Background
Methods
Design
Participants
Data collection
Domain of Inquiry | Questions |
---|---|
Attitudes and knowledge of hypertension | Does high blood pressure worry you? Tell me why. What do you think might happen as a complication from high blood pressure? What would make life better for people with high blood pressure? Any final thoughts for what you think may achieve good blood pressure control? |
Current SMBP behaviors | Do you get your blood pressure regularly checked? (probe for public device use, availability of home monitor) |
Barriers and facilitators to SMBP | Do you face difficulties in getting your blood pressure checked regularly? What are they? Do you think your monitor is accurate? Why? In what ways has the refugee experience impacted your hypertension management? |
Data analysis
Trustworthiness of data
Ethical approval
Theoretical framework
Results
Iraqi n = 85 | Syrian n = 24 | All n = 109 | ||
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Age, years (mean, SD) | 63 (9.2) | 53 (7.6) | 61 (9.7) | |
Years in the U.S (mean, SD) | 10.6 (6.2) | 6.0 (1.3) | 9.6 (5.8) | |
Gender | ||||
Female | 44 (51.7) | 9 (37.5) | 53 (48.6) | |
Male | 41 (48.3) | 15 (62.5) | 56 (51.4) | |
Marital Status | ||||
Married | 70 (82.4) | 22 (91.7) | 92 (84.4) | |
Divorced | 3 (3.5) | 0 | 3 (2.75) | |
Widowed | 11 (12.9) | 2 (8.3) | 13 (11.9) | |
Never Married | 1 (1.2) | 0 | 1 (0.95) | |
Highest level of education | ||||
Less than high school | 29 (34.1) | 13 (54.1) | 42 (38.5) | |
High school | 18 (21.2) | 9 (37.5) | 27 (24.7) | |
Vocational certificate | 15 (17.6) | 1 (4.2) | 16 (14.7) | |
Undergraduate | 18 (21.2) | 0 | 19 (17.5) | |
Postgraduate | 5 (5.9) | 1 (4.2) | 5 (4.6) | |
Employed | ||||
Yes | 13 (15.3) | 2 (8.3) | 15 (13.8) | |
No | 72 (84.7) | 21 (87.5) | 93 (85.3) | |
No Response | 0 | 1 (4.2) | 1 (0.9) | |
Annual income | ||||
Less than $15,000 | 49 (57.6) | 18 (75.0) | 67 (61.5) | |
$15,001 - $25,000 | 26 (30.6) | 5 (20.8) | 31 (28.5) | |
$25,001 - $35,000 | 7 (8.2) | 0 | 7 (6.4) | |
$35,001 - $50,000 | 2 (2.4) | 0 | 2 (1.8) | |
$50,000+ | 1 (1.2) | 1 (4.2) | 2 (1.8) | |
Proficient in English | ||||
Yes | 33 (38.8) | 5 (20.8) | 38 (34.9) | |
No | 52 (61.2) | 19 (79.2) | 71 (65.1) | |
Do you think you have hypertension? | ||||
Yes | 77 (90.6) | 14 (58.3) | 91 (83.5) | |
No | 4 (4.7) | 4 (16.7) | 8 (7.3) | |
I don’t know | 5 (5.9) | 5 (20.8) | 10 (9.2) | |
Can you give us a value or a number if we asked you about your own blood pressure? | ||||
Yes | 67 (77.9) | 18 (75.0) | 85 (78.0) | |
No | 16 (18.6) | 4 (17.4) | 20 (18.3) | |
I don’t know | 3 (3.5) | 2 (8.7) | 5 (4.6) | |
When was the last time you had your blood pressure checked? | ||||
Less than a month ago | 72 (84.7) | 21 (87.5) | 93 (85.3) | |
1–6 months ago | 10 (11.6) | 2 (8.7) | 12 (11.0) | |
6–12 months ago | 3 (3.5) | 1 (4.3) | 4 (3.7) |
Clinical factors
SMBP through public devices presents barriers
There are always long waiting lines [at the pharmacy] and I feel like my blood pressure increases more just by waiting in line. (Male, 56).
There is no privacy when measuring your blood pressure at the pharmacy; everyone is staring at your reading. (Female, 52).
Sometimes I used to go to [a pharmacy] and use their public device. After the pandemic, they stopped so I had to stop. (Male, 48).
Before the pandemic, I used to use the pharmacy’s device to measure my blood pressure, but now I bought a device. (Male, 63).
Sociodemographic factors
Poor hypertension literacy hinders SMBP
My daughter is the one that helps me and measures [my blood pressure] for me. I do not know how to use the device. (Female, 53).
I genuinely do not know how to use [my home device] and turn it on. I need to learn how. I am being transparent with you because I really want to learn since I can’t keep relying on my son to come and help me with it, he has his own busy life and schedule. (Female, 57).
My neighbor helps me out when I need to measure my blood pressure since I do not know how to read the measurements… I do not measure it if she is not home to help me. [This bothers me] because [hypertension] is serious. I need to know when my blood pressure is high in case I need to be hospitalized as mentioned by my doctor. (Female, 49).
Affect
Fear and anxiety from hypertension impact monitoring
[Hypertension does worry me], of course. I heard that hypertension can cause heart attacks and other diseases. Therefore, I always measure my blood pressure and make sure I am managing it. And recently I have developed anxiety and I talked to my doctor about it. This anxiety stems from my fear of something happening to me and leaving my kids on their own. (Male, 47).
Yes, [hypertension] worries me a lot, especially when I go to the doctor’s appointment and I have already taken my medication, eaten well and still see that my blood pressure is high. It really surprises me. Then I go home and check it and it is still high. I keep checking and after 24 hours, it is still high. (Male, 51).
When I see that my blood pressure is high, this triggers my anxiety and then this anxiety causes my blood pressure to increase… So, I try my best not to increase my blood pressure, thus, I decided not to measure my blood pressure regularly. I get so scared to see a high reading, so I avoid measuring. (Female, 62).
Usually, [I measure my blood pressure] once a month or once every three weeks, but when I see it is higher, I start drinking a lot of water and drinking lemons. After one hour, I measure it… or every two to three hours until it decreases all the way to normal. (Male, 51).
I heard and read a lot about the disease and how people manage it; I have a friend who was diagnosed with hypertension, yet she never believed it and felt fine. I heard about how pharmaceuticals capitalize on hypertension medications and emphasize the selling of medications. So, I guess with all these conflicting ideas my worry about hypertension fluctuates if it ever existed in the first place. I even do my own research and I never find a solid answer about how to manage hypertension. Same thing goes for the discrepancies in doctors’ opinions. Every time a different doctor gives a different opinion about hypertension… I am not convinced with the disease. (Male, 55).
Utility
Belief in inaccuracy of home monitor discourages its use
Sometimes [my home device is inaccurate]. When I measure three times, I get different readings. (Female, 52).
I am not fully convinced with the accuracy of my home device. However, when I am at the clinic and measuring my blood pressure over there, I always find discrepancies between my clinic readings and home readings. Usually, the clinic’s device gives higher readings. (Male, 46).
There is a difference between the clinic’s reading and home reading. At the clinic, [my blood pressure] is usually higher, so I don’t know. Maybe it is because I get more anxious at the clinic. (Male, 46).
I do not [monitor my blood pressure] regularly… As I told you my home device is old, maybe with a new device I will start measuring more regularly. (Female, 51).
No [I do not measure regularly], only every two months because I have to go to the pharmacy to measure it. My home device is not accurate. (Male, 80).
At this point, I know that my device is within two degrees of error from the clinic’s device, however, I still measure my blood pressure using my device and then I estimate my actual blood pressure by subtracting two points from my device’s reading. (Male, 36).
SMBP is not a priority in hypertension care regimens
I am not that invested in my blood pressure. I am already preoccupied with my diabetes and insulin shots. (Female, 57).
I used to measure my blood pressure regularly, but when I started taking my medications, I stopped and started measuring my blood pressure every 15–20 days… [I used to keep a journal for my blood pressure] for about a month… Now I do not really [worry about checking my blood pressure]. (Male, 56).
Whenever I am measuring [my blood pressure], it is mostly for reassurance. I count more on my medications [for my hypertension management]. (Male, 49).
I was never [prescribed a device]. My husband had open heart surgery so that is why he was given one. [My doctor did not advise me to measure my blood pressure regularly]. (Female, 51).
If my doctor tells me to measure my blood pressure I would do it, however my doctor does not tell me, and I feel normal. If I ever feel dizzy or have any other symptoms, I will definitely measure my blood pressure. (Male, 73).
Norms
Cultural stigma of illness as a barrier to SMBP
Culturally as Arabs, we refuse to admit that we are sick, so we tend to neglect our health. (Female, 40).
The fear comes from the cultural and social stigma perpetuated by our family members and friends. They might make you more anxious about your health and well-being by trivializing the importance of keeping up with one’s own health. I can commit to this intervention and the next day I will find my family and friends questioning my health and telling me undesirable jokes about being fixated with my own health. (Male, 46).
The idea of taking my blood pressure in front of my kids and showing them that I am sick makes me feel uncomfortable. (Male, 56).
Habits
Hypertension symptoms trigger SMBP
When I feel frustrated, or heating up, or agitated, I know that my blood pressure is high. This immediately prompts me to measure my blood pressure and take medications to manage it. (Male, 47).
When [I sense my blood pressure] gets high, I start measuring it every three minutes and more frequently. (Male, 68).
I do not [monitor my blood pressure regularly], just when I feel extra tired. Sometimes I check three to four times a day on the days when my symptoms are extreme. (Female, 62).
When I feel better, I tend to forget to measure my blood pressure. (Male, 66).
Facilitating factors
Family members’ roles as caretakers in SMBP
Yes, [I need help measuring my blood pressure]. [My husband and I] alternate in helping each other measure our blood pressure. (Female, 63).
When I get migraines, I ask my husband to measure my blood pressure at home. This prompts him to give me my hypertension medications. (Female, 51).
My wife [reminds me to measure my blood pressure]. We also use the same device. (Male, 65).
I do not [measure my blood pressure regularly], only when my wife pressures me to measure it. (Male, 55).