What influences a patient's desire to participate in the management of their hypertension?
Introduction
Patient participation has been described as `the process whereby a person can function on his or her own behalf in the maintenance and promotion of health, the prevention of disease, the detection, treatment and care of illness and adaptation to continuing disability' [1]. The concept of patient participation was embodied in the Alma-Ata Declaration [2]and has been promulgated more recently by the British government via initiatives such as the Patients' Charter [3]. Social change has led to increased consumerism, allied to which has been a call for more active patient involvement in health care [4]. The concept of patient participation is derived from patient autonomy, which encompasses decision-making and control. Health professionals have begun to move from a paternalistic approach to patient management towards an acknowledgement of the patient's right for self-determination.
The form participation should take and the extent to which patients wish to participate in their health care have been the subjects of many papers [5]. There is a continuum from passive compliance with treatment regimes to choosing to be closely involved in the management of one's condition, working in co-operation with the health professional [6]. Steele et al. [7]characterise the active patient as someone who asks questions, seeks explanations, states preferences, offers opinions and expects to be heard. Sehnert and Eisenberg [8]suggest that some patients can be `activated' to ask questions, be aware of bodily symptoms and adapt behaviour accordingly and to present concerns to the doctor. In relation to hypertensive patients, active participation would entail not only taking prescribed medication, but also making healthy lifestyle changes, for example in diet and physical activity.
The increasing number of chronically ill people in our population has perhaps served as an impetus for the promotion of greater patient participation in health care [5]. Chronic conditions such as hypertension lend themselves to mutual management strategies. The patient can provide important information to aid management. This seems appropriate since, once on medication, the hypertensive patient will largely manage himself. The patient will naturally choose the regime that best fits his lifestyle [9]. The health professional's role will be to help the patient help himself [10]. Research with hypertensives has tended to focus on compliance rather than exploring offering patients the option of participation in their health care via making lifestyle changes. However, for some hypertensives, allowing the patient a more active part in the management of his condition, beyond simply taking antihypertensive medication, may facilitate compliance and improve blood pressure (BP) control [11]. The perception that one has been able to choose to take a more active role may in itself enhance the patient's overall sense of well-being [12].
To date, patient participation studies have largely addressed secondary care issues, such as shared decision-making about surgical intervention for benign prostatic hypertrophy [13]. Participation is equally important in primary care situations. The current research considered the role of patient participation in the management of hypertension. The guiding premise was that giving patients the choice to become involved in the management of their hypertension could help to improve BP control by promoting compliance and a healthy lifestyle. This report outlines a preliminary study. An inductive process was used to gain background information, prior to proceeding with an intervention to test the above hypothesis. The purpose was to determine how hypertensive patients perceive their role in the management of their condition and to assess their desire for future participation in BP management. It was hypothesised a priori that those wishing to participate would be more likely to:
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Have more negative feelings about their BP status
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Report BP status having an impact on their daily lives
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Have experienced more symptoms or illness as a result of treatment
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Think about their BP status more
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Actively comply with medication regime
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Report more self management activities
Section snippets
Method
The setting was a three-partner practice within a health centre in Surrey, England. The practice is situated in a relatively affluent area of the commuter belt. The practice has approximately 5000 patients, of whom 469 have a Read code for hypertension on the practice computer. Of these, about 300 attend a practice nurse-led BP clinic. The clinic has been in operation since 1993. There is a protocol for the management of hypertension and for the BP clinic itself. Quarterly attendance is
Patient characteristics
Interviewees were 68 years old on average (S.D. 8.8, range 38–84 years); 51% were female. The mean BP was 157/88.5 mmHg and the median number of years since diagnosis eleven (range: less than 1–35 years). Two thirds (67%) had a positive family history of hypertension and/or cardiovascular disease. The majority (73%) were married. They were (or had been) most commonly in non-manual occupations. Only 8% of the group smoked. All but four were currently on anti-hypertensive medication.
Demographic
Discussion
This research set out to examine the patient's perspective on existing BP management and views on future participation in BP management. Data was obtained from 49 patients. Although they were a specialised sample, many being regular attendees of a BP clinic, they represent a group where the greatest opportunities for health promotion exist.
The majority of patients interviewed were generally aware of healthy lifestyle factors. Many had already made some lifestyle changes that could benefit their
Conclusions and implications for practice
These findings highlight issues for future research and clinical practice. First of all, BP control could particularly benefit from increased participation [11]. Secondly, it would appear that those more recently diagnosed hypertensive are more likely to be willing to participate in BP management. Health professionals could target such patients, exploring suitable modalities for sharing knowledge and discussing options. Whilst patient participation may be desirable, education and training for
Acknowledgements
The author would like to thank Andrew Singleton and the two anonymous referees for their useful comments on an earlier version of this article. Thanks to the practice staff and patients for their cooperation in the research.
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