A qualitative study on illness perceptions and self-mastery among Chinese elderly with hypertension

Hong Yao; Weijing Zhang; Yifan Qie

doi:10.1515/ajmedh-2024-0002

Artikel Open Access

A qualitative study on illness perceptions and self-mastery among Chinese elderly with hypertension

Hong Yao , Weijing Zhang und Yifan Qie

Veröffentlicht/Copyright: 19. Juni 2024

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Aus der Zeitschrift Asian Journal of Medical Humanities Band 3 Heft 1

Abstract

Objectives

Hypertension stands as the most prevalent chronic disease globally, making self-care a crucial determinant in the trajectory of the illness. Yet, a significant challenge faced by many elderly individuals with hypertension is the accurate perception of the condition as an embodied symptom. The aim of this paper is to delve into the illness perceptions of older adults with hypertension and further gain insights into their self-management efforts.

Methods

This qualitative study involved 20 older adults living in community settings, all clinically diagnosed with hypertension. Data collection was conducted using semi-structured interviews from May to August 2022, and the data was subsequently analyzed through thematic analysis.

Results

Based on data analysis, two primary themes emerged: Illness Ambiguity regarding Hypertension and Self-Mastery of Holistic Health. Illness ambiguity regarding hypertension was manifested by incidental discovery and elusive triggers of recurrence, hypertension management approaches and emotional complexities associated with aging. The participants demonstrated self-mastery as an effective strategy in coping with hypertension as well as other health problems, including psychological flexibility, active body ownership, and meaning-making for illness acceptance.

Conclusions

Older adults with hypertension faced illness ambiguity regarding their condition; however, they effectively coped by exercising self-mastery and adopting holistic health strategies to maintain their overall well-being. Future interventions in hypertension therapy and psychosocial care should be customized, taking into account these embodied experiences and the sociocultural contexts of the patients.

Keywords: hypertension; illness ambiguity; self-mastery; Chinese older adults

Introduction

Hypertension ranks as the most prevalent chronic condition among older adults globally, often leading to severe consequences such as heart disease and failure, diabetes, stroke, and kidney diseases [1]. The number of people living with hypertension (blood pressure of ≥140 mmHg systolic or ≥90 mmHg diastolic or on medication) doubled between 1990 and 2019, from 650 million to 1.3 billion,^[1] and by 2020, over a quarter of China’s population was affected.^[2] Compared to high-income countries, China exhibits lower awareness of hypertension risk factors and preventive measures, despite its mass population having higher average blood pressure levels and a greater proportion of individuals with severe hypertension [2]. Despite the availability of antihypertensive medications, many Chinese older adults may still experience undiagnosed, undetected, and uncontrolled hypertension, owing to the asymptomatic nature of the condition and misconceptions about treatment [3, 4]. Furthermore, even when individuals are diagnosed and prescribed long-term medication, their perceptions and experiences of living with hypertension can significantly influence their self-management behaviors, potentially impacting the effectiveness of blood pressure control in their daily lives [5].

Self-regulation model of illness

Effective management of hypertension undeniably necessitates a degree of self-regulation. However, current approaches to self-regulation, which primarily focus on individual decision-making, often overlook the complexity of the illness cognitions and the actual capability of patients in managing a chronic condition. Informed by Leventhal’s common-sense model, the representations of illness in hypertension patients vary greatly, influenced by each individual’s cognitive appraisal and personal understanding of their medical condition [6]. These representations may not always align with the conventional medical knowledge held by healthcare professionals [7]. Moreover, these illness representations significantly affect clinical outcomes through the affective responses and coping strategies employed by patients, particularly highlighting their self-regulatory competence and ability to adjust [3, 8].

Given that hypertension is most prevalent among older adults, they are tasked with integrating medical advice into their daily routines while managing the emotional and psychosocial impacts of living with a chronic illness. In dealing with hypertension, older adults often face ambivalence about reducing medication to avoid side effects and seeking clear guidance on controlling their condition [9]. Failures in controlling hypertension are frequently attributed to low medication adherence, aging-related cognitive decline, and insufficient self-management capacity [10–13]. A significant barrier to self-management among the elderly with hypertension is often a lack of awareness about the condition and its treatments [14]. Patients often expect healthcare providers to consider their specific preferences and concerns when prescribing treatment plans [9, 15]. Therefore, it is crucial to understand how older adults perceive hypertension as an illness and further cope with such illness cognitions, in order to tailor patient-centered clinical services by incorporating patients’ preferences.

Materials and methods

This study uses a qualitative descriptive approach, which aims to elaborate the lived experiences of interviewees in their own words and uses low inference interpretation to present facts in everyday language [16, 17]. Purposive sampling was adopted to collect data.

Participants

By referral of community clinical staffs, this study recruited 20 older adults dwelling in YQ community of Shanxi Province during June and August 2022. The average age of interviewees was 71.8 years old (SD=4.96 years). There are 12 females and 8 males. Hypertension history ranged from 1 to 43 years (mean years of hypertension history=15.37 years, SD=10.02 years). Twelve participants live with their spouses, five live with their children, and three live alone. Most of them had Grade I hypertension (systolic blood pressure of 140–159 MMHG and diastolic blood pressure of 90–99 MMHG) or Grade II hypertension (systolic blood pressure of 160–179 MMHG and diastolic blood pressure of 100–109 MMHG)^[3] for an average of 15 years. In addition to high blood pressure, most elderly people also suffer from other chronic diseases such as diabetes, heart disease, nephritis, fatty liver, and other comorbidities. Table 1 describes the demographic information of the sample.

Table 1:

Demographic information of the sample.

No.	Gender	Age	Marriage status	Residence	No. of children	Hypertension history	Grade of hypertension	Other chronic illness
1	Female	77	Widowed	Alone	One son and two daughters	30	III	High blood pressure
2	Female	70	Married	Cohabited with partner	One son	10	II	Allergies; heart disease; cerebral infarction
3	Male	65	Married	Cohabited with partner	Two sons	10	I	High blood pressure; fatty liver
4	Male	70	Married	Cohabited with partner	One son	15	III	High blood pressure
5	Female	83	Widowed	Cohabited with daughter	One daughter	25	I	Lumbar disc herniation
6	Male	78	Married	Cohabited with partner	One son	12	I
7	Female	60	Married	Cohabited with partner	Two sons	5	I
8	Female	72	Widowed	Cohabited with daughter	One son and one daughter	42	II	Nephritis
9	Female	80	Widowed	Cohabited with son	One son	2	II
10	Female	71	Married	Cohabited with partner	Three children	32	I	High blood pressure; heart disease
11	Male	78	Married	Cohabited with partner and son	One son and one daughter	7	II
12	Male	68	Married	Cohabited with partner	One son and one daughter	2	II	High blood pressure
13	Female	70	Married	Cohabited with partner	One son and one daughter		I	High blood pressure
14	Male	66	Married	Alone	One son	1	I
15	Female	80	Widowed	Alone	One son and one daughter	43	II
16	Female	68	Married	Cohabited with partner	One son	10	I
17	Female	76	Widowed	Cohabited with daughter	One daughter	14	II	Heart disease
18	Male	68	Married	Cohabited with partner	Two daughters	8	I
19	Male	70	Married	Cohabited with partner	Two sons	12	II	High blood pressure
20	Female	66	Married	Cohabited with partner	Two daughters	12	II	High blood pressure

Inclusion criteria

To be eligible for the study, participants needed to meet several criteria: they had to be aged 60 or older with a documented history of hypertension for at least one year; they are currently on prescribed antihypertensive medications, and are capable of engaging in an interview. We excluded individuals who had specific medical or psychiatric conditions that would impede their ability to participate in face-to-face interviews. According to Chinese Clinical Practice Guidelines for Hypertension in 2022, a systolic blood pressure of ≥130 mmHg or a diastolic blood pressure of ≥80 mmHg is considered the diagnostic threshold for hypertension [18]. These criteria set the standard for the blood pressure levels of participants recruited for our interviews.

Data collection

Data collection for this study was conducted from June to August, 2022. This study employed was semi-structured and face-to-face interviews, aimed at capturing the participants’ perspectives in depth. During each interview, participants were encouraged to share their experiences with hypertension, covering aspects such as the onset and recurrence of the condition, their medication schedules and history, personal perceptions of hypertension, and self-care strategies. Questions such as “Could you describe how you discovered you had hypertension?” and “What steps do you take to manage your hypertension in your daily life?” were posed. By the time the last three interviews were conducted, no new themes or categories emerged, indicating that data saturation had been reached. The average duration of each interview was approximately 40 min. All interviews were audio-recorded and transcribed into text after their completion.

Data analysis

For data analysis, thematic analysis was employed. Initially, the authors thoroughly read and familiarized themselves with the data to obtain a comprehensive understanding of the database. The first author then engaged in a meticulous examination of the transcripts, during which they identified and developed various codes and themes, thereby creating a structured thematic framework. To ensure the robustness of the analysis, the author team conducted bi-monthly face-to-face meetings to review and discuss the emerging codes and themes. Any discrepancies encountered during these discussions were resolved collaboratively, allowing for the refinement and finalization of the thematic structure. NVivo 11 software was utilized for the storage and analysis of the data. The transcripts referenced in this study were translated into English by the first author and subsequently reviewed by the team, all of whom are proficient in both English and Mandarin.

Ethical considerations

This research received approval from the Ethics Committee of Minzu University of China (Reference No. EUMUC2023009CO). All participants in the study provided informed consent and their participation was entirely voluntary. The researchers clearly explained the objectives of the study to the participants and guided them in discussing their experiences and perceptions related to living with hypertension.

Results

Illness ambiguity regarding hypertension

Incidental discovery and elusive triggers of recurrence

The incidental discovery of hypertension among participants underscores the condition’s silent and asymptomatic nature, often revealed through routine health check-ups, community screenings, or accidental checks. This silent discovery aligns with the unexpected onset of symptoms, initially noticed through sore eyes, which highlights the subtle and unpredictable manifestation of hypertension.

Actually, it generated something. I cannot tell clearly. It just happened, quickly. First of all, I felt it in my sore eyes. (No. 7)

Community doctors diagnosed me with hypertension and advised me to take medicine. Well, the number is indeed high, but I did not feel anything abnormal. (No. 12)

Furthermore, the recurrence of hypertension was frequently associated with elusive triggers such as excessive eating, inadequate sleep, cervical discomfort, lack of physical activity, and elevated stress levels. Despite recognizing these factors, many interviewees found it challenging to elaborate on these physiological indicators, suggestive of a notable gap in understanding the direct causes and bodily experiences related to hypertension episodes.

Ambiguity in hypertension assessment

The complexity of hypertension assessment is evident in the divergent methods adopted by older adults to understand and assess their condition. Interviews reveal a dichotomy in their approaches: non-reflective self-experience vs. reflective self-understanding method.

The non-reflective self-experience approach is rooted in the objective measurement of blood pressure using tools such as oscillometric devices or aneroid sphygmomanometers. This method defines hypertension based on the numerical values of diastolic and systolic pressures. Its straightforward nature, however, often results in a diminished sense of control over medication choices and a reduced effectiveness of treatment strategies, attributed to an overreliance on quantitative data and professional guidance.

Community doctors diagnosed me with hypertension and advised me to take medicine. Well, the number is indeed high, but I did not feel anything, and I don’t care about it. (No. 12)

On the contrary, the reflective self-understanding approach champions a more nuanced perception, suggesting an increased self-awareness. Individuals employing this strategy engage deeply with their interoceptive senses, which allows for a more informed self-management of their condition. They leverage blood pressure metrics as a guideline while also tuning into their bodily and mental shifts, actively seeking knowledge and community support, and fostering open dialogues with healthcare practitioners. This empowers them with the autonomy to adjust their medication and lifestyle interventions for optimized health results.

For me, I prefer to use less medicine as long as I felt fine. As long as it is a medicine it has to have some poison components. I had blood pressure machine at home, 3 times a day. I looked for the average and consult the doctors with these recordings to see if I need to continue or change medication. When we decide, I shall resist. (No. 14)

This exploration into the differing approaches highlights the ambiguity in hypertension assessment among the elderly, which underscores the tension between objective measurements and subjective experiences in perceiving and assessing this prevalent condition.

Emotional complexities associated with aging

When confronting hypertension, older adults often prioritize self-regulation, motivated either by the realization of their deviation from medical norms or by the adverse effects and diminished efficacy of medication. This focus on bodily function monitoring and management can lead to emotional disturbances, such as distress, depression, anxiety, frustration, despair, loss, and anticipatory grief. Many participants viewed these negative emotions as a sense of powerlessness against aging and the inevitable progression of chronic conditions like diabetes, heart attacks, nephritic syndromes, strokes, and other severe health issues.

Actually, my diabetes is more troublesome than my high blood pressure. It is more frustrating. Usually, I felt nothing about hypertension as long as I took medicine. For diabetes, you have to pay attention when you go out for meals, lots of things to care about. (No. 19)

Heart disease and diabetes. I had three stents already. This is more severe than hypertension. I had it all, no solution to this as aging. (No. 10)

Self-mastery of holistic health

Integrated body awareness and self-care practices

The majority of participants approached hypertension management through a holistic lens, perceiving their body as an interconnected unit. They identified specific physical discomforts such as eye pain, neck stiffness, and backaches as proprioceptive signals of hypertension.

When it (hypertension) hits, my neck, the back, the bottom of body is uncomfortable. Sometimes serious, sometimes tender. This place (neck) is the same as being pinched, felt like I cannot breathe. (No. 10)

With a viewpoint of holistic wellbeing, participants were able to leverage their awareness of bodily signals to collaboratively adjust their medication and lifestyle with healthcare providers, enhancing treatment effectiveness and personalizing care. Together with consistent medication adherence, a commitment to healthy lifestyle choices – regular exercise, balanced nutrition, relaxation techniques – supported effective hypertension management as well. For many interviewees, activities including walking, Tai Chi, and Baduanjin were particularly valued for their metabolic benefits and ability to reduce hypertension episodes, suggestive of the dual advantages of integrating physical activity into their overall health strategy.

I walk every day, [this] makes me feel good. Not too much activity. Moderate walking, regular time to eat, a nap after lunch. When you eat and sleep well, you will have a refreshing status. Of course, it is beneficial for hypertension control (No 1)

Psychological flexibility and ownership of health

Many participants underscored the pivotal role of emotional regulation in navigating blood pressure fluctuations, highlighting psychological flexibility as a cornerstone of hypertension management. This adaptability is perceived as an indispensable internal process, with individuals actively distancing themselves from negative thoughts related to their condition. By adopting a mindset focused on the present and fostering an optimistic outlook, they proactively address hypertension, particularly during episodes of relapse.

I kept optimistic every day, then I feel good. If you are concerned about something, then blood pressure will rise, blood sugar will rise, then you should pay attention to. Otherwise, you will have trouble sleeping or something (No. 1).

Acknowledging the challenges posed by uncontrollable stressors, both within oneself and in interaction with others, participants placed high value on achieving a state of neutral valence; that is, maintaining a mental state unswayed by extremes. Yet, they emphasized the importance of a consistently positive outlook on life and in managing hypertension, viewing emotional well-being as a vital tool for overseeing their overall health.

The most important thing is health for me. If you are obsessed with the negatives or do not let it go, it will harm your health in every aspect, though you had many doctors served. The secret of long- life is to be optimistic. (No. 14)

As many mentioned, mine (hypertension) is under control. I am not nerve wracked in daily life. I try to keep calm. To keep psychological well-being is better than any medication. (No. 8)

These narratives reveal a common thread among interviewed older adults dealing with hypertension: the strategic use of emotional resilience and positivity as essential elements of their health management toolkit. By fostering psychological well-being, they navigate the complexities of hypertension with greater ease and effectiveness, illustrating a profound understanding of the interplay between mental and physical health.

Illness acceptance through meaning-making

Hypertension in older adults serves as both a challenge and a catalyst for significant life reevaluation and transformation. Research by Heine et al. [19] and Park [20] reveals how this condition prompts older individuals to rethink their approach to health and life, leading to increased self-awareness and active engagement in health management. Despite recognizing hypertension as a part of aging, many celebrate their resilience and capacity for self-care, contrasting their situation with that of others who may be less capable and functioning. This realization often motivates a shift towards a more fulfilling lifestyle, marked by regular exercise, social interactions, and engaging in activities that bring joy and satisfaction. This positive adjustment to their health journey emphasizes the importance of proactive health management and the impact of a positive outlook on overall well-being.

When people get older, they get sick. It is a natural thing … In the past two years, I often went out for exercise, go out to meet friends and etc. Once life is interesting, I don’t mind the sickness (hypertension), then my mood is good. (No. 19)

Hypertension is common among old people. You know, the older more or less has symptoms anyway … I see others had dementia, can’t get out of bed or what, but I am still capable. [That is] enough. (No. 17)

Additionally, the process of managing hypertension extends beyond mere physical health strategies and involves a deeper exploration of life’s meanings through various dimensions. Older adults often find purpose and enrichment in their relationships, spiritual beliefs, hobbies, personal development, and contributions to the community. This multifaceted approach to health management reflects a broader understanding of well-being, emphasizing the significance of mental and emotional health alongside physical health. By actively engaging in these areas, older adults not only navigate the challenges of hypertension more effectively, but also enhance their quality of life, highlighting the role of personal growth and proactive health literacy in aging with grace and fulfillment.

I ask for nothing now. I have earned 25 years. Now, I just make every day count. Nothing special to do, just take a walk and keep happy (No. 5)

I take care of myself, so that they (adult children) do not need to worry me. (No. 12)

Discussion

This study delves into the illness cognition experienced by Chinese older adults with hypertension and further explores their effective coping strategies in hypertension management. As a result, the participants reported illness ambiguity in assessing hypertension, primarily due to the chronic nature and the vague bodily symptoms associated. Their emotional response to the illness was predominantly characterized by a sense of loss, as they often perceived hypertension as an inevitable consequence of aging, a symbol of which suggests the decline in strength and health. Furthermore, the acceptance that aging is inescapable, coupled with the belief that hypertension can be managed, led to the establishment of self-care objectives. These objectives were found to be positively linked with adaptive outcomes such as enhanced self-efficacy and improved psychosocial functioning [21, 22]. Notably, Chinese older adults demonstrated a particular inclination towards self-mastery techniques in managing their hypertension, placing significant emphasis on holistic wellness that integrates the body, mind, and spirit.

Illness ambiguity represents a significant form of uncertainty for individuals with chronic conditions like hypertension [23]. This ambiguity is defined as the individual’s struggle to understand their illness due to the difficulty in assigning clear meanings to symptoms with limited or ambiguous information [24, 25]. For those with hypertension, this ambiguity primarily arises from their inability to discern clear causal links between their symptoms and the condition itself. This is particularly challenging when there is a disconnect between objective blood pressure readings and subjective experiences that are not directly tied to tangible sensations, often resulting in heightened anxiety and a sense of vulnerability. As Glas and Dings [26] suggest, illness ambiguity tends to be a diachronic process, oscillating between narrative self-understanding and unreflective engagement with the external world. In coping with this ambiguity, the older individuals interviewed in this study found it challenging to distinguish between self and illness. Instead, they endeavored to construct a definition of health that encompasses the maintenance of holistic well-being, even in the presence of hypertension [27].

In fact, participants’ perception of health in this study resonates with the concept of ‘body and spirit’ as described in the Huangdi Neijing,^[4] which underscores the intricate interplay between physical functioning and psychological well-being [28]. This broader interpretation of the spirit highlights its role as an outward manifestation of human life activities, representing a comprehensive integration of one’s physiological and mental states. In this study, it was evident that older individuals with hypertension placed a significant emphasis on psychological flexibility as the key to managing their condition. Empirical research supports this approach, showing that efforts to sustain psychosocial well-being are instrumental in enhancing medication adherence, which is a crucial factor in effective blood pressure management [29, 30].

Elderly individuals with hypertension who diligently practiced self-care often viewed their successful management of the condition as a favor to their offspring and families by alleviating potential caregiving burdens. Moreover, the ability of an older adult to find meaning in their illness is a significant aspect of hypertension management and contributes positively to the process of aging. A growing body of empirical research suggests that the presence of life meanings in older adults is predictive of a wide range of physical and mental health outcomes over time [31–33]. For most interviewees, health was not merely about the absence of physical discomfort but was linked to an individual’s active involvement in growth-oriented healthy behaviors. This includes leveraging both internal and external resources to cultivate situational and broader life meanings throughout their lifespan.

This study carries two limitations. First, the generalizability of our findings is limited due to the small sample size, the use of a single sampling site, and the reliance on purposive sampling methods. These factors may restrict the extent to which the results can be applied to a broader population. Second, while semi-structured interviews were effective in gathering patients’ perceptions and experiences regarding hypertension management, this approach posed challenges for some interviewees when they were asked to articulate their bodily experiences. To enhance the depth and clarity of future research, it is recommended that additional tools be employed. This includes body scanning techniques or mobile health (mHealth) technologies to assist participants in more accurately conveying the dynamics of their embodied experiences [34].

In terms of implications, findings underscore the importance of incorporating medical humanities and adopting a humanistic approach in medical practice, especially in community health services. By understanding the unique illness experiences and coping strategies of the elderly, medical professionals can tailor hypertension care to better meet individual needs [35]. Engaging deeply with patients’ narratives and self-perceived symptoms offers insights into their self-management practices and medication adherence. This patient-centered approach involves actively listening to patients’ personal stories, understanding their risk perceptions, and providing holistic care options that respect their sociocultural backgrounds [36, 37]. For elderly Chinese patients who often embrace a holistic view of health, integrating hypertension management into a broader health maintenance plan can promote a more cohesive and effective self-care regimen. This aligns with the need for personalized care plans that consider the patient’s entire well-being rather than focusing solely on disease management.

Moreover, enhancing public health education to develop a community-based model of blood pressure control can significantly improve hypertension awareness and management across the population. Emphasizing the importance of medication literacy and the role of lifestyle changes in managing blood pressure can foster a more proactive and informed patient population [38]. Overall, our study advocates for a shift towards more humanistic medical practices that value the experiences and voices of the elderly, offering a more compassionate and comprehensive approach to healthcare that goes beyond traditional medical treatment.

Conclusions

This study provides a comprehensive analysis of how older adults navigate the complexities of hypertension management, focusing on illness ambiguity regarding hypertension as well as self-mastery in holistic health. Findings reveal that the incidental discovery of hypertension highlights its asymptomatic characteristics, complicating the identification of specific triggers for its recurrence. The comparison between non-reflective and reflective management strategies illustrates the importance of a nuanced approach to ensure effective medication adherence and treatment outcomes. Emotional challenges that accompany aging and hypertension emphasize the need for psychological well-being in the management of chronic conditions.

Furthermore, the study underscores the integration of holistic health practices and psychological resilience by older adults, identifying self-mastery of holistic health as a key theme. Participants showed profound understanding of the link between physical health, psychological states, and overall well-being, leading to illness acceptance through meaning-making. This process allows older adults to weave their hypertension experiences into a larger narrative of their lives.

By highlighting the significance of patient empowerment, the findings suggest that healthcare providers play a crucial role in assisting older adults through the intricacies of hypertension management. Such support can lead to enhanced health outcomes and an improved quality of life, showcasing the need for a compassionate, patient-centered approach in healthcare practices.

Corresponding author: Hong Yao, School of Ethnology and Sociology, Minzu University of China, Beijing, China, E-mail: yaoh@muc.edu.cn

Funding source: National Social Science Foundation of China

Award Identifier / Grant number: 23CSH054

Acknowledgments

The authors thank all the participants who shared their perceptions and experiences with us.

Research ethics: This research received approval from the Ethics Committee of the XX Department at XX University (Reference No. EUMUC2023009CO).
Informed consent: Informed consent was obtained from all individuals included in this study.
Author contributions: The authors have accepted responsibility for the entire content of this manuscript and approved its submission.
Competing interests: The authors state no competing interests.
Research funding: National Social Science Foundation of China “A Study on Social Work Intervention on Health Promotion for Rural Elderly with Chronic Illness” (23CSH054)
Data availability: The raw data can be obtained on request from the corresponding author.

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Received: 2024-01-29

Accepted: 2024-03-31

Published Online: 2024-06-19

This work is licensed under the Creative Commons Attribution 4.0 International License.

Artikel in diesem Heft

https://doi.org/10.1515/ajmedh-2024-0002

Schlagwörter für diesen Artikel

hypertension; illness ambiguity; self-mastery; Chinese older adults

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