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      Being as an iceberg: hypertensive treatment adherence experiences in southeast of Iran

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          Abstract

          Background

          Treatment adherence is often an important issue in the management of hypertension. Deep understanding of adherence behavior as well as its influential factors can expand knowledge about treatment adherence among hypertensives.

          Objective

          The aim of this study was to explore patients, their families, and healthcare providers’ experiences about hypertension treatment adherence in southeast of Iran.

          Design

          A qualitative study was conducted to explore the experience of patients, family members, and healthcare providers ( n=18) by using a conventional content analysis. The purposive sampling method was used. Data were collected through semi-structured and deep interviews.

          Results

          Data analysis showed that hypertensive treatment adherence in an Iranian context is like an iceberg with two subthemes. The first subtheme relates to the upper and clear part of this iceberg and it consists of two categories, including 1) healthy and 2) unhealthy regimens. The second subtheme associates with under-water and unanticipated part and it consists of four categories, including 1) the nature of disease and treatment, 2) the individual resources, 3) the healthcare organization, and 4) the socio-cultural environment.

          Conclusions

          The treatment adherence features emerged in this study can be useful in designing and developing context-based hypertension interventions. Further qualitative and quantitative studies with a closer collaboration between the social, natural, and medical sciences in other Iranian populations are needed to confirm the findings.

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          Most cited references53

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          Adherence to long-term therapies: evidence for action.

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

            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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              Does psychosocial stress cause hypertension? A systematic review of observational studies.

              Acute stress promotes transient elevation of blood pressure, but there is no consistent evidence that this effect results in hypertension. In this systematic review of cohort and case-control studies that investigated the association between psychosocial stress and hypertension, we conducted a complete search up to February 2007 in MEDLINE, EMBASE, PSYCINFO and LILACS, through a search strategy that included eight terms to describe the exposure, six related to the design of the studies and one term for outcome. The quality was assessed by the Newcastle-Ottawa Quality Assessment Scale. The selection was done in duplicate by two teams of independent reviewers. Among 82 studies selected in the second phase, only 14 (10 cohort studies and 4 case-control studies), totalling 52,049 individuals, fulfilled the selection criteria. The average quality of the studies was 6.6+/-1.3 in a 9-point scale. Acute life events were associated with hypertension in one and were not associated in two studies. Five out of seven studies found a significant and positive association between measures of chronic stress and hypertension, with risk ratios ranging from 0.8 to 11.1. Three out of five studies reported high and significant risks of affective response to stress for hypertension, one a significant risk close to a unit and one reported absence of risk. Acute stress is probably not a risk factor for hypertension. Chronic stress and particularly the non-adaptive response to stress are more likely causes of sustained elevation of blood pressure. Studies with better quality are warranted.
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                Author and article information

                Journal
                Glob Health Action
                Glob Health Action
                GHA
                Global Health Action
                Co-Action Publishing
                1654-9716
                1654-9880
                21 September 2015
                2015
                : 8
                : 10.3402/gha.v8.28814
                Affiliations
                [1 ]Nursing and Midwifery Care Research Center, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
                [2 ]Department of Medical Surgical Nursing, School of Nursing and Midwifery, Kerman University of Medical Sciences, Kerman, Iran
                Author notes
                [* ]Correspondence to: Mahlagha Dehghan, Department of Medical Surgical Nursing, School of Nursing and Midwifery, Kerman University of Medical Sciences, Kerman, Iran, Email: m_dehghan86@ 123456yahoo.com

                Responsible Editor: Malin Eriksson, Umeå University, Umeå, Sweden.

                Article
                28814
                10.3402/gha.v8.28814
                4579246
                26395925
                d1bc5c8e-fc06-4e38-9dfe-5750a996d9cc
                © 2015 Nahid Dehghan Nayeri et al.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International License, allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material for any purpose, even commercially, provided the original work is properly cited and states its license.

                History
                : 10 June 2015
                : 04 August 2015
                : 25 August 2015
                Categories
                Original Article

                Health & Social care
                hypertension,treatment adherence,qualitative content analysis,iran,lived experience

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