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Psychological Resistance to Drug Therapy in Patients with Hypertension: a Qualitative Thematic Analysis

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Psychological Resistance to Drug Therapy in Patients with Hypertension: a Qualitative Thematic Analysis Korean Journal of Adult Nursing eISSN 2288-338X Vol. 32 No. 2, 124-133, April 2020 https://doi.org/10.7475/kjan.2020.32.2.124 ORIGINAL ARTICLE Open Access Psychological Resistance to Drug Therapy in Patients with Hypertension: A Qualitative Thematic Analysis Kang, Jiyeon1 · Jeong, Yeon Jin2 1Professor, College of Nursing, Dong-A University, Busan, Korea 2Assistant Professor, Department of Nursing, Dongju College, Busan, Korea Purpose: To explore the nature of psychological resistance to the initiation of antihypertensive medication. Methods: Participants were 13 adults with hypertension who were refusing or had refused to take antihypertensive drugs from July 2016 to October 2016. The data were collected through face-to-face in-depth interviews, and analyzed according to Braun and Clarke’s 6 steps of thematic analysis. Results: Analysis of the psychological resistance experience to drug therapy in hypertensive patients resulted in 5 themes and 10 sub-themes from a total of 42 free codes. Participants were “holding out as much as possible without medication” without taking antihypertensive drugs due to “psychological opposition to starting treatment” and “situational barriers related to medication”. However, they were “coming to grips with reality” that they were not taking medication but would take it someday, and they gained “momentum for change” to start taking it. Conclusion: The 5 themes derived from the data analysis of the experiences of 13 participants are interrelated and suggest the direction of intervention to lower psychological resistance. In particular, we propose the development of an intervention to assist patients in self-decision regarding taking antihypertensive medication. Additional research into the role of medical staff in lowering the psychological resistance of young hypertensive patients is needed. Key Words: Hypertension; Patient compliance; Treatment refusal; Qualitative research INTRODUCTION has been reported that antihypertensive medication is ef- fective in lowering the incidence of cardiovascular disease Hypertension is a major risk factor for cardiovascular and the mortality of the hypertensive adults [5]. In addi- and cerebrovascular diseases, which are the leading caus- tion, the timing of initiation of hypertension medication is es of death in adults [1]. According to a Korean National important. Xu et al. [6] reported an increase in the inci- Health and Nutrition Examination Survey in 2015, 29.6% dence of cardiovascular disease and mortality in patients of adults aged 30 years or older had hypertension, and who started taking medication at a systolic blood pressure 40.3% of hypertensive patients were not treated for hyper- greater than 150 mmHg. tension [2]. The risk of cardiovascular disease in patients The World Health Organization (WHO) defines medi- with uncontrolled hypertension is greater, which can lead cation adherence as the continuous use of medication in to an economic burden on the entire society [3]. accordance with a physician’s recommendations [7]. Per- To prevent complications of hypertension, lifestyle sonal experience, beliefs, autonomy, social support, and changes, such as limitation of sodium intake, proper ex- socioeconomic factors can influence medication adher- ercise, and stress control, should be attempted. However, ence [8-10]. A variety of educational and behavioral inter- the use of antihypertensive agents is recommended for pa- ventions, such as a team approach, motivational inter- tients with blood pressure of 140/90 mmHg or more [4]. It views, direct observation, and self-monitoring, have been Corresponding author: Jeong, Yeon Jin https://orcid.org/0000-0002-0015-921X Department of Nursing, Dongju College, 55 Sari-ro, Saha-gu, Busan 49318, Korea. Tel: +82-51-200-3305, Fax: +82-51-240-2920, E-mail: [email protected] Received: Nov 25, 2019 / Revised: Jan 26, 2020 / Accepted: Feb 6, 2020 This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/ by-nc/3.0), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. ⓒ 2020 Korean Society of Adult Nursing http://www.ana.or.kr Psychological Resistance to Antihypertensives introduced to improve medication adherence [11-14]. The 2. Participants result of a meta-analysis of medication adherence [15] sug- gested that it was important to consider various character- In this study, the participants were 13 patients who istics of the participants rather than to provide fixed inter- were diagnosed with hypertension but refused to take hy- ventions to improve compliance in patients with hyper- pertensive drugs. To recruit participants, recruitment no- tension. The majority of these studies focused on patients tices were posted on the outpatient waiting room board at who had initiated medication but not sustained it for some D University hospital. Interviews were conducted with reason. participants who expressed their intention to participate Meanwhile, some hypertensive patients refuse the ini- in the study. The mean age of the participants was 52.4 tiation of antihypertensive agents and seek traditional years, and they consisted of 6 men and 7 women. Of the to- remedies even though they were recommended for drug tal participants, 5 had experienced refusing medication therapy [10]. Hypertensive patients are reluctant to take but were currently taking hypertensive medication, and medication because they are skeptical about lowering the remaining 8 were not taking medication at the time of blood pressure, have concerns about side effects and de- the interview. All the participants had no other disease pendencies, and have a reaction to the patient identity when they were diagnosed with hypertension (Table 1). [16,17]. In a similar vein, Jang et al. [18] have defined the concept of psychological resistance to antihypertensive 3. Data Collection drugs as “a phenomenon of denial of being diagnosed with hypertension, avoiding the need to take the drug it- Data were collected from July 2016 to October 2016 us- self, expressing the reluctance, opposing the use of the ing face-to-face in-depth interviews. If further interviews drug according to the physician's decision, and seeking al- were required, a telephone interview was conducted. Each ternative measures to control blood pressure”. This is not participant was interviewed 1~2 times (20~70 minutes per only a simple rejection of the drug but also a complex phe- interview). Suitable places for interviewing were selected nomenon that includes various psychological and social while considering the accessibility to the participants. All factors of the individual involved in the drug therapy. interviews were conducted by one of the authors (JYJ), As seen above, effective hypertension management re- who is experienced in conducting interviews for qual- quires the development of appropriate strategies for those itative study and in nursing patients with hypertension. who are refusing medication despite the knowledge of The interviews were conducted through semi-struc- their own hypertension. To do so, a thorough understand- tured questions. The interviewer began the interviews ing of psychological resistance to hypertensive medication with general questions, such as, “When did you know that should be prioritized. We intended to understand the sub- you were hypertensive?” and “Tell me how you felt when stantial nature of psychological resistance, and provide you first got diagnosed”. Once a familiar atmosphere was basic data necessary for resolving psychological resistance created, the interviewer proceeded to the main question, using a qualitative thematic analysis method. The purpose “Tell me about your experience of refusing medication”. of this study was to conduct an in depth investigation of Finally, the interviewer summarized the contents of the in- the nature of psychological resistance to the initiation of terview and requested the confirmation of the participant. drug treatment in hypertensive patients, and the key ques- All interviews were recorded using 2 audio recorders tion was, “What is the psychological resistance experience with the consent of the participants. The interviewer wrote to starting medication in hypertensive patients?” the field and debriefing notes for each interview. The par- ticipants were interviewed until there was saturation of METHODS data. The authors found that the content of the interviews was repeated after the twelfth interview. Thus, we com- 1. Design pleted the data collection after confirming the repetition at the thirteenth interview. This was a qualitative study exploring the psychologi- cal resistance experience to drug treatment in hyperten- 4. Ethical Considerations sive patients using in-depth interviews and thematic ana- lysis. We have adhered to the consolidated criteria for re- The protocol of this study was reviewed and approved porting qualitative research (COREQ) [19]. by the Institutional Review Board of Dong-A University (approval number: 2-104709-AB-N-01-201607-HR-027-02). Korean J Adult Nurs. 2020;32(2):124-133 125 Kang, J · Jeong, YJ Table 1. Participants Characteristics (N=13) Age Years from Current Duration of Time of Number of † ID Gender Job Comorbidity (year) diagnosis medication medication 1 interview interviews 1 Woman 36 Teacher 2 No 0 20 2 No 2 Man 54 Teacher 3 No 0 60 1 No 3 Woman 66 Businessman 14 Yes 10 years 30 1 No 4 Woman 64 Housewife
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