Exploration of families' experiences in managing hypertension control in Denpasar, Indonesia : a qualitative study

Background: Hypertension is understood to be a lifestyle disease and is most commonly experienced in adulthood. The prevalence of hypertension in Indonesia among individuals aged ≥18 years old in 2018 was 34.1% (Ministry of Health Republic of Indonesia, 2018). In 2012 hypertension was a major cause of hospitalisation in Indonesia, with cardiovascular diseases and stroke being the main reasons for deaths in hospital (Centre for Data and Information, 2012). The current hypertension management model in Indonesia follows the Ministry of Health, Republic Of Indonesia's guideline and is focused on the individual patient. The individual approach to hypertension control may not be the most appropriate if families have a significant influence on daily practices and all matters of particular relevance to those members who are affected by hypertension (Tull et al., 2013; Ribeiro et al., 2011). Family life in Indonesia reflects an inter-generational family structure, with families living together in one house. Given the importance of intergenerational families and family life, daily hypertension management often goes beyond the patient and includes other family members such as the marital partner, children (adult and dependent) or grandchildren. It is this complexity and interaction within and between family members that requires an in-depth exploration into how patients and their families deal with the day-to-day management of hypertension and thus this is the unique contribution of this study. Aim: The aim of this study is to understand families' experiences in managing hypertension control on a daily basis in Denpasar. Methodology: This focused ethnographic study draws on General system theory, the agency-structure concepts, and Protection motivation theory. Semi-structured interviews (individual, dyadic, and group), and participant observations were conducted with 11 families (44 individuals participants) in Denpasar. The individual interviews were conducted with 13 participants, dyadic interviews with 9 couples, and group interviews with three families. The participant observations were carried out between February - July 2016 at the families' premises, clinics, and parks in Denpasar. The data was analysed using Coffey and Atkinson's (1996) approach to analysing qualitative data; included in the process are: coding, generalising and theorising. Findings: The most important insight from this study is that hypertension is not controlled by the individual patient alone, but that there are dynamic processes within families that influence daily hypertension control. This finding shows that the government's intervention approach, which is informed by a focus on the individual patient, may not be relevant for hypertension management in Indonesia. The main theme that emerged from the analysis is 'the family as a dynamic system in mediating the control of hypertension'. This main finding is substantiated by four aspects: 1) the roles and responsibilities in the family, 2) the economic status of the family, 3) stresses and coping processes in the family, 4) the presence and absence of any hypertensive symptoms. The dynamic process of hypertension control is firstly influenced by the roles and responsibilities in the family, which in particular refers to each patient's roles and responsibilities as a grandparent and as a member of wider social systems. Secondly, the economic status of the family was found to be a significant aspect of family dynamics that often obliged the participant patients, as well as the other family members, to compromise their diets. Thirdly, hypertension control was dynamic because of stresses and the coping process, as this research has revealed the family can be both the sources of stress and relief for individuals. Lastly, the family members' support was triggered only in the presence of a patient's hypertensive symptoms. Conclusion: Decisions that individual family members make to control hypertension are made within the context of wider family dynamics, including the prescription of medication, diet, undertaking physical exercise, and the management of stress. This study pointed out the various processes in the family have challenged the patients' ability to control hypertension. Thus, to have an understanding of a family's readiness to provide care at home is important in order to improve illness management and prevent relapses. This study's results can be interpreted as an evaluation of non- communicable diseases (NCDs)-related policies and associated regulations. Evaluations are needed to ensure NCDs management related improvements to mitigate health inequalities in Indonesia.