled blood pressure level among hypertensive patients.

5-7 The rate of medication

adherence in many developing countries including Malaysia was reported lower when compared to developed countries.

8-11

Likewise, in 2015, 30.3% of the Malaysian adults (i.e. 18 years and above) had hypertension, with 13.1% of known hypertension and 17.2% of undiagnosed hypertension.

12 Of

note, only 26.8% of these hypertensive patients had their blood pressure under control

13 and up to 46.6% of them

were reported to have poor medication adherence. 14

A recent local study revealed that a total of 20,799 excessive pills were returned by hypertensive patients at a single Malaysian government hospital, with a total cost of (Malaysian Ringgit) MYR 4,362.28 (equal to USD 1037) was wasted during the 8 months of study period with an average wastage of MYR 42.35 (equal to USD 10) per patient; changing medication by the doctor and death of patients were the most common reasons accounted for the wastage.

15

Low rate of adherence to antihypertensive medication has significantly increased blood pressure and was associated with higher rate of hospitalization and mortality.

16 Previous

studies have found that many hypertensive patients did not adhere to antihypertensive medication because they had wrong perception towards hypertension or they were unconfident with their antihypertensive medication such as concern of potential adverse effects.

17-19 Lack of knowledge

about usage of medication and various misleading perceptions of hypertension management have resulted

Original Research

A qualitative exploration of hypertensive patients’ perception towards quality use of medication and hypertension management at the community level Ching S. TAN , Mohamed A. HASSALI , Chin F. NEOH , Fahad SALEEM . Received (first version): 18-Jul-2017 Accepted: 15-Nov-2017 Published online: 18-Dec-2017

Ching Siang TAN. Bpharm, MSc (Pharmacy Practice). Program Coordinator. School of Pharmacy, KPJ International College. Penang (Malaysia). [email protected] Mohamed Azmi Ahmad HASSALI. BPharm (Hons), M.Pharm (Clin Pharm), PhD. Professor of Social and Administrative Pharmacy. School of Pharmaceutical Sciences, Universiti Sains Malaysia. Penang (Malaysia). [email protected] Chin Fen NEOH. BPharm (Hons), MPharm (Clinical Pharmacy), PhD. Senior Lecturer. Faculty of Pharmacy, Universiti Teknologi MARA. Selangor (Malaysia). [email protected] Fahad SALEEM. BPharm (Hons), M-Phil (Pharmacy), MBA, PhD. Associate Professor. Faculty of pharmacy & Health Sciences, University of Balochistan. Quetta (Pakistan). [email protected]

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Tan CS, Hassali MA, Neoh CF, Saleem F. A qualitative exploration of hypertensive patients’ perception towards quality use of medication and hypertension management at the community level. Pharmacy Practice 2017 Oct-Dec;15(4):1074.

https://doi.org/10.18549/PharmPract.2017.04.1074

www.pharmacypractice.org (eISSN: 1886-3655 ISSN: 1885-642X) 2

inappropriate use of medication especially medication adherence among community-dwelling hypertensive patients.

20,21 Furthermore, there is a paucity of local data

about hypertensive patients’ perspective towards quality use of medication and hypertension management at the community level. Hence, this study aims to explore hypertensive patients’ perspectives on quality use of medication and issues related to hypertension management among community-dwelling hypertensive patients in Malaysia. The generated local data from this study is anticipated to yield different views from previous studies, such as poorer knowledge among local hypertensive patients towards hypertension management compare to the developed country

17 and different

perspective towards quality use of medication compare to the research studies from the Asia countries.

18,22 The

emerged findings from this study will be useful for healthcare provider and policy maker in the treatment of hypertension.

METHODS

Study Design

This study adopted qualitative methodology via focus group. This qualitative study was based on the COREQ Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups.

23 Phenomenology approach was utilized in this

study to develop an understanding about patients’ view on medication and hypertension management. Phenomenology approach involves the use of the meanings of living experiences and it is essentially “consciousness of” or an “experience of another”.

24 Phenomenological

analysts provide a close examination platform of individual experiences to capture the meaning and common features, or essences, of an experience or event.

24 The content of

focus group with semi-structured interview guide questionnaire was prepared based on literature reviews on patients’ hypertension management and earlier work on patients’ perceptions on quality use of medication.

17,18,25,26

Three focus group discussions were carried out from August 2015 to September 2015.

In order to achieve the objectives of focus group discussion, the content of semi-structured interview was developed based on the English literatures

17-19,22 which have

highlighted the global hypertension management and quality use of medication issues encountered by the hypertensive patients. The participants were asked with the semi-structured questionnaires and they were encouraged to interact with each other, exchange ideas and issues based on their experiences or points of view.

27

The questions were developed in English and translated into Malay language (the national language) by a professional translator from a local university. Backward translation from Malay language into English language was conducted by another independent translator who was different from the forward translator. The purpose of back translation is to maintain the quality control in step demonstrating. To ensure the inter-translation validity and similarity of conceptual during the translation, harmonization is an important process to discuss the

inconsistencies and discrepancies between the source and the target language versions. The questions were prepared in an open ended format and were pre tested for content validity, face validity, and clarity by three pharmacists with vast experience in pharmacy practice research and further adjusted after pilot testing with five patients with hypertension in Penang who were not part of the study target population. The topic of discussion was then sent to an independent experienced moderator for further cleaning. The moderator ensured that topics to be discussed are up to the level of patients.

Study Sample and Setting

This study was conducted at Flat Desa Wawasan. Flat Desa Wawasan is a low cost flat which accommodates about 3000 residents in Bukit Mertajam, Penang, Malaysia. With the collaboration Penang Family Health Development Association (FHDA) Non-governmental Officer (NGO), this study could have an established relationship with the participants in order to produce a better quality focus group discussion.

23 FHDA is one of the NGO with non-profit,

voluntary citizens' group which is organized on a local, national or international level. Posters invitation were put on the notice board one month prior the event and those hypertensive patients who were interested in this program contacted the researchers. Participants were recruited by using purposive sampling method. The selected participants represented variation of characteristics and the potential to provide rich, relevant, valid and generalizable information. Hence, the selection of the participant was based on age, living status and the different range of blood pressure levels. The inclusion criteria were the following: being diagnosed with hypertension by a registered medical doctor for at least six months ago, treated with antihypertensive medication for the past three months prior to the study and aged 18 years old and above. Patients with enduring mental health problems or cognitive impairment were excluded. Initially 20 participants were invited to participate in the focus group discussion, but three participants did not turn up in the discussion due to time constraint. Eventually a total of 17 participants were divided into three groups which followed the standard guideline.

28,29 A focus group comprises of 4-8 people are

usually recommended 30

as group exceeded than eight people are difficult to control.

28

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

Information sheet was explained and signed informed consent was obtained prior to the commencement of focus group discussion. The researcher with experience of a qualitative research in a previous study

31 , played a role as

moderator and was assisted by six pharmacy students and two NGOs in the focus group discussion. The participants

Tan CS, Hassali MA, Neoh CF, Saleem F. A qualitative exploration of hypertensive patients’ perception towards quality use of medication and hypertension management at the community level. Pharmacy Practice 2017 Oct-Dec;15(4):1074.

https://doi.org/10.18549/PharmPract.2017.04.1074

www.pharmacypractice.org (eISSN: 1886-3655 ISSN: 1885-642X) 3

comprised of Malay, Chinese and Indian hypertensive patients and some of the Indian participants did not understand English and Malay languages. Moreover, some of the participants were old and weak in listening. Therefore the six Indian students assisted the Indian participants in the translation of questionnaires.

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

In order to achieve the objective of focus group discussion, the participants were encouraged to interact with each other, exchange ideas and issues based on their experiences or points of view.

27 Malaysia is a multi-racial,

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

Ethical Approval

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

Data Analysis

After the focus group discussion, all the conversation were transcribed verbatim into Malay language while listening to the audiotape by the two project assistants and the data were counterchecked by the researcher. The field notes were referred during transcribing process. The transcriptions were translated into English by two appointed translator and back translation was performed to ensure correctness and reliability in linguistic. Textual data were explored using content analysis method. Textual data were read several times by the researcher to identify themes and categories. Numerous codes were identified and relevant quotes were categorized under each code. “Open coding” procedure was carried out by writing down as many categories as necessary to address all aspects of

the content. In order to reduce the number of categories, the listed categories were filtered by rearranging based on the priority to produce a new list of categories and sub- headings. At the same time, another researcher carried out the same procedure independently to generate the category system. Then the two lists of categories were compared and adjustments were made when necessary. The final list of categories and sub-headings was compared again with the original transcript to ensure all aspects of data were identified and tested for constant comparison. When there were no new themes identified, a conclusion would be made at this saturation point. In order to add validity to the study, the research findings were presented to the participants and feedback were taken to ensure the participants’ own idea and perception were represented and not curtailed by researchers’ own agenda and perspective.

RESULTS

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

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

Theme 1: Medication adherence among hypertensive patients

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

Table 1. Participants’ demographic characteristics

Description N (%)

Gender Male 1 (5.9%)

Female 16 (94.1%)

Age (years) 31-40 3 (17.6%) 41-50 1 (5.9%) 51-60 8 (47.1%) 61-70 4 (23.5%) 71-80 1 (5.9%)

Occupation Private 4 (23.5%)

Unemployed 13 (76.5%)

Living status Alone 5 (29.4%)

With family 12 (70.6%)

Blood pressure level 50

[mmHg] Optimal (SBP < 120 and DBP <80) 3 (17.6%) Normal (SBP < 130 and DBP < 85) 3 (17.6%)

High normal (SBP 130-139 and/ or DBP 85-89) 2 (12.0%) Hypertension stage I (SBP 140-159 and/or DBP 90-99) 3 (17.6%)

Hypertension stage II (SBP 160-179 and/or DBP 100-109) 3 (17.6%) Hypertension stage III (SBP ≥ 180 and/or DBP ≥ 110) 3 (17.6%)

Duration of hypertension (years) 1-5 5 (29.4%)

6-10 6 (35.3%) >10 6 (35.3%)

Tan CS, Hassali MA, Neoh CF, Saleem F. A qualitative exploration of hypertensive patients’ perception towards quality use of medication and hypertension management at the community level. Pharmacy Practice 2017 Oct-Dec;15(4):1074.

https://doi.org/10.18549/PharmPract.2017.04.1074

www.pharmacypractice.org (eISSN: 1886-3655 ISSN: 1885-642X) 4

i) Medication adherence

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

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

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

However, four participants did not take medication every day. Three participants missed antihypertensive medicine for 2 to 3 days in a week. The reasons given were too busy

Table 2. Patients’ quotes about their views on quality use of medication and hypertension management

Subthemes Quotes

Routine-lifestyle I take medicine every day. Never forget. (P1, P16,P17,P18) I take medicine every day. I never forget to take medicine. (P2) I take medicine everyday even though I brought my medicine during visiting to relatives’ houses. (P3) Sometimes I forgot to take medicine. About 2-3 days in a week I forgot to take medicine. (P4) I only take hypertensive medicine 2-3 days in a week (P13) Sometimes when I felt tension then I take medicine. (P5) I rarely took medicine because I have many concerns about medicine especially it would interfere with my thought and turn to be less intelligent. (P12) Yes I bought medicine for migraine and headache only. (P7) Never stop medicine because I am the only one who diagnosed with high blood pressure. (P10) I also never share antihypertensive medicine because it may cause death. (P14) I took my medicine every day before going to work as a habit. (P5) I must be remembered to take medicine every day as have been suffering from high blood pressure. (P8)

Factors affecting medication compliance

Suppose my antihypertensive medicine should be taken after meal but sometimes I took it before meals. (P1,P3,P8) I am afraid to take medicine before meal because I felt stomach empty. (P5,P7,P9) In early morning, I take all medicines at once before going to work although some of the medicines should be taken either before or after meal. (P10) I don’t care whether the medicine need to be taken before or after meal (P15) I was bored with the medicine. (P5) Feeling tired because I had been taking medication for a period of 10 years. (P8) I felt nausea when taking medicine (P16) Sometimes I feel tired and afraid of hair loss. (P6) I fear the side effects of the drug and the consequences of causing cancer, so I will eat more fruit like apples rather to take antihypertensive medicine every day. (P4) I think my high blood pressure medicines are not suitable to me. It causes me headache and dizziness. So I did not take it regularly. When I felt uncomfortable and backache, then I will take the medicine, otherwise I would not take it. But every month I still collect my hypertensive medicine from hospital. (P5)

Barriers No problem because family members were willing to send me to hospital. (P13) I have vehicle to go to the hospital. (P14) I don’t have problem of transportation. (P15) I have problem in getting transportation because hospital is too far. (P15) I have problem of transportation. (P16)

Facilitator/ reminder I have problem of transportation but a nurse (NGO officials) will help the patient to collect medicine from hospital, so I share my medication problem with her (P2,P4,P14) I prefer to share my medication problem with member of the NGO because they know me well. (P5, P9) I like to discuss medication problem with Ms. Jaya (NGO officer)who always take medicine for me (P3,P6, P8) I have chosen pharmacist because they are drug expert. (P8) I would happy talk my medication problem with NGO who can remind me to take medicine. (P13) I will share my medication problem with NGO officer. (P17) I keep in a plastic bag. I will write or record in a book when taking medicine to avoid from forgetting because I am stroke patient. (P9)

Financial I have no problem because I received medicine from government hospitals. (P3)

Side effect I have hair loss problem after taking antihypertensive medicine. (P9) I felt uncomfortable and also feel dizzy. (P14) I felt drowsy, sleepy and tired. After wake up from sleeping, I felt normal. (P16)

Storage I keep inside refrigerator and on the refrigerator.(P3) I keep in the cabinet at home. (P6) I prefer to put inside tupperware containers (P8) Now hospital only supplies 1 month medicine, so not much medicine need to be kept in house. (P12)

Solutions I will sit and relax. Then I will eat Panadol ® (Paracetamol). (P12)

I will take Paracetamol when high blood pressure cause me headache (P2,P5) I will go to pharmacy buy Panadol

® if high blood pressure cause me headache (P7)

I will take my high blood pressure medicine together with Panadol ®

when headache (due to high blood pressure) (P14,P17) I will take Tramadol

® medicine. (P3)

I would feel very emotional and angry when my blood pressure is high. Then I will take high blood pressure medicine and then sleeping. (P9) I will sit at a side and rest (P4) I prefer have a rest when feel headache (due to high blood pressure) (P8)

Tan CS, Hassali MA, Neoh CF, Saleem F. A qualitative exploration of hypertensive patients’ perception towards quality use of medication and hypertension management at the community level. Pharmacy Practice 2017 Oct-Dec;15(4):1074.

https://doi.org/10.18549/PharmPract.2017.04.1074

www.pharmacypractice.org (eISSN: 1886-3655 ISSN: 1885-642X) 5

with work, concerned about side effect of medication, bored with the medication and felt inappropriate use of their antihypertensive medication by doctor.

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

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

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

confused with the item to be taken with empty stomach or after food.

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

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

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

Table 2 (cont.). Patients’ quotes about their views on quality use of medication and hypertension management

Subthemes Quotes

Herbal/ alternative medicine I used to eat a traditional medicine in the form of seeds to control blood pressure. (P9) I like to take herbal medicine to control my high BP (P2,P15) I used to take the herbal medicine / traditional medicine in the form of small tablet to control my high blood pressure (P13) I prefer to visit Chinese Sinseh to get some herbal medicine to control my high blood pressure. (P8) I always take my herbal supplement to control my high blood pressure (P10) I trust to herbal medicine and that’s why I always keep it at my house and take it to control for my high blood pressure. (P14) I will drink Chinese tea to “wash” my blood. (P1) I have never taken herbs, herbal remedies or traditional medicine to control blood pressure. (P5) I don’t take herbal medicine to control my high pressure (P3, P11,P12) I am not familiar with herbal medicine. (P17)

Checking of blood pressure I check my blood pressure (level) at every month. (P4) I check blood pressure level at every 3 to 4 month which is during my appointment with doctor. (P6)

Signs and symptoms I felt dizziness and sleepy. (P6) I would have a feeling of dizziness and tightness at the neck after eating beef which may increase my blood pressure. (P9) I was notified by doctor when my blood pressure increased. (P7) When I forgot to take medicine, I would feel the symptoms like dizzy and neck stiffness. Then I would take high blood pressure medication. (P2) I feel dizziness and headache (P3,P4) Definitely is dizziness (P5) Dizziness and headache! (P8) I think is dizziness. (P10) Obviously is dizziness (P11,P12) I felt sweating and headache (P13) I felt hot and sweating then start heachache (P14) Sweating….headache and blur vision (P16)

Learning I got the knowledge from education talk and health briefing. (P8)` My NGO officer always share with me the knowledge of hypertension. (P15, P16) I always receive hypertension counselling from hospital pharmacists. (P13) I always join to the education talk nearby my house (P1) I like to attend educational talk (P3, P5) The health talk gave me a lot information (P6) I learn hypertension management from the health education talk (P2) Definitely education talk taught me a lot (P7) I received a lot of information (hypertension management) from TV (television) and radio. (P12) TV and Radio gave me a lot health information (P8, P17) I used to read health information from Facebook (P10)

Medication recognition I do not know the name of the drug, but usually takes a sample of the drug. (P7) I have forgotten and do not know the name of the medicine. (P8) I do not know. I just take medicine by looking at the shape and physical characteristics of the medicine. (P12) I don’t know the name of medicine but is round and white color. (P1) The name is too long, I don’t know and even remember. (P3) For me, the name of medicine is too hard to remember but my medicine is round shape. (P9) I don’t remember the name. (P11) I only remember the share and logo on my medicine (P13) My hypertensive medicine is pentagon shape. (P14) My medicine shape like Panadol shape and white color. (P16) I don’t even know the name of medicine. (P17)

Tan CS, Hassali MA, Neoh CF, Saleem F. A qualitative exploration of hypertensive patients’ perception towards quality use of medication and hypertension management at the community level. Pharmacy Practice 2017 Oct-Dec;15(4):1074.

https://doi.org/10.18549/PharmPract.2017.04.1074

www.pharmacypractice.org (eISSN: 1886-3655 ISSN: 1885-642X) 6

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

“I was bored with the medicine”. (P5)

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

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

Five participants were reluctant to take antihypertensive medicine regularly due to some concerns. However, these participants conti

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