Being as an iceberg: hypertensive treatment adherence experiences in southeast of Iran

Figures & data

Table 1 Characteristics of the participants (n=18)

Participant	Gender (male/female)	Age (years)	Experience of illness/living with hypertensives/work (years)	Job/relative to patient
Patients	5, 5	38–74	2–25	Pensioner: 5 Employee: 1 Teacher: 1 Housewife: 2 University Lecturer: 1
Family member	1, 3	20–40	1–25	Daughter Wife Sister Son
Healthcare team	2, 2	27–45	5–12	Nurse: 2 Physician: 2

Table 2 Example of questions

Participant	Question
Patients	1) How much is your blood pressure? Is it controlled?, 2) In your daily living, how do you adhere to hypertensive treatment regimen?, 3) How about physician's recommendation about diet and medication?, 4) What about exercise?, 5) In your experience which factors affect your adherence?
Family members	1) Does your patient adhere to his/her treatment regimen?, 2) What did you do to make your patients adhered to his/her regimen?, 3) In your daily living with a hypertensive patient which factors facilitate her/his treatment adherence?, 4) What were the barriers?
Healthcare providers	1) Do your hypertensive patients adhere to their treatment regimen?, 2) In your daily care of hypertensive patients which factors affect their treatment adherence?, 3) Which factors were related to healthcare system and healthcare providers?

Table 3 Example of qualitative content analysis process

Meaning unit	Condensed meaning unit	Code	Subcategory	Category	Subtheme	Theme
When I take Amlopres, my blood pressure fall to 12 and it makes me not to be fine, i.e. when my blood pressure is 16, I feel better than when it is 12. (Patient No. 8)	By improving blood pressure the symptoms were manifested	Appearance of symptoms by blood pressure improvement	Get the habit to hypertension	Being connected to the nature of disease and treatment	The floating platform of the hypertensive treatment adherence iceberg	Hypertensive treatment adherence as an iceberg
Since I have done regular checkups in previous years my hypertension was detected, otherwise I had no hypertensive symptoms such as dizziness or being uncomfortable. (Patient No. 9)	No symptoms were seen during increasing of blood pressure	Lack of symptoms during hypertension	Hypertension as a silent illness
I feel that my body has not adapted to Losartan and Metoral. At first, I tried to adhere to Doctor's prescription to take half of the pills, and then I took one pill in the morning and one at night, but with no effect. (Patient No. 8)	The prescribed medication and frequent changes of medication had no effect on the patient	No hypertension control despite frequent changes of medication	Hypertension as a resistant illness
She took the medication for some days, the medication was not consistent with her body and she coughed severely, so severely that it seemed her tonsils were coming out. It was very bad. (Patient's daughter, No. 1)	The patient coughed severely while taking medication	Coughing after taking medicine	Medication adverse effect
The patient does not like to take multiple medications. For example, they argued that why do they have to take three medications to reduce blood pressure of 14/9! (Physician No. 12)	The patients were reluctant to take multiple medications for mild high blood pressure	No tendency to take multiple medications for mild hypertension	Need to consuming more drugs

Table 4 Theme, sub-themes, categories, and subcategories

Theme	Sub-theme	Category	Sub-category
Hypertensive treatment	The tip of the hypertensive	Being connected to the	Diet regimen
adherence as an	treatment adherence	healthy regimen	Medication regimen
iceberg	iceberg		Monitoring
			Exercise
		Being connected to the	Smoking
		unhealthy regimen	Stress
	The floating platform of the	Being connected to the nature	Get the habit to hypertension
	hypertensive treatment	of disease and treatment	Hypertension as a silent illness
	adherence iceberg		Hypertension as a resistant illness
			Medication adverse affect
			Need to consuming more drugs
		Being connected to the individual	Beliefs, attitudes, and knowledge
		resources	Values and desires
			Emotional and mental concerns
			Experiences and lessons
			Forgetting and being busy
		Being connected to healthcare	The role of government and the Health Ministry
		organization	The role of doctors and the medical team
		Being connected to the	Insistence offering culture
		socio-cultural environment	Non-knowledgeable counseling
			Traditional and herbal treatments
			Media
			The context of the family