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Patient and Doctor Perceptions of Hypertension and Its Treatment: a Qualitative Study in Urban Hospitals of Pakistan

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Patient and Doctor Perceptions of Hypertension and Its Treatment: a Qualitative Study in Urban Hospitals of Pakistan Patient and Doctor Perceptions of Hypertension and its Treatment: A Qualitative Study in Urban Hospitals of Pakistan Qurrat Ul Ain Submitted to the University of Hertfordshire in partial fulfilment of the requirements of the degree of Doctor of Philosophy October 2019 1 Abstract Hypertension (HTN) is a chronic disease that has become a growing public health problem in countries around the world, including Pakistan. Successful HTN control is an essential cornerstone in the prevention of morbidity and mortality associated with uncontrolled HTN. However, patients’ beliefs about their disease, treatment and control are related to the outcome of successful HTN control and management. Likewise, doctors’ understanding of HTN and its treatment is equally important and can affect their practice and HTN management. There is little qualitative research considering patients’ and doctors’ understanding of HTN, its treatment and how it influences HTN management in Pakistan. Therefore, the current study aimed to elicit patients’ and doctors’ perceptions, attitudes and beliefs about HTN and its treatment in urban areas of Pakistan. A qualitative study that drew on grounded theory principles was undertaken in two public hospitals of Pakistan. Thirty in-depth semi-structured interviews with hypertensive patients and thirty interviews with doctors were conducted in two hospitals. Interviews were translated and transcribed from Urdu into English and NVivo was used to organise the data in a systematic way. Data were analysed using a constant comparative approach based on the principles of grounded theory. The study revealed that patients’ (n=30) beliefs were complex, deep-rooted and influenced their attitude towards HTN treatment. Patients’ beliefs were informed by understanding gleaned from the socio-cultural environment (local norms, social relations, religion), individual factors (e.g. income, co-morbidities) and interactions with doctors. In contrast, doctors’ (n=30) own understandings on what constitutes successful HTN management often contradicted patients’ beliefs. Doctors’ reported that time restraints and work burden affected their approach to treatment and the provision of information to patients. Findings also revealed an overlap between patients’ and doctors’ beliefs, however, in relation to adopting lifestyle changes for management of HTN. In general, though doctors paid less consideration to patients’ beliefs in routine clinical practice and evaluated patients through the filter of their own beliefs. The findings suggest that doctors could provide a better service care by aligning with their patients on a common understanding about HTN management and providing culturally appropriate information. Doctors should be aware of the understanding hypertensive patients attach to HTN and avoid providing treatment based on their own beliefs. Doctors must engage with patients’ beliefs and identify their particular healthcare needs in order to achieve control of HTN in Pakistan. Keywords: Hypertension, high blood pressure, lifestyle recommendations, understanding, patient, doctor, Pakistan, qualitative research. 2 Declaration I Qurrat ul Ain, declare that this dissertation is entirely my own work and has not been submitted for any other degree or professional qualification. Signed: Date: October 2019 Qurrat Ul Ain 3 Acknowledgments First and foremost, I am thankful to Almighty Allah; due to His blessings I could finish my research work and thesis. I would like to thank the following people for the help and support they provided me during the course of this journey. I am grateful to my parents for their endless support and encouragement. Words fail to describe my feelings of respect for my supervisors Professor Wendy Wills and Doctor Angela Dickinson for providing guidance and mentoring me throughout this study. I also owe a special thanks to Waqar for keeping things light-hearted for me during the periods of stress. Kudos to my colleagues Dr Iram Rasheed, Dr Saira Bilal, Dr Sumera Shahzad, Dr Asghar, Dr Abdul Rasheed, Shahab, Zulqarnain and Adnan my brothers for their assistance and for making things possible for me. I would also like to thank the management of two hospitals for allowing me to recruit study participants and the participants themselves who generously gave their time and took part in the study. Finally, I would like to dedicate my work to my gorgeous grandmother Fahmeeda Begham, who died due to hypertension related complications and is sadly no longer with us. 4 List of Abbreviations CVD Cardiovascular Disease BHUs Basic Health Units HTN Hypertension LHWs Lady Health Workers OPD Out Patient Department PMDC Pakistan Medical and Dental Council THUs Tertiary Health Units UK United Kingdom WHO World Health Organization 5 TABLE OF CONTENTS Abstract...................................................................................................................................... 2 Declaration ................................................................................................................................ 3 Acknowledgments ..................................................................................................................... 4 List of Abbreviations ................................................................................................................. 5 Chapter One……………………………………………………………………………………………………………………11 Introduction ............................................................................................................................. 11 1.1 HTN and Cardiovascular Disease ............................................................................................ 12 1.2 Treatment of HTN ................................................................................................................. 12 1.3 Pakistani Context .................................................................................................................. 13 1.3.1 An overview of the situation regarding HTN in Pakistan ..................................................... 14 1.3.2 Healthcare system in Pakistan ............................................................................................. 15 1.4 HTN and Lifestyle Recommendations ..................................................................................... 17 1.4.1 Exercise ................................................................................................................................ 17 1.4.2 Diet ....................................................................................................................................... 18 1.4.3 High salt consumption ......................................................................................................... 19 1.4.4 Smoking ................................................................................................................................ 19 1.4.5 High alcohol intake ............................................................................................................... 20 1.5 Rationale for the Study .......................................................................................................... 21 1.6 Research Question, Aim and Objectives of the Study ............................................................... 23 1.7 Structure of the Dissertation .................................................................................................. 24 Chapter Two……………………………………………………………….…………………………………………….……25 Literature Review……………………………………………………………………………….……………………..…..25 2.1 Rationale for Systematic Review ............................................................................................ 25 2.2 The Review Protocol ............................................................................................................. 25 2.2.1 Inclusion and exclusion criteria ............................................................................................ 26 2.2.2 Search strategy..................................................................................................................... 26 2.3 Results from the Review ........................................................................................................ 27 2.3.1 Analysis of included studies ................................................................................................. 27 2.4 Patients’ Understanding of HTN and its Treatment .................................................................. 29 2.4.1 Understanding of HTN ......................................................................................................... 29 2.4.2 Causes of HTN ...................................................................................................................... 30 2.4.3 Drug non-adherence ............................................................................................................ 31 2.4.4 Using alternative treatments ............................................................................................... 33 2.4.5 Awareness about lifestyle changes ...................................................................................... 34 6 2.5 The Approach of Doctors to HTN Treatment ........................................................................... 36 2.6 Summary and Identification of Gaps ....................................................................................... 38 2.7 Search Strategy for the Broader Literature Review .................................................................
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