Knowledge, attitudes, beliefs, and blood pressure control in a community-based sample in Ghana.

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KNOWLEDGE, ATTITUDES, BELIEFS, AND BLOOD PRESSURE CONTROL IN A COMMUNITY-
BASED SAMPLE IN GHANA
Cardiovascular disease, in particular hyper-
tension (HTN), is a significant and growing
public health problem in developing countries,
such as sub-Saharan Africa. As such, it is
imperative to develop a public health ap-
proach to the management and treatment of
hypertension. In order to address the growing
prevalence of hypertension in this region, an
in-depth understanding of patients’ knowl-
edge, and awareness about the treatment
and prevention of hypertension is needed. As
part of a faith-based medical clinic in the
Sekondi-Takoradi area in Ghana, we con-
ducted a cross sectional survey of 1135
patients who attended a free medical clinic
between March 2001 and March 2002, to
assess the prevalence, awareness, knowledge,
and treatment of HTN. Using qualitative
methodology, wealso
beliefs about hypertension and its conse-
quences. Of the 1135 patients, 30% were
hypertensive (and 62% of these had Stage II
hypertension), 73% were aware of their di-
agnosis, 59% were being treated, and only 5%
had adequate blood pressure (BP) control
defined as blood pressure ,140/90 mm Hg.
Patients with hypertension were typically older
(average age was 61 vs 42 for normotensives),
obese (30% had a BMI $30) and not physically
active (65%). These findings resemble trends
noted in developed countries. Results of the
qualitative interviews indicated that patients
had several misconceptions about hyperten-
sion that were not consistent with a traditional
biomedical model. For example, one person
defined high blood pressure as having ‘‘too
much blood in the body.’’ In collaboration
with the Ghana ministry of health we plan to
utilize the findings of this study to develop
a community-based educational program that
will provide culturally competent patient
educationabouthypertension,withaparticular
emphasis on the misconceptions about the
etiology of hypertension and its associated
complications. (Ethn Dis. 2005;15:748–752)
exploredpatients’
Key Words:
pertension, Knowledge
Attitudes, Beliefs, Ghana, Hy-
Jacqueline Spencer, MD; Erica Phillips, MD, MS;
Gbenga Ogedegbe, MD, MPH, MS
BACKGROUND
Historically, the reported prevalence
of hypertension in rural African com-
munities has been relatively low, rang-
ing from 2% to 13%.1–3More recently,
studies have revealed that hypertension
is on the rise with prevalence rates
approximating 28%.4,5This rate is
comparable to that noted among Afri-
can Americans6and represents a sub-
stantial rise in the reported prevalence of
hypertension in sub-Saharan African
countries. This rising rate of hyperten-
sion parallels increasing rates of obesity
globally. This trend has been directly
linked to unhealthy diets and physical
inactivity as leading causes of noncom-
municable diseases, including cardiovas-
cular disease, and contributes substan-
tially to the global burden of disease,
death and disability.7,8
Research by Amoah et al demon-
strated that 33% of hypertensive pa-
tients in Ghana were aware of their
diagnosis, 18% were treated, and 4%
had adequate blood pressure (BP)
control.4Possible explanations for these
low numbers may reflect the complex
relationship between patients, providers,
and economic resources in this part of
the world. For example, patients may
lack knowledge about hypertension, or
they may harbor beliefs that are discor-
dant with those of the traditional
medical paradigm regarding the treat-
ment and causes of hypertension.9Pro-
viders may have insufficient time and
resources to provide the necessary
education and treatment, given that
healthcare resources in these countries
have been historically used for infectious
diseases such as malaria and tuberculosis
rather than chronic conditions such as
hypertension.
One practical and cost-effective
approach to improving the management
of hypertension in sub-Saharan African
countries is to address patient-centered
factors such as knowledge and health
beliefs. We conducted a study in
collaboration with the Ghana Health
Mission (GHM) to evaluate the health
needs of community residents in Se-
kondi, Ghana. The objectives of this
study were to assess the prevalence,
knowledge, awareness, and treatment
of hypertension among community-
dwelling residents who attend a free
health clinic and to qualitatively explore
the meaning of hypertension and its
consequences among these residents.
METHODS
A monthly blood pressure clinic was
established at the GHM to treat and
monitor a group of patients with
hypertension. Each patient is expected
to return monthly for follow-up for
blood pressure levels and attend the two
From the Department of Medicine,
Weill Medical College of Cornell University
(JS, EP); Behavioral Cardiovascular Health
and Hypertension Program, Division of
General Medicine, Columbia University
College of Physicians and Surgeons (GO);
New York; New York.
Address correspondence and reprint
requests to Jacqueline Spencer, MD; 505
East 70th Street – HT4; New York, NY
10021;718-482-0053;
(fax); jks2002@med.cornell.edu
718 482-9648
More recently, studies have
revealed that hypertension [in
rural African communities] is
on the rise with prevalence
rates approximating 28%.
748
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sessions for re-evaluation and an addi-
tional supply of medication. Throughout
the year, the clinic is overseen by a local
healthcare provider who corresponds
regularly with the executive board mem-
bers on the progress of patients.
Population, Setting, and Data
Collection
The study was conducted during
two of the established GHM clinic
sessions from March 2002 to March
2003. Patients were predominantly
from the Sekondi-Takoradi area, adja-
cent communities referred to as the
‘‘twin cities,’’ with a combined popula-
tion of 400,000 (the third largest city in
Ghana). Patients were eligible for in-
clusion in the survey if they were aware
that they had hypertension, if they were
currently receiving treatment for hyper-
tension, or had BP $140/90 mm Hg
on two consecutive readings. Patients
who were unable to provide verbal
consent were excluded from the study.
Verbal rather than written consent was
obtained from patients because of the
high level of illiteracy in this commu-
nity. A total of 100 patients were
enrolled in this study. Approval for this
study was obtained from the Weill
Medical College of Cornell University
and the New York-Presbyterian Hospi-
tal Institutional Review Board for
Human Research. In addition, the
board of the GHM granted approval
for the participation of its members and
access to the clinic site. The local
Ministry of Health in Ghana was also
in support of the study.
Cross Sectional Survey
Blood pressure, weight, and height
were measured on all patients as part of
the standard clinic triage. Two blood
pressure readings were obtained with
a mercury sphygmomanometer while
patients were seated with their arm at
a 90-degree angle; a small or large cuff
was used depending on appropriate fit.
Readings were based on Korotkoff
first- and fifth-phase sounds. Patients’
weights were measured on a locally
purchased standard scale in kilograms
rounded to the nearest 1 kg. Height was
measured in inches to the nearest 0.5
inch by using a measuring tape attached
to the wall (patients were asked to
remove their shoes before each mea-
surement). Patients’ body mass index
(BMI) was computed by using the
standard formula: BMI5weight (kg)/
height (m)2. Overweight was defined as
having a BMI $25 and obesity was
a BMI $30. Patients were offered
cholesterol screening obtained with
a fingerstick on a portable cholesterol
meter (Accu-check Instant Plus #976,
Roche Diagnostics).
A standardized questionnaire was
administered in a semistructured, face-
to-face interview with the assistance
of an interpreter when needed. The
questionnaire obtained information
on basic demographics, such as educa-
tion and marital status, tobacco use,
and general health status. Patients’
beliefs about hypertension
assessed by asking them whether they
thought salt, being overweight, exer-
cise, tobacco, or alcohol each had an
effect on high blood pressure. If
patients responded yes, then they were
asked whether it raised or lowered
blood pressure. In addition they were
asked, ‘‘Do you think hypertension can
be cured?’’
were
Qualitative Interviews
Individual interviews were con-
ducted with each patient by using an
open-ended format.10,11Patients were
asked the following questions:
1) What does high blood pressure
mean to you?
People explain their illnesses in
many different ways, what do
you think has caused your high
blood pressure?
What does high blood pressure
do to you? How does it affect
your body?
What do your fear most about
high blood pressure?
2)
3)
4)
5)Are there any consequences
from having high blood pres-
sure?
Patients’ responses were recorded
verbatim in field notes.
DATA ANALYSIS
Cross-Sectional Survey
Patients were categorized as hyper-
tensive if they reported a prior diagnosis
of hypertension, if they were receiving
treatment for hypertension, or if they
had an elevated BP ($140/90 mm Hg)
at the clinic on two separate occasions.
Blood pressure was further classified
into prehypertension, stage I, and stage
II according to JNC-7 criteria.6Stan-
dard univariate descriptive statistics
were used to describe the study sample.
The Student t test was used to compare
continuous variables between patients
with hypertension and those without.
Chi-square tests were used to compare
categorical variables. All reported prob-
ability values were two-tailed, and
values of P #.05 were considered sig-
nificant. Analyses were computed by
using SPSS 11 statistical package (SPSS
software version 11, SPSS Inc. Chicago,
Ill).
Qualitative Analysis
Patients’ responses to the open-
ended questions were analyzed by using
standard qualitative research tech-
niques.11Interview notes were read
multiple times and responses coded into
recurring concepts, which were then
sorted and grouped into categories of
similar content. At the point of data
saturation, when no new concepts
emerged on analysis of additional re-
sponses, the identified categories were
labeled and the themes uniting them
identified. To address issues of reliabil-
ity, two of the authors analyzed the data
independently (JS and EP), and differ-
ences in categories and themes generat-
ed from the analysis were resolved by
discussion.
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RESULTS
Cross-Sectional Survey
A total of 1135 patients were seen in
the clinic during the 12-month study
period. The overall mean age of the
patients was 48 years, and 76% were
female. Thirty percent were not work-
ing (unemployed, retired, homemaker,
or student). Among those individuals
who were working, 30% were traders,
11% worked in the fishing and agricul-
tural industry, and 7% were employed
in personal services (eg, hairdresser).
The mean systolic blood pressure was
134 mm Hg (633), and the mean
diastolic blood pressure was 79 mm Hg
(618). When patients were classified
according to JNC-7 criteria, 31% were
normotensive, 39% had pre-hyperten-
sion, and 30% were hypertensive; 62%
of hypertensive patients had stage II
hypertension. Normotensive patients
were younger (42 vs 61 years), had
a lower BMI (24 kg/m2vs 27 kg/m2),
and were more likely to be working
(74% vs 64%) compared to patients
with hypertension (all values significant
at P,.05).
Among those with hypertension, no
difference was seen in rates between
men and women. The prevalence of
hypertension increased with age and
BMI. Rates were highest in those aged
55–74 years (59%) and those with BMI
$30 kg/m2(30%). The lower rate of
hypertension in the age group 75 and
older is most consistent with the shorter
life expectancy of this population
(Table 1). A subgroup (n5100) of
patients with hypertension were ques-
tioned about their awareness of their
diagnosis and treatment plan and basic
knowledge questions about hyperten-
sion. Characteristics of the subgroup are
shown in Table 2. The mean age of the
group was 63 years, 68% were female,
40% were married, and 45% had no
formal education. Most of these patients
reported fair general health (62%). Few
people smoked tobacco (2%), and one
third reported engagement in any daily
physical activity. While more than half
of the group was overweight or obese,
5% had a cholesterol level .200 mg/
dL. As shown in Table 3, the awareness
of hypertension in this group of patients
was high (73%). Among those who
knew they had high blood pressure,
59% were treated and 5% were con-
trolled (SBP ,140 and DBP ,90). As
with awareness, the knowledge of hy-
pertension was high in this group of
patients. More than 50% knew that salt,
being overweight, smoking tobacco, and
drinking alcohol had a negative effect
on BP, and almost 40% recognized the
beneficial effect of physical activity on
BP.
Qualitative Analysis
A more detailed understanding of
each patient’s knowledge and attitudes
about hypertension was revealed in the
qualitative segment of the interview. In
response to the question, ‘‘What does
high blood pressure mean to you,’’
many patients reported physical char-
acteristics, such as rapid heart rate,
increased blood volume, and symptoms
of headache or fatigue. Other patients
reported no knowledge of the disease.
When asked about what they thought
caused high blood pressure the follow-
ing concepts emerged: 1) daily life
Table 1.
gender, age and BMI (N5343)
Hypertension rates by
n%P (x2)
Gender
Men
Women
Age, y
18–34
35–54
55–74
$ 75
Body mass index, kg/m2
Normal
Overweight
Obese
78
265
23
77
.338
52
25
59
14
.000*
87
203
48
128
114
101
37
33
30
.000*
* P,.05.
Table 2.
tensive survey patients (N5100)
Characteristics of hyper-
Marital status, %
Married
Never married
Divorced
Widowed
Highest level of education, %
No formal education
Primary school
Secondary school
College/technical
General heath status, %
Very good
Good
Fair
Poor
Health compared to age
counterparts, %
Very good
Good
Fair
Cholesterol (mg/dL), %
#200
.200
Smoked tobacco
Reported any level of physical
exercise, %
40
10
26
19
45
28
17
8
13
21
62
3
14
39
46
76
5
2
35
Table 3. Awareness and knowledge of hypertension among survey patients
Items%
Aware of high blood pressure
Aware, treated
Aware, treated, controlled
Do any of the following have an affect on high blood pressure?
Salt raises blood pressure
Being overweight raises blood pressure
Exercise lowers blood pressure
Tobacco raises blood pressure
Alcohol raises blood pressure
Do you think it (hypertension) can be cured?
Yes
73
59
5
68
50
39
67
64
58
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stressors, 2) traumatic life events, 3)
comorbid health conditions, and 4)
behavioral factors.
Regardless of individual belief about
the cause of hypertension, almost all
patients reported various physical symp-
toms that hypertension caused. These
symptoms included joint pain, dizzi-
ness, and headaches. These symptoms
played a major role in the concepts that
emerged in response to the question,
‘‘Are there any consequences from
having high blood pressure?’’ Patients
described how symptoms negatively
affected them by restricting activities;
some felt that hypertension symptoms
were a sign that death was imminent.
However, several patients reported that
hypertension had no long term effects.
Lastly, the concept of control over
adverse consequences was represented
by patients’ beliefs that medications and
nonpharmacologic approaches such as
diet and exercise could prevent long-
term sequelae of high blood pressure.
DISCUSSION
We assessed the prevalence, aware-
ness, knowledge, and treatment of
hypertension among a community-
based sample of residents who attended
the GHM free medical clinic in the
Sekondi-Takoradi area of Ghana. Our
results indicate that 30% of residents
were hypertensive, and 39% were pre-
hypertensive. This prevalence is compa-
rable to other community-based studies
conducted in West Africa4,5and under-
scores the importance of hypertension as
a major cause of morbidity and mortal-
ity in Ghana.14–16
In contrast to findings in Ghana and
other developing countries,13,17–19the
rates of hypertension awareness and
treatment in our study were high
(73% and 59%, respectively). This
finding may reflect the presence of the
GHM hypertension clinic as well as the
proximity of local and regional hospitals
in the Sekondi-Takoradi area. However,
in spite of this we found similar low
rates of blood pressure control (5%).
These low rates of control warrant
further investigation, given the high
prevalence of hypertension in these
communities. While potential reasons
for such low rates of hypertension
control have been well outlined by
Amoah4we propose that another barrier
to BP control is patients’ beliefs about
hypertension.20–22
Our findings reveal that patients’
beliefs were mostly discordant with the
traditional medical paradigm of hyper-
tension. For example, patients believed
that high blood pressure was secondary
to having ‘‘too much blood in the
body,’’ and they attributed a consider-
able number of physical ailments, such
as joint pain, to the diagnosis of
hypertension. In addition 58% of
patients reported that hypertension
was curable, which represents a miscon-
ception that high blood pressure is an
acute condition rather than a chronic
condition requiring lifelong treatment.
This perception could affect compliance
with long-term use of antihypertensive
medication. These misconceptions
could explain the disparately lower rate
of hypertension control noted in our
study population (5%), despite a high
rate of awareness (73%) and treatment
(59%). Previous studies have shown BP
control to be closely linked to patients’
beliefs, ie, patients whose beliefs are
discordant with traditional biomedical
concepts of hypertension have poorer
BP control than those whose beliefs
are concordant with the biomedical
paradigm.22–26In one study, patients
whose beliefs corresponded to the bio-
medical model were twice as likely to
have their BP controlled compared to
patients whose beliefs did not corre-
spond.22
Our study had several limitations.
First, the burden of disease may be
greater in this self-selected group of
patients who were aware of the activities
of the GHM and came seeking health
care. This fact may in part explain the
high level of awareness and hyperten-
sion treatment noted in our study.
Second, during the interviews, some
information may have been lost in the
process of translation. Words such as
‘‘cure’’ do not have a direct correlation
in the Ghanaian dialect and thus may
have led to misinterpretation. Thirdly,
because of staffing limitations, we were
only able to interview approximately
one third of the hypertensive patients in
our clinic population.
To our knowledge this study is the
first to explore patients’ beliefs about
hypertension and its treatment in sub-
Saharan Africa. In collaboration with
the Ghana ministry of health we plan to
use the findings of this study to develop
a community-based educational inter-
vention that will form part of the GHM
annual sessions. Our goal is to provide
culturally competent patient education
about hypertension, with emphasis on
misconceptions about the etiology of
hypertension and its associated complica-
tions. In addition, we will focus on
nonpharmacologic approaches to BP
management such as increased physical
activity,lowsodiumdiet,andweightloss.
ACKNOWLEDGMENTS
We thank the executive board of the Ghana
Health Mission for their support and
assistance on site in Sekondi, Ghana,
especially Leda McKenry, PhD, NP and
Anita Sarro, RN, JD. We also thank those
who helped administer the hypertension
questionnaires over the past two years:
Darrah Wagner, Liza Ramlow, Jennifer
Lerner, Debbie Orre, Rebecca Roberts,
Rachel Roberts, and Katy O’Meara.
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AUTHOR CONTRIBUTIONS
Designand concept
Ogedegbe
Acquisition of data: Spencer, Phillips
Data analysis and interpretation: Spencer,
Ogedegbe, Phillips
Statistical expertise: Phillips, Ogedegbe
Acquisition of funding: Spencer
Administrative, technical, or material assis-
tance: Spencer
Supervision: Spencer
ofstudy:
Spencer,
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