Pressing need to fully explain hypertension
MEDICAL MATTERS:Preventive interventions are commonly ignored
“It is the burden of my family. BP is a sort of. . . Actually it doesn’t make a difference how you call it: BP or worrying too much; it seems to be the same thing.”
“When I got on medication I felt a change for the better in 14 days . . . the headache lifted and I felt 95 per cent well . . . and that’s where it’s at. It hasn’t changed since then. It’s not headache, it’s a heaviness which makes you constantly aware of the fact that there is something wrong. It’s like a chunk of lead swimming around inside the head and I can feel in the teeth and in my gums and when I’m sitting quietly in a chair I can feel the pumping pressure.”
“I dropped them . I didn’t last long with them. I said to myself, ‘I’ll try to fix my pressure myself’ . . . . I worked with doctors. They told me that I would end up having to take them but I didn’t want to. . . . I’m not a big pill-taker.”
THESE ARE quotes from participants in a global study of people’s understanding of hypertension or blood pressure. Published in the British Medical Journal recently, it has shaken up doctors’ views of how they might explain the disease to patients. In particular, it has shed light on why many don’t take their medications as prescribed.
Based on an analysis of studies involving qualitative interviews or focus groups among people with uncomplicated hypertension, the research includes the views of participants from some 16 countries. As well as the usual Western nations such as the UK, Denmark and Canada, the countries included Ghana, Thailand and Tanzania.
Many of those who took part in the studies thought hypertension was principally caused by stress and that it produced symptoms such as headache and dizziness.
Participants often felt that their blood pressure improved when they were not stressed; this was also a signal to some that treatment was no longer needed. Some patients said they were not keen on the side effects of treatment and that they were even afraid of addiction.
The authors of the research expressed some surprise at how consistent the findings were across different cultures.
With significant numbers stopping treatment without consulting their doctor, the reasons for this included being unable to find time to take the drugs or to see the doctor, having insufficient money to pay for treatment and even forgetfulness.
What are we to make of the work of Iain Marshall and his colleagues at King’s College London?
What jumps out from the research is how the condition of hypertension we define as doctors only partly matches the lay person’s perspective of the disease. And that these perspectives are pretty constant throughout the world and across cultures.
The science of hypertension shows that the condition is asymptomatic except in severe cases; yet patients commonly connected high blood pressure with symptoms.
This probably reflects patients’ expectations of having some symptoms in order to feel they have a real disease. They also strongly associated stress and being worried with hypertension, which contrasts with a more biological explanation.
Deliberately choosing to modify or not take their prescribed drugs was a feature right across cultures.
Rather than interpreting this as blatant non-compliance, it may simply be patients wishing to participate actively in their care. Which begs the question: are doctors responding to this need?
Perhaps we need to take the focus off the “numbers” in high blood pressure. We also need to engage more with people’s ideas about what causes hypertension. Most importantly of all, doctors should help patients understand exactly what they get from preventive interventions, such as a better prognosis and improved quality of life. And we have to acknowledge and discuss in greater detail the side effects of drugs.
The interventions doctors propose for high blood pressure need to be much more related to patients’ perspectives and to the outcomes that people think are relevant. It’s what shared decision making is all about.