An inquiry into medication meanings, illness, medication use, and the transformative potential of chronic illness among African Americans with hypertension

Abstract

Background

Hypertension is a chronic illness with serious economic and clinical consequences. The asymptomatic nature of this condition contributes to the challenge of persistent medication use.

Objectives

The objectives of this qualitative study were to explore perceptions of medication meanings, illness, identity, and biographical disruption among people with hypertension, and to examine how salient themes and categories relate to medication use.

Methods

In-person interviews were conducted with 20 participants. Eligibility criteria included being 18 years or older, diagnosed with hypertension, and currently taking antihypertensive drug treatment. Interviews were tape-recorded and transcribed. Data were analyzed with grounded theory methodology using coding techniques and constant comparison.

Results

All participants were African American and most were between 45 and 64 years. Key themes including perceptions of the medication being effective, lifesaving, part of life, and a reminder of the regimen were found to have a positive impact on medication use. Themes including fear of side effects, fear of dependency, forgetting to take medication, the medication being a hassle, and the experience of medication-related sexual side effects were found to be negatively related to medication use. Participants were cognizant of consequences of uncontrolled hypertension, and illness control was important to them. Biographical disruption was minimal. Taking medications and changing diet were the most significant changes in the lives of participants after being diagnosed with hypertension. Achievement of lifestyle modifications had a positive impact on identity.

Conclusions

Findings contribute to our understanding of medication use behavior and have implications for patient education and counseling.

Introduction

Cardiovascular disease and stroke have been identified as the first and third leading causes of death, respectively, in the United States.¹ Hypertension is well recognized today as a leading risk factor responsible for coronary heart disease.² Results from the 1999-2000 National Health and Nutrition Examination Surveys indicate that hypertension and prehypertension were prevalent in approximately 60% of the adult US population with evidence of a 10% increase in hypertension prevalence during the past decade.³ However, hypertension control was reported only in 31% of individuals diagnosed with hypertension.³ Over the last 3 decades, a number of effective medications have been discovered, developed, and improved for the treatment of hypertension. Medication adherence is crucial to hypertension control and has generally been defined as consumption of 80% of the prescribed antihypertensive medication.4, 5 Only 50% of people with hypertension regularly follow advice concerning dietary regimens, physician appointments, and drug therapy.⁶ Hypertension, termed the “silent killer,” is primarily asymptomatic,⁷ resulting in an absence of a compelling reason to persistently take medication. This aspect of the condition contributes further to challenges related to medication use.

During the last 30 years, sociologists, anthropologists, nurses, and other qualitatively oriented health researchers have developed a comprehensive theory of chronic illness and the role of medication in illness management.8, 9, 10, 11 This theory is strongly influenced by symbolic interactionism social constructionism.12, 13 On this account, the impact of illness is not the direct result of physiological defects or physical impairments. Instead, it is shaped by personal and cultural interpretive processes that give meaning to the lived experience of illness.14, 15 To understand how and why patients follow (or choose not to follow) treatment regimens, one must understand the meanings that individual patients attach to their illnesses and their treatments.16, 17, 18, 19, 20, 21

Meanings are described as “fundamental to people in perceiving, interpreting, and defining symptom states and in motivating them to seek care”²² and play an important role in the formation of human behavior. According to the symbolic interactionist notion, meanings are derived from social interaction, and emerge from individual and collective interpretations.¹² These meanings, therefore, do not arise in a vacuum. Rather, as many authors have noted, the significance of an illness can be understood in relation to the sick person's unique identity, biography, and cultural background. Identity refers to “attributes, actions, performances, and appraisals of self.”²³ Chronic illness can disrupt plans, performances, and meanings, which formerly contributed to valued appraisals of self, resulting in loss of previously valued self-image or appraisal without reconstruction of a new, valued self-image, an experience described as “loss of self.”²⁴

Related to loss of self is the concept of biographical time. The 3 major dimensions of biography are conceptions of self, biographical time, and body.²⁵ Biography revolves around time and biographical time refers to past, present, and future time in which self-conceptions are formed and embedded.²⁵ Chronic illness interrupts performances and biographical time resulting in what is termed “biographical disruption.”²⁵ The 2 related notions that (a) chronic illness brings about a loss of self,12, 21, 22, 23, 24, 25, 26, 27, 28 and (b) chronic illness constitutes a biographical disruption,29, 30, 31, 32, 33, 34 have become cornerstones of qualitative research on chronic health problems. Against this theoretical backdrop, the goals and motivations underlying a chronically ill person's treatment decisions become clearer. People with chronic illness are primarily motivated to slow or reverse the illness-induced loss of self and to restore continuity to their disrupted biographies.³⁵ Understanding the ill person's situation in these terms allows one to make predictions about treatment adherence. If a recommended treatment is perceived to assist in slowing or reversing loss of self or in restoring continuity to one's biography, then the recommended treatment will be followed. If it is perceived to obstruct goals related to identity or biography, then recommendations may be modified or ignored.36, 37

This general perspective on chronic illness has stimulated a large body of research and has led to important insights into the experience and management of chronic illness. However, most of the work in this tradition has focused on people with serious, often life-threatening, illnesses, injuries, and disabilities. The illnesses studied, including schizophrenia,³⁸ chronic fatigue syndrome,³⁰ major depression,³⁹ multiple sclerosis,³¹ asthma,⁴⁰ and epilepsy,⁴¹ among others, are often serious enough to cause unambiguous biographical disruption and loss of self. Studies of such serious illnesses illustrate important themes and demonstrate how people grapple with problems more or less successfully. But not all chronic illnesses are the same. Some illnesses, such as hypertension, are largely asymptomatic. There is a paucity of research on whether and to what extent the themes of identity damage, medication meaning, loss of self, and biographical disruption resonate among people with less obviously intrusive illnesses.

Investigating the impact of medication and illness meanings on medication use in hypertension and the effects of identity transformation and biographical disruption is significant in increasing our understanding of how people manage this condition, its prescribed medication regimens, and the associated impact on daily life. To explore these questions, we chose to interview people with hypertension. The purpose of this study was to explore and describe the salient themes, patterns, and categories in participants' meaning structures related to medications, illness, biographical disruption, and medication use, and to examine how these patterns can be linked with one another. In doing so, we sought to extend and elaborate on the themes of identity change, medication meaning, and biographical disruption that have been so central to the sociological analysis of chronic illness.