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      Lay perspectives on hypertension and drug adherence: systematic review of qualitative research

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          Abstract

          Objective To synthesise the findings from individual qualitative studies on patients’ understanding and experiences of hypertension and drug taking; to investigate whether views differ internationally by culture or ethnic group and whether the research could inform interventions to improve adherence.

          Design Systematic review and narrative synthesis of qualitative research using the 2006 UK Economic and Social Research Council research methods programme guidance.

          Data sources Medline, Embase, the British Nursing Index, Social Policy and Practice, and PsycInfo from inception to October 2011.

          Study selection Qualitative interviews or focus groups among people with uncomplicated hypertension (studies principally in people with diabetes, established cardiovascular disease, or pregnancy related hypertension were excluded).

          Results 59 papers reporting on 53 qualitative studies were included in the synthesis. These studies came from 16 countries (United States, United Kingdom, Brazil, Sweden, Canada, New Zealand, Denmark, Finland, Ghana, Iran, Israel, Netherlands, South Korea, Spain, Tanzania, and Thailand). A large proportion of participants thought hypertension was principally caused by stress and produced symptoms, particularly headache, dizziness, and sweating. Participants widely intentionally reduced or stopped treatment without consulting their doctor. Participants commonly perceived that their blood pressure improved when symptoms abated or when they were not stressed, and that treatment was not needed at these times. Participants disliked treatment and its side effects and feared addiction. These findings were consistent across countries and ethnic groups. Participants also reported various external factors that prevented adherence, including being unable to find time to take the drugs or to see the doctor; having insufficient money to pay for treatment; the cost of appointments and healthy food; a lack of health insurance; and forgetfulness.

          Conclusions Non-adherence to hypertension treatment often resulted from patients’ understanding of the causes and effects of hypertension; particularly relying on the presence of stress or symptoms to determine if blood pressure was raised. These beliefs were remarkably similar across ethnic and geographical groups; calls for culturally specific education for individual ethnic groups may therefore not be justified. To improve adherence, clinicians and educational interventions must better understand and engage with patients’ ideas about causality, experiences of symptoms, and concerns about drug side effects.

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          Most cited references79

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          Making sense of qualitative data analysis: an introduction with illustrations from DIPEx (personal experiences of health and illness).

          This paper outlines an approach to analysing qualitative textual data from interviews and discusses how to ensure analytic procedures are appropriately rigorous. Qualitative data analysis should begin at an early stage in data collection and be highly systematic. It is important to identify issues that emerge during the data collection and analysis as well as those that the researcher may have anticipated (from reading or experience). Analysis is very time-consuming, but careful sampling, the collection of rich material and analytic depth mean that a relatively small number of cases can generate insights that apply well beyond the confines of the study. One particular approach to thematic analysis is introduced with examples from the DIPEx (personal experiences of health and illness) project, which collects video- and audio-taped interviews that are freely accessible through http://www.dipex.org. Qualitative analysis of patients' perspectives of illness can illuminate numerous issues that are important for medical education, some of which are unlikely to arise in the clinical encounter. Qualitative studies can also cover a much broader range of experiences - of both common and rare disease - than clinicians will see in practice. The DIPEx website is based on qualitative analysis of collections of interviews, illustrated with hundreds of video and audio clips, and is an innovative resource for medical education.
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            Patient adherence to treatment: three decades of research. A comprehensive review.

            Low compliance to prescribed medical interventions is an ever present and complex problem, especially for patients with a chronic illness. With increasing numbers of medications shown to do more good than harm when taken as prescibed, low compliance is a major problem in health care. Relevant studies were retrieved through comprehensive searches of different database systems to enable a thorough assessment of the major issues in compliance to prescribed medical interventions. The term compliance is the main term used in this review because the majority of papers reviewed used this term. Three decades have passed since the first workshop on compliance research. It is timely to pause and to reflect on the accumulated knowledge. The enormous amount of quantitative research undertaken is of variable methodological quality, with no gold standard for the measurement of compliance and it is often not clear which type of non-compliance is being studied. Many authors do not even feel the need to define adherence. Often absent in the research on compliance is the patient, although the concordance model points at the importance of the patient's agreement and harmony in the doctor-patient relationship. The backbone of the concordance model is the patient as a decision maker and a cornerstone is professional empathy. Recently, some qualitative research has identified important issues such as the quality of the doctor-patient relationship and patient health beliefs in this context. Because non-compliance remains a major health problem, more high quality studies are needed to assess these aspects and systematic reviews/meta-analyses are required to study the effects of compliance in enhancing the effects of interventions.
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              Synthesising qualitative and quantitative evidence: a review of possible methods.

              The limitations of traditional forms of systematic review in making optimal use of all forms of evidence are increasingly evident, especially for policy-makers and practitioners. There is an urgent need for robust ways of incorporating qualitative evidence into systematic reviews. In this paper we provide a brief overview and critique of a selection of strategies for synthesising qualitative and quantitative evidence, ranging from techniques that are largely qualitative and interpretive through to techniques that are largely quantitative and integrative. A range of methods is available for synthesising diverse forms of evidence. These include narrative summary, thematic analysis, grounded theory, meta-ethnography, meta-study, realist synthesis, Miles and Huberman's data analysis techniques, content analysis, case survey, qualitative comparative analysis and Bayesian meta-analysis. Methods vary in their strengths and weaknesses, ability to deal with qualitative and quantitative forms of evidence, and type of question for which they are most suitable. We identify a number of procedural, conceptual and theoretical issues that need to be addressed in moving forward with this area, and emphasise the need for existing techniques to be evaluated and modified, rather than inventing new approaches.
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                Author and article information

                Contributors
                Role: clinical academic fellow
                Role: professor of public health medicine
                Role: reader in social science and health
                Journal
                BMJ
                BMJ
                bmj
                BMJ : British Medical Journal
                BMJ Publishing Group Ltd.
                0959-8138
                1756-1833
                2012
                2012
                09 July 2012
                : 345
                : e3953
                Affiliations
                [1 ]King’s College London, Division of Health and Social Care Research, London SE1 3QD, UK
                [2 ]National Institute for Health Research Comprehensive Biomedical Research Centre, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
                Author notes
                Correspondence to: I J Marshall iain.marshall@ 123456kcl.ac.uk
                Article
                mari003757
                10.1136/bmj.e3953
                3392078
                22777025
                78283efc-8c61-4658-9a7f-822cd1603134
                © Marshall et al 2012

                This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://creativecommons.org/licenses/by-nc/2.0/ and http://creativecommons.org/licenses/by-nc/2.0/legalcode.

                History
                : 23 April 2012
                Categories
                Research
                1778
                UK
                Drugs: Cardiovascular System
                Headache (Including Migraine)
                Pain (Neurology)
                Nursing
                Hypertension
                Pregnancy
                Reproductive Medicine
                Internet
                Health Education
                Health Promotion
                Sociology
                Qualitative Research

                Medicine
                Medicine

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