A Qualitative Study of Communication between Individuals with Hypertension and Healthcare Professionals
A research proposal in partial fulfillment of the requirements needed in 204
RATIONALE OF THE STUDY
Communication in health is a serious aspect of care for health providers and people in communities because it has a direct influence on their engagement and outcomes.
In the Philippines, 31.8 percent of the country’s top ten causes of death are related to diseases of the heart (National Statistics Office, 2009). Heart disease and diseases of the vascular system has been increasing through the years with mortality rates in 2005 reaching 90.4 and 63.8 deaths per 100,000 population respectively.
In 10 years, the prevalence of hypertension has increased 20 percent from its rate in 1998 (National Statistics Office, 2008).
The Department of Health’s overall goal of reducing morbidity and mortality from lifestyle-related diseases and improving the quality of life of those who are suffering from such diseases, are a set of strategies that were established to implement in 2011 to 2016.
One of the five strategies focuses on the implementation of sound, long-term and sustained healthy lifestyle promotion programs using community-based approaches, with DOH supplementing local campaigns with regular mass media campaigns and Commission on Higher Education (CHED) improving medical and paramedical curricula in the area of healthy lifestyle and behaviour modification.
The yearly increase of deaths from non-communicable diseases, specifically cardiovascular diseases, indicates insufficient efforts in promoting and preventing health among Filipinos. Knowledge about the preventative measures of such diseases is essential to one’s well-being. The issue is within the health promotion strategies of the DOH as communication materials are not tailored to specific groups. Hence, without effective information dissemination, an individual is deprived from being health literate.
Health literacy is significant in every person’s life. Being health literate equips people with cognitive and social skills that determine their driving force and ability to gain access to, understand, and utilize information in ways that promote and maintain good health.
Patients’ perceptions of the quality of the healthcare they have received are highly dependent on the quality of their interactions with their healthcare professionals (Clark, P. A., 2003). The connection that a patient feels with his or her clinician can ultimately improve their health mediated through participation in their care, adherence to treatment, and patient self-management.
Communication is important and critical in influencing one’s beliefs and decisions towards adequate health and improvement of quality of life.
THE RESEARCH PROBLEM
The study intends to answer the question “How do healthcare professionals communicate with individuals with hypertension?”
OBJECTIVE OF THE STUDY
The study aims to explore the experiences of individuals with hypertension in terms of their communication with healthcare professionals.
IMPORTANCE OF THE STUDY
The new information generated by the study of the research problem has the potential of contributing to the body of knowledge in health and communication in the Philippines context.
The following groups can benefit from the results of the study:
- Healthcare Professionals – The various opinions of people seeking for health-related advice or help would greatly suggest how healthcare professionals would deal or communicate with individuals and their needs. He or she could adjust as to what type of communication is essential to provide the most efficient teaching or instruction for their patients.
- Hospitals and Health Centers – From the results of the study, institutions can provide a system of individualized health teachings that can be implemented to promote good health and prevent occurrence of heart diseases.
The proposed research title of the study is: “Hearty Conversations: A Qualitative Study of Communication between Individuals with Hypertension and Healthcare Professionals.”
REVIEW OF RELATED LITERATURE
Hypertension, commonly known as high blood pressure, is a vascular condition where the arteries have persistently elevated blood pressure. Blood pressure is the force of blood pushing up against the vascular walls of the blood vessel. The higher the pressure exerted on the walls, the harder the heart has to pump.
Hypertension could lead to damaged organs and several illnesses like renal failure (kidney failure), heart failure, aneurysm, stroke, or heart attack. The normal level for blood pressure is between the range of 90/60 mmHg to 120/80mmHg, where 120 represents the systolic measurement (peak pressure in the arteries) and 80 represents the diastolic measurement (minimum pressure in the arteries). Blood pressure readings between 120/80 mmHg and 139/89 mmHg is known as prehypertension (to denote increased risk of hypertension), and a consistent blood pressure of 140/90 mmHg or above is considered already as hypertension.
Hypertension may be classified as essential or secondary. “Essential” is a term for high blood pressure with an unknown cause where it accounts for 95% of cases. Secondary hypertension is the term for high blood pressure with a known, direct cause, such as kidney disease, tumors, or overuse of contraceptive pills.
28 percent of adult Filipinos have hypertension, adding that the number is still increasing despite treatment advances and that majority of those being treated have poor BP control. More than 276 Filipinos die of heart disease on a daily basis and at least one Filipino suffers from stroke every nine minutes. Survivors have a 75% chance of becoming permanently disabled (Medical Observer Philippines, 2014).
The prevalence of hypertension in the country has significantly grown in recent years, and the need to address it should all the more be prioritized, especially with the lack of awareness, treatment, compliance, and blood pressure (BP) control rates among hypertensive patients in the country (Philippine Heart Association – Council on Hypertension, 2014).
The exact causes of hypertension are still unknown but there are several factors that have been highly associated with the condition. These are smoking, obesity, diabetes, sedentary lifestyle, lack of physical activity, and high levels of salt intake.
The main goal of treatment for hypertension is to lower blood pressure to less than 140/90 mmHg – or even lower in some groups such as people with diabetes, and people with chronic kidney diseases. Treating hypertension is important for reducing the risk of stroke, heart attack, and heart failure (Department of Health Philippines, 2015).
Hypertension may be treated medically, by changing lifestyle factors, or usually a combination of the two. Important lifestyle changes include losing weight, quitting smoking, eating a healthful diet, reducing sodium intake, exercising regularly, and limiting alcohol consumption.
There are also medical options to treat hypertension which include several classes of drugs. ACE inhibitors, ARB drugs, beta-blockers, diuretics, calcium channel blockers, alpha-blockers, and peripheral vasodilators are the primary drugs used in treatment (Medical News Today, 2014).
Health Dialogue and Communication
“Extensive research has shown that no matter how knowledgeable a clinician might be, if he or she is not able to open good communication with the patient, he or she may be of no help (Asnani, M.R., 2009).”
Communication is native to human beings. It is a way of exchanging information and signifies symbolic capability. There are two functions that reflect what James Carey characterized, transmission and ritual views of communication, respectively. He recognized that communication serves an instrumental role (acquisition of knowledge) and it also fulfils a ritualistic function, one that reflects humans as members of a social community. Communication is the symbolic exchange of shared meaning, and all communicative acts have both a transmission and a ritualistic component (Brashers, D.E., 2001).
Much effort in the current healthcare setting is being put into improving communication among patients and families and members of the healthcare team, among family members, and among members of the team. Good communication is important in terms of patient safety, cultural sensitivity, and serves as a pillar of palliative care, aligning patient’s wishes and goals with treatment plans.
Health communication is seen to have relevance in all aspects of health and well-being, including the prevention of diseases, promotion of health, and improvement of the quality of life (Rimal, R.N., Lapinski, M.K., 2009).
In a study conducted by Thorne and co-researchers, in the context of a disease called multiple sclerosis, it has been found that good communication with healthcare providers helped patients with multiple sclerosis to cope and adapt. People with multiple sclerosis found that effective healthcare communication and support helped them to manage their disease. Poor communication, on the other hand, or too little information, and minimisation of their disease hindered adaptation (Thorne, S., et al., 2004).
It has shown that multiple sclerosis patients emphasized that their experiences of healthcare and their ability to manage their illness on a daily basis were affected by the communication between them and their healthcare providers. Moreover, three themes emerged from the study: 1) Managing fear where communication within healthcare encounters either increased or decreased patient’s fear; 2) Taking charge where patients increasingly realized the need to take full responsibility for managing personal and clinical aspects of their disease; and 3) Crafting a life where they focused on incorporating their disease into their personal, family, and work lives (Thorne, S., et al., 2004).
One study found that less than half of hospitalized patients can identify their diagnoses or the names of their prescribed medications upon discharge, an indication of communication ineffectiveness with their physician (Makaryus, A.N., et al., 2005). It has been estimated that one-third of adults with chronic illnesses underused their prescribed medications due to cost concerns and yet they have failed to communicate the information to their physician (Piette, J. D., et. al.,2004).
Patient-centered care model emphasizes the essential features of healthcare communication which heavily relies on core communication skills like open-ended questioning, reflective listening, and empathy, as a way to respond to individual needs, values, and preference of patients (Stewart, M., 2000).
Research evidence indicates that there are strong positive relationships between a healthcare team member’s communication skills and a patient’s capacity to follow through with medical recommendations, self-manage a chronic medical condition, and adopt preventive health behaviours. Communication among healthcare team members influences the quality of working relationships, job satisfaction and has a profound impact on patient safety (Wanzer, M. B., et al, 2004).
Theory of Planned Behaviour
In 1980, the Theory of Reasoned Action (TRA) was formulated by Icek Ajzen and Martin Fishbein. They formulated the TRA after trying to estimate the discrepancy between attitude and behaviour. The TRA was related to voluntary behaviour. Later on, behaviour appeared not to be entirely voluntary and under control which resulted in the addition of perceived behavioural control. With the addition, the theory was eventually called the Theory of Planned Behaviour (TPB). The TPB is a theory that predicts deliberate behaviour, since behaviour can be deliberative and planned.
The TRA suggests that a person’s behaviour is determined by his/her intention to perform the behaviour and that the intention is a function of his/her attitude toward the behaviour and his/her subjective norm. The best predictor of behaviour is intention. So, intention is the cognitive representation of a person’s readiness to perform a given behaviour, and it is considered to be the immediate antecedent of behaviour.
Intention is determined by three things: their attitude toward the specific behaviour, their subjective norms and their perceived behavioural control. The TPB holds that only specific attitudes toward the behaviour in question can be expected to predict that behaviour. In addition to measuring attitudes toward the behaviour, people’s subjective norms should be measured – their beliefs about how people they care about will view the behaviour in question. To predict someone’s intentions, knowing the beliefs can be as important as knowing the person’s attitudes.
Figure 1. The Theory of Planned Behaviour, Ajzen, I. (1991)
Perceived behavioural control influences intentions. It refers to people’s perceptions of their ability to perform a given behaviour. The predictors lead to intention. The more favorable the attitude and the subjective norm, and the greater the perceived control the stronger should the person’s intention to perform the behaviour in question.
The TPB was intended to explain all behaviours over which people have the ability to exert self-control – intent. Behavioural intentions are influenced by the attitude about the likelihood that the behaviour will have the expected outcome and as well as the subjective evaluation of the benefits and risks of that outcome.
It has been used successfully in predicting and explaining a wide range of health behaviours and intentions which includes smoking, drinking, health services utilization, substance use, and breast feeding among others. The TPB emphasizes that behavioural achievement depends on both intention and behavioural control. Thus, it distinguishes between three types of beliefs: behavioural, nominative, and control.
The theory has six constructs that represents a person’s actual control over the behaviour:
- Attitudes – the degree to which a person has a favorable or unfavorable evaluation of a behaviour or interest.
- Behavioural intention – the motivational factors that influence a given behaviour where the stronger the intention to perform the behaviour, the more likely the behaviour is performed.
- Subjective norms – the belief about whether most people approve or disapprove the behaviour. It relates to a person’s belief about people of importance which thinks he or she should engage in the behaviour.
- Social norms – customary codes of behaviour in a larger cultural context.
- Perceived power – the perceived presence of factors that may facilitate of impede performance of the behaviour. Perceived power affects a person’s perceived behavioral control over those factors.
- Perceived behavioral control – a person’s perception of the ease or difficulty of performing the behaviour of interest. It varies across situations and actions which results in a person having varying perceptions of behavioral control depending on the situation.
Attitude toward the behaviour, subjective norm, and perception of behavioral control lead to the formation of behavioral intention. Given the sufficient degree of actual control over the behaviour, people are expected to carry out their intentions when the opportunity arises. Intention is assumed to be the antecedent of behaviour.
Realism is based on the thought that there is an external reality which exists independently of people’s beliefs about or understanding of it. In other words there is a distinction between the way the world is, and the meaning and interpretation of that world held by individuals. It is an external reality that exists independent of our beliefs or understanding. Subtle realism is a variant of realism that illustrates that an external reality exists but is only known through the human mind and socially constructed meanings.
People see reality as something that exists independently of those who observe it but is only accessible through the perceptions and interpretations of individuals. The critical importance of the participants’ own interpretations of the issues researched is recognized and is believed that their varying vantage points will yield different types of understanding. External reality is itself diverse and multifaceted and it is the aim of research to capture that reality in all its complexity and depth.
Subtle Realism, according to Martyn Hammersley, acknowledges the existence of an independent reality, a world that has an existence independent of our perception of it, but denies that there can be direct access to that reality, emphasising instead representation not reproduction of social phenomena. This representation entails that it will be from the perspective of the researcher, thereby implicitly acknowledging reflexivity, which is acknowledgement that researchers influence the research process.
Combined Theory of Planned Behaviour and Subtle Realism
The combined approach will enable an examination of the pathway between beliefs and intentions of improved health within the context of a hypertensive patient’s day to day life. The Subtle Realism concept states that the social world does not exist independently of individual subjective understanding but is only accessible through the research participants’ interpretations. Meanwhile, the TPB stresses that intentions predict behaviour and that the three sets of beliefs mediate behavioral intentions in relation to behavioral beliefs (perceived benefits and harms), control beliefs (control over necessary resources to engage in behaviour), and normative beliefs (determined by perceptions of others). The combination of the two approaches will be used to examine hypertensive patient’s views and experiences with healthcare professionals within the context of their day to day lives.
This chapter includes the discussion of the research design, sample and sampling scheme, research instrumentation and analysis that will be utilized and applied in the interpretation of the study.
This qualitative research will use the Phenomenological study design to examine human experiences through the descriptions provided by the participants to be involved. Their experiences (lived experiences) and perceptions of it, in the context of communication with healthcare professionals, will be studied.
In order to understand the participant’s lived experience from their vantage point, the researcher will set aside what he or she expects to discover and the ideas that come with it, employing the process of bracketing. The researcher’s own idea about the phenomenon will be discounted in order to see the experience from the eyes of the people who have lived the experience.
SETTING OF THE STUDY
The study will be conducted in Brgy. Linaon, Cauayan, Negros Occidental, Philippines.
SAMPLING AND SAMPLING SCHEME
The study will make use of purposive sampling where only diagnosed hypertensive patients will be taken into consideration as representatives of the population. A written letter of intent will be sent out to the Brgy. Linaon Health Center in order to obtain consent and contact information of patients diagnosed with hypertension. A letter of informed consent will then be given to the study participants.
Inclusion criteria for the study are as follows: 1) Any person diagnosed with hypertension; 2) resident of Brgy. Linaon, Cauayan, Negros Occidental for more than 3 years; and 3) people who sought medical advice from healthcare professionals.
METHODS FOR DATA COLLECTION
Data collection will involve semi-structured, in-depth interviews based on a topic guide to enable a more detailed exploration of the patient’s views and experiences using a flexible approach. Interviews will be audio-recorded with the participant’s permission.
The topic guide will include the following prompts to elicit views and experiences: 1) Reasons for consulting with healthcare professionals; 2) Frequency of consultations or health center visits; 3) Compliance to advice of healthcare professional; 4) Health beliefs in the context of hypertension; 5) Current activities of daily living; 6) Experiences on mismanagement of condition; 7) Perception of people’s opinion towards him/her and disease; 8) General experiences with healthcare professionals.
ANALYSIS OF DATA
The study will utilize the Interpretative Phenomenological Analysis (IPA) where the individual’s personal perception of an event will be explored rather than an objective record of the event itself.
The interview transcripts will be indexed and mapped on the basis of themes that are recurring. The synthesized data will be examined. The emergent themes will then be clustered.
Descriptive analysis will explore the subjective experiences of communication styles and reported feelings. In-depth analysis will involve examining semantic content and language focusing on words, phrases, and the use of metaphors within the context of all hypertension discussions.
In depth analysis of interviews will examine the data within the context of how the diagnosed individuals made sense of the information communicated to them and the impact it had on himself and others.
Pseudonyms will be used to protect the identity of participants of the study.
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(Published: June 22, 2015)