Perceptions of inhibitors and facilitators for adhering to hypertension treatment among insured patients in rural Nigeria: a qualitative study

To establish a consistent open coding procedure, two members of the research team (AOO and JAH) coded fragments of 15 interviews independently. Results were compared and if differences occurred (for instance with respect to the most plausible naming of a code) they were resolved through discussion and by going back to the original data.

To establish the (short) list of conceptual codes, two members of the team (AOO and JAH) independently reviewed the code book and created relevant concepts. Differences of opinion with respect to the clustering of codes or the naming of concepts were resolved by discussion and by going back to the original data.

The categorization of concepts under the main themes (inhibitors and facilitators of adherence) was done by AOO and supervised by JAH, who made sure that every decision was plausible and could be justified.

The preliminary results of the data analysis were based on 30 interviews. Overlooking these results, AOO and JAH acknowledged that some additional interviews (10) were needed to further confirm or explore some of the themes and concepts that had emerged from this preliminary analysis, so that thematic saturation could be reached. Examples of such themes were related to the perceived role of religion on (non-) adherence to medication and patients’ ideas about “local practices” that can inhibit or enhance healthy eating habits and physical exercise.

Based on the analysis of the last set of interviews some new conceptual codes were added to the original list, where appropriate. The researcher returned to the transcripts of the first set of interviews to check if any of these new codes could also be applied here.

Thematic coding was done by AOO and JAH. They reviewed the conceptual coding trees for each of the four major themes (research questions) and independently categorized those concepts into categories and subcategories. Differences in opinion were resolved by discussions and by checking the underlying data. At several occasions other members of the research team (KS, CS) asked critical questions as regards the categorization of the concepts, and this led to some adaptations in the final ordering and presentation of the categories and sub categories and consequently the results.

The final results of the analyses that are presented in the Tables in this paper were reviewed by all authors.

Healthcare related factors: The way in which hypertension care was organized was perceived as one inhibitory factor for medication adherence. In general patients at Ogo Oluwa hospital are required to attend hypertension clinic once a month for follow-up and medication refills. The hypertension clinic is always held at fixed hours on Fridays. Other obligations such as attending Muslim praying hours (Fridays), work, household chores or being on a trip out of town will sometimes prevent patients from meeting their appointments at these fixed hours. The distance to the clinic was also mentioned as a reason for missing appointments. Highlighting the resultant financial challenge, a 50 year old woman with uncontrolled hypertension [ID6] said – visiting [regularly] is problematic for me in the sense that the clinic is far from my residence and travel cost is prohibitive; I spend 500 naira (3USD) to get here and another 500 naira to go back home. Long waiting times at the clinic were also cited as a reason for missing appointments. Asked how regularly he attends clinic, a 72 year old man with uncontrolled hypertension [ID27] replied – visiting is difficult for me because of the many hours spent in clinic, which could be used on my business; in fact I once stopped coming for about 2 months when I realized my hypertension was ‘under control’. Sometimes, the pharmacy is out of stock for particular drugs and not all prescribed medications can be dispensed. A 50 year old woman with controlled hypertension [ID11] responded – sometimes, the pharmacy doesn’t have all the drugs prescribed so they write it in paper for me to buy or come back to collect them oftentimes days after being without pills to use.

Patient related factors: patients’ own views such as the idea that hypertension is a transient, curable condition also emerged as a consideration for deviating from the prescribed medication. Responding to a question on how long she expects to continue to use hypertension medication, a 64 year old woman with uncontrolled hypertension [ID13] replied – surely, hypertension can be cured, one cannot continue to use drugs all days of one’s life; with prayers, in no time it will go.

Medication related factors: side-effects experienced and the complexity of prescribed regimens also emerged as adherence inhibitors. A 55 year old woman with uncontrolled hypertension [ID38] responded – I am okay with everything but the helplessness of the doctor about the serious side-effects that I experience with my drugs; I sometimes miss my clinic appointments because of these side-effects. A 50 year old woman with uncontrolled hypertension [ID6] responded – if the pills can be formulated such that fewer pills will do the work of the 8 pills that I currently take daily perfectly; then fewer pills are preferred as they are easier for me to manage. Some patients mentioned incompatibility between religious fasting and regular pills use, and some others unilaterally substituted or supplemented prescribed pills with herbal remedies without recourse to their doctor. A participant [ID11] responded – in order to observe my religious obligation (Ramadan fast), I usually skip my afternoon dose for the pills I normally take three times a day although I do not inform my doctor about this. Asked what other treatments she uses, a 55 year old female participant with uncontrolled hypertension [ID16] responded – apart from the pills given to me by my doctor, I also take ‘bitter leaf water’; it is said to be good for hypertension.

Religious factors: the potential inhibitory influence of religion on adherence manifested in the accounts of some patients who strongly believe in faith healing. A woman with controlled hypertension [ID37] stated – I use only the drugs prescribed to me, but ordinarily, as a member of Christ Apostolic Church Christian faith, I really do not use drugs if not that this is really important; I believe in faith healing.

Social support: sometimes, lack of social support was an inhibitory factor for hypertension clinic visits. For instance, a husband (family head) may sometime disapprove his wife’s outings for reasons that may be personal. The wife of a religious leader (an Imam), with uncontrolled hypertension [ID6] responded – I usually get a month’s supply of drugs from the pharmacy, but for reasons best known to him my husband would sometimes not allow me to come to the clinic and I cannot come without his permission.

Health care related factors; four sub-categories emerged from this category namely: affordability of care; appreciation of healthcare provider; thrust in orthodox medicines; and availability of prescribed pills. Some patients view the virtually free Hygeia Community Health Care Plan, previously unavailable in that community as a good and timely blessing from God. This encouraged them to adhere to their medications. A 61 year old man with controlled hypertension [ID22] stated – this Hygeia insurance program is very useful for me and I do pray regularly for success for the operators of the program; the program manages my hypertension well and makes me healthier and stronger to work for my ‘daily bread’.

Patient related factors: responses grouped under this category show that knowledge and fear of complications of hypertension may motivate patients to comply with their medications. A 60 year old man with controlled hypertension [ID24] stated – hypertension is something that brings death in different forms; one can be working and suddenly fall down and slump or become paralyzed. It is called ‘kosibale okan‘in Yoruba meaning ‘there’s no peace of mind’. Another patient [ID29] similarly alluded to the danger of hypertension thus – hypertension is dangerous and can kill suddenly; it shows no mercy.

Medication related factors: many patients said they comply with their medications because they firmly believe orthodox ‘western’ medicines are effective, especially when compared with alternative ‘traditional’ medicines. A 70 year old man with uncontrolled hypertension [ID29] responded – I am into herbs and I have used them severally in the past but they did not work like the white man’s medicine.

Social support: some patients view reminders and monitoring by family members and support from peers with same condition as important factors that motivate compliance. Asked how carefully she uses her medicines, a 56 year old woman with controlled hypertension [ID37] replied – I don’t miss my pills; if I do, my children will be annoyed with me, they monitor me closely to be sure I take my drugs regularly every day.

Religious factors: many patients said prayer supported them in using and in improving the beneficial effect of their medications. Moreover, additional health education from religious leaders was also deemed important by some. A 62 year old man with controlled hypertension [ID25] said – I have received enlightenment about hypertension from some radio programs and from my church too; they are useful advices and I usually followed them.

Salt: while most participants said they had been informed by their doctor that they need to be prudent with the use of salt, our data also suggest that some patients were aware of the impact of salt on their BP. Local food practices may inhibit salt reduction; in some communities, salt is used to preserve food, particularly meat and fish against microbial decomposition over time. When asked what local customs encourage salt use, a 70 year old man with controlled hypertension [ID19] replied – in some parts of the north where I come from, we use salt to preserve food and meat. Food preparation practices can also inhibit compliance with advice to reduce salt. In the study region, adding salt and salt substitutes/seasoning agents like maggi (salt plus hydrogenated oil plus monosodium glutamate – MSG), ajinomoto (an MSG product) etc. has become standard practice while cooking. The consumption of canned (processed) foods, often salty is also increasingly common in the region. The previously fairly common cultural habit of drinking salted water in attempts to treat ‘undiagnosed’ abdominal discomfort of all sorts was practiced by some respondents. A 50 year old woman with uncontrolled hypertension [ID6] stated – it is more or less customary for people to cook food with salt in this region,… and for some people who may sometimes have stomach upset, tradition demands that one should pour salt into a cup of water and drink to treat the ailment; I used to do this too but being better aware, have now stopped the practice.

Weight control: participants mentioned a number of local or cultural practices that may prevent people from losing weight including the cultural perceptions; that large body sizes are associated with wealth, comfort or beauty; that weight loss is associated with disease; and that weight (fatness) is an unchangeable family trait. A 50 year old woman with uncontrolled hypertension [ID3] responded – people often see being fat as synonymous with affluence, comfort and peace of mind; they also sometimes associate fatness in a woman with beauty. Some of us women prefer to be fat or robust believing that by so doing; we will be more attractive to our husbands and men generally. Some men too prefer to be plump so they will be liked by women. A 63 year old man with controlled hypertension [ID30] said – in this region, people often link weight loss to disease particularly if the slimming down is getting too much, suggesting that such might be due to disease; at other times they suggest that slim people are very miserly and would rather not spend money to eat well and get robust. Highlighting the perceived link with inheritance, a 55 year old woman with uncontrolled hypertension [ID16] responded – my friends and neighbors often say I was too fat, but I’m not bothered about such comments as I believe I inherited the trait from my mother; we are usually fat in my family. Local food practices may also inhibit weight control. Some participants highlighted the difficulty in avoiding some of the main “fattening” ingredients of local popular dishes such as cassava, groundnut oil, (red) palm oil and meat. The first three ingredients are commonly grown by farmers in the community while meat is widely available due to popular goat breeding practice in the community whereby owning and breeding goats is a pastime that many families engage in.

Exercise: perceived inhibitors of exercising include ‘local practices’ and lack of information. Prevailing local or cultural views that exercise is “needless or useless’, dangerous, or incompatible with advancing age, may prevent people from being physically active. Exercise is sometimes regarded by people as an activity for unserious fellows, the unengaged or the miserly that rather walk habitually than pay for transportation costs to destinations. An elderly male patient with controlled hypertension [ID30] responded – when people see me ‘walking to exercise’ they often slight me and make derogatory comments that one is greedy and would rather walk long distances than spend money on transportation. Asked further how people see exercising or sporting activities, he replied – some people see those who exercise as unserious people. Sports like playing football are only engaged by youths not elderly people like me.

Tobacco and stimulants: besides cigarettes and alcohol, other locally accessible stimulants like snuff (fine-ground tobacco) and kola (caffeine-containing) nuts are also used by some people in the region. Some patients perceive positive effects from using these substances, as illustrated in the following expressed views: cigarette is useful in relieving stress/tension; palm wine (local alcoholic beverage) and Ogogoro (distilled palm wine) make vision clearer; snuff stimulates work; and eating kola nuts is ideal norm for elders. A 65 year old man with controlled hypertension [ID23] responded – our fore fathers used to say palm wine makes one to see very well, but it is glaring to me now that such thing is not good. Another elderly (70 year old) man with uncontrolled hypertension [ID29] said – in this environment, we believe kola nuts and snuff aid work, though I personally don’t use any of them. A 60 year old woman with controlled hypertension [ID33] said – I still eat Kola nuts although I have reduced the quantity I consume since I became hypertensive. Such views make it difficult to quit using these substances. Another 64 year old man with controlled hypertension [ID25] highlighted the social consequences of giving up smoking and drinking thus – the people and friends I used to drink and smoke with had to separate from me gradually after I stopped these habits, but this is fine with me as my health is more important.

Salt: some patients mentioned that ‘health education’ had facilitated the reduction of their use of salt. Respondents highlighted the usefulness of getting health education from multiple ‘channels’ such as churches and mosques, besides the doctor, and of getting information about suitable local substitutes for salt and maggi. Iru (African locust bean paste) is a harmless locally available substitute for salt; it has similar taste as salt, is natural and normally contains no added sodium. A 49 year old female respondent with controlled hypertension [ID14] stated – I got useful advices and was able to apply them though with little difficulty; I later (…) replaced salt and maggi with Iru which serves same purpose although I have also been using Iru together with salt before now. The availability of substitutes for salt in local markets was similarly viewed as a facilitator. Finally ‘social support’ particularly the family’s willingness to eat low salt meals was identified as an important motivator for reducing salt. As one respondent, a 50 year old woman with controlled hypertension [ID11] puts it – yes, I was able to make use of the advice; we now reduce the quantity of salt added to common ‘family pot’ food generally; thereafter those in the family that desire more salt in their food can add extra salt to their portion after dishing.

Weight control: the perceived facilitators of weight control related mostly to local practices. Some people said the changing local and cultural perceptions on linkages between: ‘weight, wealth, beauty and health’ are an important condition to facilitate weight control. Being too fat is sometimes viewed as being tantamount to ugliness and physical unfitness or sluggishness. When asked what people’s comments on fatness are, a 65 year old man with controlled hypertension [ID23] replied – people will say, look at him, ‘big for nothing’, yet he will not be able to enjoy breathing, worse still, his bigness really has nothing to do with wealth. Another respondent [ID26] said – beauty is a good thing that sometimes goes with bigness but some people are ugly looking when fat. The ample availability of affordable healthy foods from local vegetable farmers and fishermen was equally seen as an important motivator for changing one’s diet and for weight control.

Exercise: some respondents saw their regular daily activities as good and socially acceptable ways for getting enough exercise without much extra effort. A 63 year old man with controlled hypertension [ID30] said – exercise is generally good but the only ways I exercise is to walk to the farm, work on the farm and walk back home. I do walk regularly where I sometimes can otherwise use transportation. Another woman [ID33] said – exercising is good for hypertension; although I can’t farm, I exercise by washing clothes in the river and axing woods to make fire for cooking. A 55 year old woman with uncontrolled hypertension [ID16] said – I was told to do some exercise every morning like doing some domestic chores, walking (…); also, dancing and clapping in church are other kinds of exercise although we don’t normally clap in my church but we dance and sweat in the process. Alluding further to the usefulness of household chores in exercising, an elderly male respondent with controlled hypertension [ID21] said – in my community, women pound yam using mortar to prepare pounded yam, a popular local delicacy; this is also a form of exercise because they sweat a lot when they grind the mortar. Another respondent, a 57 year old man with uncontrolled hypertension [ID26] said – I get some fitness while paddling my canoe on the river in the mornings while fishing or transporting; this can also serve as exercise. I don’t have time for extra activities.

Tobacco and stimulants: social support was perceived as the most important facilitator for cessation of smoking and reduction of the use of alcohol and other local stimulants. This category is sub-divided into supports people get from ‘faith-based’, and ‘gender-based’ social norms. These habits are seriously frowned upon and discouraged by the two major religions – Islam and Christianity. A 56 year old female respondent with controlled hypertension [ID37] stated – I have been advised about the danger of all these things (smoking, alcohol, snuff, kola nut) but I don’t even do them before; my religion does not allow me to use them. Similarly, there exists a prevailing gender-based perception or norm in most African societies that a woman should not smoke cigarette or drink alcohol, although this has become less stringent nowadays.

Despite ‘affordability of care’ – a feature of community based health insurance programs and insured care in general, hypertensive patients in SSA settings may still face other challenges in adhering effectively to prescribed treatment. More than ‘just’ health insurance is required to improve adherence and treatment outcomes.

Using information from exploration of patients’ perspectives on adherence to prescribed treatment this study suggests that local communities in low resource settings may offer specific barriers but also opportunities for adhering to medications and to healthier behaviors.

Adherence counseling and education for patients may benefit from addressing the identified specific inhibitors and facilitators perceived or experienced by patients.