Patients with recently diagnosed hypertension described risk in terms of acceptance and denial narratives, which served as personal frameworks of coping
11 patients (6 men and 5 women, 41–82 y of age) who were diagnosed with hypertension in the previous 6 months.
Patients participated in 30–45 minute interviews that explored perceptions of risk in general, risk to health, and risk in the context of the new diagnosis of hypertension. Interviews were recorded and analysed using constant comparative methods. Patterns and discontinuities were identified from participants’ use of language to describe risk. The “risk” narratives that emerged were then examined for conformity and variation.
The personal narratives of individuals provided an understanding about how participants described risk. Individuals presented a coherent personal position about risk in general or in relation to the diagnosis of hypertension. 2 main types of narratives were noted: denial narratives and acceptance narratives. These narratives served as personal frameworks for dealing with risk.
In denial narratives, participants described themselves as not being at risk (risk deniers) because they did not expect things to happen to them or because they had taken steps to deal with the risk, thereby avoiding the consequences. Such “distancing” of risk, shown in participants’ responses of “not thinking about risk,” was seen as an important way of coping. At the same time, many participants with denial narratives demonstrated knowledge of the risks associated with hypertension and appropriate responses to these risks. For example, a 41 year old woman who was not easily engaged in a conversation about risk seemed to suggest that “not thinking about risk” was a choice, which she rationalised, in part, by the lack of symptoms associated with hypertension: “Another thing with blood pressure is that you don’t know that you’ve got it really because you haven’t got any problems like making you feel ill…And it’s I don’t think you worry so much.” However, she also demonstrated an understanding of the relation between hypertension and stroke.
In acceptance narratives, participants described risk in terms of an everyday unavoidable phenomenon to be accommodated as a normal part of everyday life (risk acceptors). Such normalisation of risk can also be seen as a way of coping with risk. For example, a 77 year old man said “…life is risky isn’t it? I mean you have to accept things haven’t you?” But when speaking about a possible transient ischaemic attack that he had experienced, he stated “…have to put things in order because er…this could happen again.”
Some narratives suggested conflicting positions. For some participants who used a denial narrative, a diagnosis of hypertension created conflict (ie, being free of risk and having hypertension). For example, a 44 year old man initially described himself as a healthy, worry-free person, who did, however, have a family history of heart disease. He felt angry that his physician felt that his father’s history of heart disease influenced the decision to treat his own hypertension: “Well, me father died very young, maybes that’s always on the back of your mind you know…” and then “if it hadn’t been me dad I don’t think I would have got them tablets…and I didn’t…in my mind I didn’t think that was right giving me them tablets ‘cause of them…” and “I’ve got it on the back of me mind, I’m thinking well in twelve months time me dad did die at forty five…and like, well come February I’ll be forty five…” “…I’m contradicting, aye I know.”
Patients with a recent diagnosis of hypertension demonstrated their understanding of risk in terms of risk acceptance and risk denial narratives. Both types of narratives seemed to function as a way of coping with risk.
- Carol Jillings, RN, PhD
The study by Weaver et al is small but provides important insights into the understanding of the concept of “risk” as perceived by patients with hypertension. Soliciting narratives in the context of healthcare provider-client interviews adds depth to the assessment process and allows practitioners to discover client perspectives on hypertension, including health beliefs and coping behaviours. These data can form the basis for both immediate educational interventions and long term provider-client partnerships in hypertension management and risk factor modification. Although the time required for eliciting narratives may be unrealistic in many primary care settings, this foundational activity may be “time well spent” as an investment in therapeutic relationships that will engage clients in a process of self management over the long term.
The discovery and description of “denial” and “acceptance” narratives is noteworthy but not for the reasons one might suspect. Although the accounts of both perspectives are instructive, the notion of a “spectrum in between” is perhaps most interesting. Examples from the data, which were categorised as denial or acceptance, often reveal elements of both risk perspectives. These nuances alert readers to the hazards of categorising beliefs and behaviours. Indeed, even the authors acknowledge that orientations to risk are not static aspects of personality and may change over time. An important implication for practice is that hypertension management must be perceived as a process within a relationship that integrates a client’s perspective into the treatment plan aimed at risk management or reduction. The study by Weaver et al contributes to the body of evidence supporting shared approaches to chronic illness management and underscores the need for careful and caring client assessment as a basis for developing a plan of care.
For correspondence: Dr N F Weaver, UK.
Source of funding: RCGP Scientific Foundation Board Grant.