Discussion 3 For Research Discussion Forum 3: Qualitative Research a. Read the posted article below. b. Respond to the questions below by reviewing the art

  

Discussion Forum 3: Qualitative Research

a. Read the posted article below.

b. Respond to the questions below by reviewing the article and identifying those elements (state the page number you found the element). If you indicate you support the researcher use of the element, make sure your findings are with literature. 

Your critique responses should reflect the following:
1. What type of qualitative approach did the researcher use?
2. what type of sampling method did the researcher use? Is it appropriate for the study?
3. Was the data collection focused on human experiences?
4. Was issues of protection of human subjects addressed?
5. Did the researcher describe data saturation?
6. What procedure for collecting data did the researcher use?
7. What strategies did the researcher use to analyze the data?
8. Does the researcher address credibility (can you appreciate the truth of the patient’s experience), auditability (can you follow the researcher’s thinking, does the research document the research process) and fittingness are the results meaningful, is analysis strategy compatible with the purpose of the study) of the data?

9.  What is your cosmic question? (This is a question you ask your peers to respond to based on the chapter discussed in class this week i.e. Qualitative studies).

Using in-text referencing APA 7th edition and a reference list, submit your initial discussion post 250 words by Tuesday at 1159PM 

Tan CS, Hassali MA, Neoh CF, Saleem F. A qualitative exploration of hypertensive patients’ perception towards quality use of
medication and hypertension management at the community level. Pharmacy Practice 2017 Oct-Dec;15(4):1074.

https://doi.org/10.18549/PharmPract.2017.04.1074

www.pharmacypractice.org (eISSN: 1886-3655 ISSN: 1885-642X) 1

Abstract
Objective: This study aimed to explore hypertensive patients’ perspectives on quality use of medication and issues related to
hypertension management at the community level in Malaysia.
Methods: Focus groups discussion was employed in this qualitative study. A total of 17 hypertensive patients were purposively
recruited. Three focus group discussions with semi-structured interview were carried out at Flat Desa Wawasan, Penang. All the
conversations were audio recorded, transcribed verbatim and thematically analysed.
Results: Three major themes were developed, including medication adherence among hypertensive patients, self-management of
hypertension and patients’ knowledge towards hypertension. Poor medication adherence was found and different strategies were
taken to overcome the barriers towards adherence. Use of herbal and traditional therapies was perceived as alternative method in
controlling blood pressure instead of taking antihypertensive medication. The participants were found to have poor knowledge on side
effect and mechanism of action of hypertensive medication.
Conclusions: The misconception about the side effect of antihypertensive medication has led to poor adherence among the
participants. Lack of knowledge on targeted blood pressure level has led to poor blood pressure monitoring among the participants.
Health awareness program and counselling from health care professional should be advocated among the hypertensive patients in
addressing the above gaps.

Keywords
Hypertension; Medication Adherence; Patient Medication Knowledge; Health Knowledge, Attitudes, Practice; Focus Groups;
Qualitative Research; Malaysia

INTRODUCTION

Hypertension is one of the renowned risk factors
contributing to cardiovascular disease, including stroke,
arrhythmias, coronary heart disease and myocardial
infarction.

1
About 1.39 billion adults worldwide were

diagnosed with hypertension
2
in 2010 and the number is

predicted to increase to 1.56 billion by year 2025.
3
More

than half of the hypertensive patients were unable to
achieve well-controlled blood pressure level despite the
recent advancement in the antihypertensive treatment.

4

Poor medication adherence is one of the contributing
factors that caused uncontrolled blood pressure level
among hypertensive patients.

5-7
The rate of medication

adherence in many developing countries including Malaysia
was reported lower when compared to developed
countries.

8-11

Likewise, in 2015, 30.3% of the Malaysian adults (i.e. 18
years and above) had hypertension, with 13.1% of known
hypertension and 17.2% of undiagnosed hypertension.

12
Of

note, only 26.8% of these hypertensive patients had their
blood pressure under control

13
and up to 46.6% of them

were reported to have poor medication adherence.
14

A
recent local study revealed that a total of 20,799 excessive
pills were returned by hypertensive patients at a single
Malaysian government hospital, with a total cost of
(Malaysian Ringgit) MYR 4,362.28 (equal to USD 1037) was
wasted during the 8 months of study period with an
average wastage of MYR 42.35 (equal to USD 10) per
patient; changing medication by the doctor and death of
patients were the most common reasons accounted for the
wastage.

15

Low rate of adherence to antihypertensive medication has
significantly increased blood pressure and was associated
with higher rate of hospitalization and mortality.

16
Previous

studies have found that many hypertensive patients did not
adhere to antihypertensive medication because they had
wrong perception towards hypertension or they were
unconfident with their antihypertensive medication such as
concern of potential adverse effects.

17-19
Lack of knowledge

about usage of medication and various misleading
perceptions of hypertension management have resulted

Original Research

A qualitative exploration of hypertensive patients’
perception towards quality use of medication and
hypertension management at the community level
Ching S. TAN , Mohamed A. HASSALI , Chin F. NEOH , Fahad SALEEM .
Received (first version): 18-Jul-2017 Accepted: 15-Nov-2017 Published online: 18-Dec-2017

Ching Siang TAN. Bpharm, MSc (Pharmacy Practice).
Program Coordinator. School of Pharmacy, KPJ
International College. Penang (Malaysia).
chingsiang9@hotmail.com
Mohamed Azmi Ahmad HASSALI. BPharm (Hons),
M.Pharm (Clin Pharm), PhD.
Professor of Social and Administrative Pharmacy. School of
Pharmaceutical Sciences, Universiti Sains Malaysia.
Penang (Malaysia). azmihassali@gmail.com
Chin Fen NEOH. BPharm (Hons), MPharm (Clinical
Pharmacy), PhD. Senior Lecturer. Faculty of Pharmacy,
Universiti Teknologi MARA. Selangor (Malaysia).
chinfenneoh@gmail.com
Fahad SALEEM. BPharm (Hons), M-Phil (Pharmacy), MBA,
PhD. Associate Professor. Faculty of pharmacy & Health
Sciences, University of Balochistan. Quetta (Pakistan).
fahaduob@gmail.com

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Tan CS, Hassali MA, Neoh CF, Saleem F. A qualitative exploration of hypertensive patients’ perception towards quality use of
medication and hypertension management at the community level. Pharmacy Practice 2017 Oct-Dec;15(4):1074.

https://doi.org/10.18549/PharmPract.2017.04.1074

www.pharmacypractice.org (eISSN: 1886-3655 ISSN: 1885-642X) 2

inappropriate use of medication especially medication
adherence among community-dwelling hypertensive
patients.

20,21
Furthermore, there is a paucity of local data

about hypertensive patients’ perspective towards quality
use of medication and hypertension management at the
community level. Hence, this study aims to explore
hypertensive patients’ perspectives on quality use of
medication and issues related to hypertension
management among community-dwelling hypertensive
patients in Malaysia. The generated local data from this
study is anticipated to yield different views from previous
studies, such as poorer knowledge among local
hypertensive patients towards hypertension management
compare to the developed country

17
and different

perspective towards quality use of medication compare to
the research studies from the Asia countries.

18,22
The

emerged findings from this study will be useful for
healthcare provider and policy maker in the treatment of
hypertension.

METHODS

Study Design

This study adopted qualitative methodology via focus
group. This qualitative study was based on the COREQ
Consolidated criteria for reporting qualitative research
(COREQ): a 32-item checklist for interviews and focus
groups.

23
Phenomenology approach was utilized in this

study to develop an understanding about patients’ view on
medication and hypertension management.
Phenomenology approach involves the use of the meanings
of living experiences and it is essentially “consciousness of”
or an “experience of another”.

24
Phenomenological

analysts provide a close examination platform of individual
experiences to capture the meaning and common features,
or essences, of an experience or event.

24
The content of

focus group with semi-structured interview guide
questionnaire was prepared based on literature reviews on
patients’ hypertension management and earlier work on
patients’ perceptions on quality use of medication.

17,18,25,26

Three focus group discussions were carried out from
August 2015 to September 2015.

In order to achieve the objectives of focus group discussion,
the content of semi-structured interview was developed
based on the English literatures

17-19,22
which have

highlighted the global hypertension management and
quality use of medication issues encountered by the
hypertensive patients. The participants were asked with
the semi-structured questionnaires and they were
encouraged to interact with each other, exchange ideas
and issues based on their experiences or points of view.

27

The questions were developed in English and translated
into Malay language (the national language) by a
professional translator from a local university. Backward
translation from Malay language into English language was
conducted by another independent translator who was
different from the forward translator. The purpose of back
translation is to maintain the quality control in step
demonstrating. To ensure the inter-translation validity and
similarity of conceptual during the translation,
harmonization is an important process to discuss the

inconsistencies and discrepancies between the source and
the target language versions. The questions were prepared
in an open ended format and were pre tested for content
validity, face validity, and clarity by three pharmacists with
vast experience in pharmacy practice research and further
adjusted after pilot testing with five patients with
hypertension in Penang who were not part of the study
target population. The topic of discussion was then sent to
an independent experienced moderator for further
cleaning. The moderator ensured that topics to be
discussed are up to the level of patients.

Study Sample and Setting

This study was conducted at Flat Desa Wawasan. Flat Desa
Wawasan is a low cost flat which accommodates about
3000 residents in Bukit Mertajam, Penang, Malaysia. With
the collaboration Penang Family Health Development
Association (FHDA) Non-governmental Officer (NGO), this
study could have an established relationship with the
participants in order to produce a better quality focus
group discussion.

23
FHDA is one of the NGO with non-profit,

voluntary citizens’ group which is organized on a local,
national or international level. Posters invitation were put
on the notice board one month prior the event and those
hypertensive patients who were interested in this program
contacted the researchers. Participants were recruited by
using purposive sampling method. The selected
participants represented variation of characteristics and
the potential to provide rich, relevant, valid and
generalizable information. Hence, the selection of the
participant was based on age, living status and the different
range of blood pressure levels. The inclusion criteria were
the following: being diagnosed with hypertension by a
registered medical doctor for at least six months ago,
treated with antihypertensive medication for the past three
months prior to the study and aged 18 years old and above.
Patients with enduring mental health problems or cognitive
impairment were excluded. Initially 20 participants were
invited to participate in the focus group discussion, but
three participants did not turn up in the discussion due to
time constraint. Eventually a total of 17 participants were
divided into three groups which followed the standard
guideline.

28,29
A focus group comprises of 4-8 people are

usually recommended
30

as group exceeded than eight
people are difficult to control.

28

The discussions were focused on the patterns and reasons
of irrational use of medicines, and participants’ perception
and knowledge towards hypertensive management. The
focus group discussion was carried out at the multipurpose
hall of Flat Desa Wawasan. Prior to the focus group
discussion, participants were requested to be seated for at
least 10 minutes before their blood pressures were being
measured. A blood pressure monitoring apparatus (Brand:
Omron® with model HEM-7080) was utilized to monitor
participants’ blood pressure level.

Information sheet was explained and signed informed
consent was obtained prior to the commencement of focus
group discussion. The researcher with experience of a
qualitative research in a previous study

31
, played a role as

moderator and was assisted by six pharmacy students and
two NGOs in the focus group discussion. The participants

Tan CS, Hassali MA, Neoh CF, Saleem F. A qualitative exploration of hypertensive patients’ perception towards quality use of
medication and hypertension management at the community level. Pharmacy Practice 2017 Oct-Dec;15(4):1074.

https://doi.org/10.18549/PharmPract.2017.04.1074

www.pharmacypractice.org (eISSN: 1886-3655 ISSN: 1885-642X) 3

comprised of Malay, Chinese and Indian hypertensive
patients and some of the Indian participants did not
understand English and Malay languages. Moreover, some
of the participants were old and weak in listening.
Therefore the six Indian students assisted the Indian
participants in the translation of questionnaires.

Prior to focus group discussion, moderator introduced his
background and qualification to the participants. Despite of
the personal introduction, moderator also briefed the
participants about the study goals for this focus group
discussion. The moderator encouraged all hypertensive
patients to participate actively in the discussion by giving
several probes. The examples of probes were: how do you
get high blood pressure medications? Elaborate on the
difficulties you were telling about, etc. Eventually every
participant was given an opportunity to add on anything
about medication and hypertension management.

In order to achieve the objective of focus group discussion,
the participants were encouraged to interact with each
other, exchange ideas and issues based on their
experiences or points of view.

27
Malaysia is a multi-racial,

multi-cultural and multi-religion country which comprises
of Malay, Chinese, Indian and other ethnic population.
There are many languages spoken in Malaysia as they are
from different ethnic background. Although Malay
language as national language but some elderly could not
speak well in national language (Malay language) and
English because their education level only up to primary
school and some of them never receive formal education.
Therefore it is inevitable to use multi languages in this
discussion and the pharmacy students played a vital role in
translating the questionnaire to the participants. The entire
questionnaire guide was read in Malay language and was
translated to English, Chinese and Indian language by the
moderator or assistants if requested by the participants. All
the conversation and discussion were audio-recorded and
field notes were utilized when necessary during focus
group discussion. Three focus group discussions were
carried out until saturation of the contents which ranged
from 40 to 60 minutes.

Ethical Approval

Ethical approval [USM-HLWE/IEC/2014 (0003)] was
obtained from Universiti Sains Malaysia–Hospital Lam Wah
Ee Ethics Committee prior to the study.

Data Analysis

After the focus group discussion, all the conversation were
transcribed verbatim into Malay language while listening to
the audiotape by the two project assistants and the data
were counterchecked by the researcher. The field notes
were referred during transcribing process. The
transcriptions were translated into English by two
appointed translator and back translation was performed
to ensure correctness and reliability in linguistic. Textual
data were explored using content analysis method. Textual
data were read several times by the researcher to identify
themes and categories. Numerous codes were identified
and relevant quotes were categorized under each code.
“Open coding” procedure was carried out by writing down
as many categories as necessary to address all aspects of

the content. In order to reduce the number of categories,
the listed categories were filtered by rearranging based on
the priority to produce a new list of categories and sub-
headings. At the same time, another researcher carried out
the same procedure independently to generate the
category system. Then the two lists of categories were
compared and adjustments were made when necessary.
The final list of categories and sub-headings was compared
again with the original transcript to ensure all aspects of
data were identified and tested for constant comparison.
When there were no new themes identified, a conclusion
would be made at this saturation point. In order to add
validity to the study, the research findings were presented
to the participants and feedback were taken to ensure the
participants’ own idea and perception were represented
and not curtailed by researchers’ own agenda and
perspective.

RESULTS

Seventeen hypertensive patients were recruited in this
study. The demographic characteristic of the participants
are shown in Table 1. Most of the participants obtained
their antihypertensive medication at no cost from the
government hospitals.

Three major themes were developed via the thematic
content analysis, including medication management in
hypertension, self-management of hypertension and
patients’ knowledge towards hypertension (Table 2).

Theme 1: Medication adherence among hypertensive
patients

Three subthemes were further identified in the context of
medication management in hypertension.

Table 1. Participants’ demographic characteristics

Description N (%)

Gender
Male 1 (5.9%)

Female 16 (94.1%)

Age (years)
31-40 3 (17.6%)
41-50 1 (5.9%)
51-60 8 (47.1%)
61-70 4 (23.5%)
71-80 1 (5.9%)

Occupation
Private 4 (23.5%)

Unemployed 13 (76.5%)

Living status
Alone 5 (29.4%)

With family 12 (70.6%)

Blood pressure level
50

[mmHg]
Optimal (SBP < 120 and DBP <80) 3 (17.6%)
Normal (SBP < 130 and DBP < 85) 3 (17.6%)

High normal (SBP 130-139 and/ or DBP 85-89) 2 (12.0%)
Hypertension stage I (SBP 140-159 and/or DBP 90-99) 3 (17.6%)

Hypertension stage II (SBP 160-179 and/or DBP 100-109) 3 (17.6%)
Hypertension stage III (SBP ≥ 180 and/or DBP ≥ 110) 3 (17.6%)

Duration of hypertension (years)
1-5 5 (29.4%)

6-10 6 (35.3%)
>10 6 (35.3%)

Tan CS, Hassali MA, Neoh CF, Saleem F. A qualitative exploration of hypertensive patients’ perception towards quality use of
medication and hypertension management at the community level. Pharmacy Practice 2017 Oct-Dec;15(4):1074.

https://doi.org/10.18549/PharmPract.2017.04.1074

www.pharmacypractice.org (eISSN: 1886-3655 ISSN: 1885-642X) 4

i) Medication adherence

Nine participants claimed that they never forget to take
medicine. One participant has a good habit by bringing her
antihypertensive medicine when she travels.

“I take medicine every day. Never forget”. (P1)

“I take medicine every day and I bring my medicine
during visiting to relatives’ houses”. (P3)

However, four participants did not take medication every
day. Three participants missed antihypertensive medicine
for 2 to 3 days in a week. The reasons given were too busy

Table 2. Patients’ quotes about their views on quality use of medication and hypertension management

Subthemes Quotes

Routine-lifestyle I take medicine every day. Never forget. (P1, P16,P17,P18)
I take medicine every day. I never forget to take medicine. (P2)
I take medicine everyday even though I brought my medicine during visiting to relatives’ houses. (P3)
Sometimes I forgot to take medicine. About 2-3 days in a week I forgot to take medicine. (P4)
I only take hypertensive medicine 2-3 days in a week (P13)
Sometimes when I felt tension then I take medicine. (P5)
I rarely took medicine because I have many concerns about medicine especially it would interfere with my
thought and turn to be less intelligent. (P12)
Yes I bought medicine for migraine and headache only. (P7)
Never stop medicine because I am the only one who diagnosed with high blood pressure. (P10)
I also never share antihypertensive medicine because it may cause death. (P14)
I took my medicine every day before going to work as a habit. (P5)
I must be remembered to take medicine every day as have been suffering from high blood pressure. (P8)

Factors affecting medication
compliance

Suppose my antihypertensive medicine should be taken after meal but sometimes I took it before meals.
(P1,P3,P8)
I am afraid to take medicine before meal because I felt stomach empty. (P5,P7,P9)
In early morning, I take all medicines at once before going to work although some of the medicines should
be taken either before or after meal. (P10)
I don’t care whether the medicine need to be taken before or after meal (P15)
I was bored with the medicine. (P5)
Feeling tired because I had been taking medication for a period of 10 years. (P8)
I felt nausea when taking medicine (P16)
Sometimes I feel tired and afraid of hair loss. (P6)
I fear the side effects of the drug and the consequences of causing cancer, so I will eat more fruit like apples
rather to take antihypertensive medicine every day. (P4)
I think my high blood pressure medicines are not suitable to me. It causes me headache and dizziness. So I
did not take it regularly. When I felt uncomfortable and backache, then I will take the medicine, otherwise I
would not take it. But every month I still collect my hypertensive medicine from hospital. (P5)

Barriers No problem because family members were willing to send me to hospital. (P13)
I have vehicle to go to the hospital. (P14)
I don’t have problem of transportation. (P15)
I have problem in getting transportation because hospital is too far. (P15)
I have problem of transportation. (P16)

Facilitator/ reminder I have problem of transportation but a nurse (NGO officials) will help the patient to collect medicine from
hospital, so I share my medication problem with her (P2,P4,P14)
I prefer to share my medication problem with member of the NGO because they know me well. (P5, P9)
I like to discuss medication problem with Ms. Jaya (NGO officer)who always take medicine for me (P3,P6,
P8)
I have chosen pharmacist because they are drug expert. (P8)
I would happy talk my medication problem with NGO who can remind me to take medicine. (P13)
I will share my medication problem with NGO officer. (P17)
I keep in a plastic bag. I will write or record in a book when taking medicine to avoid from forgetting
because I am stroke patient. (P9)

Financial I have no problem because I received medicine from government hospitals. (P3)

Side effect I have hair loss problem after taking antihypertensive medicine. (P9)
I felt uncomfortable and also feel dizzy. (P14)
I felt drowsy, sleepy and tired. After wake up from sleeping, I felt normal. (P16)

Storage I keep inside refrigerator and on the refrigerator.(P3)
I keep in the cabinet at home. (P6)
I prefer to put inside tupperware containers (P8)
Now hospital only supplies 1 month medicine, so not much medicine need to be kept in house. (P12)

Solutions I will sit and relax. Then I will eat Panadol
®
(Paracetamol). (P12)

I will take Paracetamol when high blood pressure cause me headache (P2,P5)
I will go to pharmacy buy Panadol

®
if high blood pressure cause me headache (P7)

I will take my high blood pressure medicine together with Panadol
®

when headache (due to high blood
pressure) (P14,P17)
I will take Tramadol

®
medicine. (P3)

I would feel very emotional and angry when my blood pressure is high. Then I will take high blood pressure
medicine and then sleeping. (P9)
I will sit at a side and rest (P4)
I prefer have a rest when feel headache (due to high blood pressure) (P8)

Tan CS, Hassali MA, Neoh CF, Saleem F. A qualitative exploration of hypertensive patients’ perception towards quality use of
medication and hypertension management at the community level. Pharmacy Practice 2017 Oct-Dec;15(4):1074.

https://doi.org/10.18549/PharmPract.2017.04.1074

www.pharmacypractice.org (eISSN: 1886-3655 ISSN: 1885-642X) 5

with work, concerned about side effect of medication,
bored with the medication and felt inappropriate use of
their antihypertensive medication by doctor.

“Sometimes I forgot to take medicine. About 2-3
days in a week I forgot to take medicine”. (P4)

“Sometimes when I felt stress then I take
medicine”. (P5)

In the context of taking antihypertensive medicine at
appropriate time, eight participants took antihypertensive
medicine at wrong time without differentiate whether the
medication should be taken prior or after meal. The
reasons were too many medications to be taken and have

confused with the item to be taken with empty stomach or
after food.

“Suppose my antihypertensive medicine should be
taken after meal but sometimes I took it before
meals”. (P8)

“I am afraid to take medicine before meal because
I felt stomach empty”. (P9)

“I rarely took medicine because I have many concerns
about medicine especially it would interfere with my
thought and become to be less intelligent”. (P12)

Table 2 (cont.). Patients’ quotes about their views on quality use of medication and hypertension management

Subthemes Quotes

Herbal/ alternative medicine I used to eat a traditional medicine in the form of seeds to control blood pressure. (P9)
I like to take herbal medicine to control my high BP (P2,P15)
I used to take the herbal medicine / traditional medicine in the form of small tablet to control my high blood
pressure (P13)
I prefer to visit Chinese Sinseh to get some herbal medicine to control my high blood pressure. (P8)
I always take my herbal supplement to control my high blood pressure (P10)
I trust to herbal medicine and that’s why I always keep it at my house and take it to control for my high
blood pressure. (P14)
I will drink Chinese tea to “wash” my blood. (P1)
I have never taken herbs, herbal remedies or traditional medicine to control blood pressure. (P5)
I don’t take herbal medicine to control my high pressure (P3, P11,P12)
I am not familiar with herbal medicine. (P17)

Checking of blood pressure I check my blood pressure (level) at every month. (P4)
I check blood pressure level at every 3 to 4 month which is during my appointment with doctor. (P6)

Signs and symptoms I felt dizziness and sleepy. (P6)
I would have a feeling of dizziness and tightness at the neck after eating beef which may increase my blood
pressure. (P9)
I was notified by doctor when my blood pressure increased. (P7)
When I forgot to take medicine, I would feel the symptoms like dizzy and neck stiffness. Then I would take
high blood pressure medication. (P2)
I feel dizziness and headache (P3,P4)
Definitely is dizziness (P5)
Dizziness and headache! (P8)
I think is dizziness. (P10)
Obviously is dizziness (P11,P12)
I felt sweating and headache (P13)
I felt hot and sweating then start heachache (P14)
Sweating….headache and blur vision (P16)

Learning I got the knowledge from education talk and health briefing. (P8)`
My NGO officer always share with me the knowledge of hypertension. (P15, P16)
I always receive hypertension counselling from hospital pharmacists. (P13)
I always join to the education talk nearby my house (P1)
I like to attend educational talk (P3, P5)
The health talk gave me a lot information (P6)
I learn hypertension management from the health education talk (P2)
Definitely education talk taught me a lot (P7)
I received a lot of information (hypertension management) from TV (television) and radio. (P12)
TV and Radio gave me a lot health information (P8, P17)
I used to read health information from Facebook (P10)

Medication recognition I do not know the name of the drug, but usually takes a sample of the drug. (P7)
I have forgotten and do not know the name of the medicine. (P8)
I do not know.

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