Background
Methods
Study setting
Study methods
Study participants
Recruitment
Characteristics | Categories | Hypertensive patients IDIs (N = 25) (%) | Hypertensive patients FGDs (N = 16) (%) |
---|---|---|---|
Age (years) | 30–40 | 6 (24) | 4 (25) |
40–50 | 5 (20) | 6 (38) | |
50–60 | 7 (28) | 5 (31) | |
60–70 | 7 (28) | 1 (6) | |
Mean age ± SD | 50.2 ± 11.3 | 44.93 ± 10.9 | |
Sex | Female | 14 (56) | 7 (44) |
Male | 11 (44) | 9 (56) | |
Education | Literate | 16 (64) | 11 (69) |
Illiterate | 9 (36) | 5 (31) | |
Occupation | Employed | 15 (60) | 14 (87) |
Unemployed | 10 (40) | 2 (13) | |
Blood pressure status | Controlled (< 140/90) | 15 (60) | 9 (56) |
Uncontrolled (≥140/90) | 10 (40) | 7 (44) | |
Duration of diagnosis of hypertension | Less than a year | 2 (8) | 3 (19) |
1–5 years | 12 (48) | 10 (62) | |
More than 5 years | 11 (44) | 3 (19) |
Characteristics of health care providers (N = 11) | Characteristics of key informants (N = 4) | Characteristics of family members (N = 5) | ||
---|---|---|---|---|
Sex | ||||
Female | 4 | 1 | Female | 3 |
Male | 7 | 3 | Male | 2 |
Position | Education | |||
Cardiologist | 3 | NCD Policy maker −1 | Literate | 3 |
Physician and medical officer | 3 | NCD program focal person at DoHS, Ministry of health – 2 | Illiterate | 2 |
Health Assistant and Community Medical Assistant | 3 | NCD Researcher - 1 | Relationship with hypertensive patients | |
Nurse (ANM, Staff nurse) | 2 | Wife | 1 | |
Work experience | Husband | 1 | ||
1–5 years | 4 | 1 | Daughter | 1 |
5–10 years | 4 | 1 | Son | 1 |
More than 10 years | 3 | 2 | Daughter in law | 1 |
Level of health care | ||||
Primary level | 5 | Both level - 4 | Primary level | 3 |
Tertiary level | 6 | Tertiary level | 2 |
The behavioural model informing the study
Data collection
Data analysis
Results
Emerging sub-theme from the transcript | Sub-components of the COM-B Model | Broad components of COM-B Model |
---|---|---|
Poor knowledge and understanding about the disease and treatment (B) | Psychological Capability | Capability |
Misconceptions about the disease and treatment (B) | ||
Physical challenges in taking treatment and modifying behaviour(B) | Physical Capability | |
Affordability: Cost of the hospital, medicine, investigation, travel costs (B) | Physical Opportunity | Opportunity |
Availability: Hospitals, medicine, investigation, chemist shop (B) | ||
Communication between providers and patients (B) | ||
Stigma of disease and fear of disclosure (B) | Social Opportunity | |
Socio-cultural beliefs shaping health behaviours (B) | ||
Beliefs about consequences of disease and treatment (B,F) | Reflective Motivation | Motivation |
Belief and trust in alternative medicine (B) | ||
Difficulty in changing habits (B) | Automatic Motivation |
Capability
Psychological capability
“If it is increased … what will happen... like... [Inaudible]... if increased may be unconscious or fall … may faint … I don’t know what happens.” (P08:50-55Y, PHC level).
“Another thing is ... neither I know what exactly salt will do or how it will affect in my pressure... I don’t have exact information.” (FGD1- P02: 40-45Y, Tertiary level).
“Yes, they are cooking food without salt and taking out vegetables for them, and they will add salt for the family members … They are not taking salt completely, and another problem will arise.” (HCW 01, PHC level).
Misconceptions about the disease and its treatment
Patients considered anti-hypertensive medication as the last option after trying other alternatives. Hence, they were taking the anti-hypertensive medicine after getting complications and at late stage. Moreover, they were worried about taking medicine for a long time. Participants also expressed that they do not need to take medication until and unless they felt symptoms such as pain or discomfort. Healthcare providers agreed that patients usually do not start their treatment on time, and if started, it was after trying all other alternatives. Patients were likely to discontinue the treatment when their pressure was under control. As one participant described:"Half of the people I met said that I am too young to take medicine for pressure. They said that I should not be taking medicine before fifty years of age." (P014: 30-35Y, Tertiary level)
It was evident that deeply rooted perceptions were guiding the hypertensive patients’ behaviour, either they were not taking treatment or stopping them in between and not following recommended behaviour."I went to see the doctor (A-pseudonym) … Doctor checked my pressure, and it was 170/100. He gave me medicine… I took the medicine for 3-4 days and my pressure was in control, and I stopped that medicine." (P020: 35-40Y, Tertiary level)
Physical capability
It was evident that most patients faced challenges in changing their lifestyles. They reported a lack of skills and difficulty in managing time for exercise, giving exercise a low priority, negligence to take medicine and not following the recommended behaviour as the main challenges. One patient briefly explains:"And yes, sometimes I forget to take medicine as well. Medicine which needs to be taken in the morning, sometimes I forget and take that in the evening. Sometimes, I don't remember that as well." (P021: 35-40Y, Tertiary level)
Mostly female participants explained that they could not manage their time for the required physical activity due to their household commitments. Differentially assigned roles based on patient sex might also have affected their ability to modify behaviour in the study setting."For physical activity, it would be good If I walk in the morning, but I don't feel waking up from the bed in the morning." (P011: 60-65Y, PHC level)
Opportunity: physical opportunity
Availability and affordability of the health services
In Nepal, anti-hypertensive medicine is not provided free of cost through the healthcare system. In PHC level, even participants expressed the concern of non-availability of antihypertensive medicine/pharmacy in nearby places."But here people in rural areas are not able to get proper treatment. There is less amount of health posts in those areas and with very little manpower. There is also a problem related to the availability of drugs. First is the geographical barrier; second is transportation problem; third is lack of health-related infrastructure; the fourth is lack of manpower and the fifth is the cost factor." (KI 04)
Medicine needs to be taken continuously for the patient’s life, so the issues of availability, cost of anti-hypertensive medicine and diagnostic tests were raised by the study participants. One of the key informants expressed that a “country like ours haven’t [sic] got the insurance policy and patient must buy the medicine from their own money and affordability is also one major barrier.”We cannot buy these medicine (antihypertensive) around here. We must go there (city) for buying it. We must go till Chabahil (name of city -2-3 hr travel). Yes, must go that much far for buying it. I usually buy for a month for my mother. (Son of P01, 60-65Y, PHC level)
Healthcare providers admitted their shortcomings in counselling to make the patient understand their disease and treatment. They stated that they could not give enough time to patients for counselling, due to heavy workloads."Now … . in the hospital, they will not tell in detail … They say, "your pressure is high, so you have to take medicine and write the name of the drug directly without any explanation." (P04: 60-65Y, PHC level)
Key informants also expressed that “if the counselling is not done properly, they won’t start taking medicine.” (KI 02)."One is the patient-doctor ratio. Especially in the government sector, there will be much rush. Must give plenty of time but we are not able to give that time." (HCW 010, Tertiary Level)
The stigma of disease and fear of disclosure
"But I feel like … after knowing this my friend might tease me about this. Maybe there will be a difference in their behaviour regarding taking food, and there might be some limitation. I cannot tell other people... I feel ashamed." (P021: 35-40Y, Tertiary level)
Stigma attached to hypertension, may have influenced health seeking behaviours, and follow up of treatment leading to uncontrolled blood pressure and complications. This was more evident with younger participants."They think that if they marry a person who has high pressure, they will be barriers to their marriage … Yes, people try to hide it also. They never say they have it even though they have pressure." (HCW 05, PHC level)
Socio-cultural norms shaping health behaviour
Furthermore, oily, and fatty foods are considered to be superior and delicious items and are commonly provided in feasts and festivals and offered to guests as a mark of hospitality. Consumption of salt also holds cultural importance. When there is a death of a close family member, people restrict salt in their diet to express their grief."In some community, it is like in their Sanskritic (cultural) program; alcohol is like necessary item. Drinks and alcohol should be there. Because of that, they are regularly consuming alcohol." (HCW 011, Tertiary Level)
The tradition and practice of salt intake during grief was a new insight for the researcher (BB) who is a member of the same society with the same cultural understandings of the process of death. Traditional and cultural norms associate obesity with good luck and wealth. These deeply engrained norms may discourage hypertensive patients from losing weight and negatively affect blood pressure control."We have deeply rooted old superstition and tradition as if anyone left salt, they ...people will say ...look she is unfortunate (aalacchini ...) look she is not taking salt as if there is death in the family. aalacchini … look … . who died in your family, so you are not taking salt...? people will say like this." (P05: 50-55Y, PHC level)
Motivation
Beliefs regarding consequences of disease and treatment
They feared consequences of complications of the disease. They were scared that if they were paralyzed, their social life would be disturbed, they will be a burden to the family and may not get enough care. Participants also expressed fears of side effects of the medication and developing addiction to the medicine due to prolonged intake. Some hesitated to start taking the medication and discontinued after commencement. One participant describes this hesitation as:“I am taking medicine. If I left 1-2 days, then I get afraid that I might get paralysis. (Laugh)... … I get scared of dying … and if I don't take medicine, then I can’t sleep as well.” (FGD2-06: 30-35Y, Tertiary level)
As for treatment, some participants believed that missing a single dose of anti-hypertensive medication could lead to instant death. Therefore, they preferred uncontrolled blood pressure over starting the prescribed medication.“I left completely.... it would become my addiction and habit … it would be like Nasha (addiction) so, I felt sad about... that I had to take it always, so I left that medicine.” (P021: 35-40Y, Tertiary level)
“It’s been around one month that my pressure is little higher.... I used to drink the juice of bitter melon (karela) before … my children used to give me that. So, I did not take medicine.” (FGD1–07: 40-45Y, Tertiary level)
These kinds of practices were favoured because they were understood to have less side effects, were easily accessible, were low cost, were advocated by close relatives and had religious significance.“While going to walk, he usually takes Jamara’s juice. That is only recently … and he also takes Aloe vera juice. It’s like if he heard anything like that will have a good impact on his health not only for the pressure; he usually takes that …” (wife of P014: 40-45Y, Tertiary level)
Automatic motivation
Similarly, participants confessed to being unsuccessful in trying to change their habits of smoking and consuming alcohol. An older participant residing in a rural area stated that she has been smoking since her childhood. Due to her long-term addiction, she was unsuccessful in her attempts to quit smoking even after being diagnosed with hypertension. She said, “yes, I tried many times to stop smoking but could not.”My wife (patient) loves eating fried meats and oily pickles (salty) a lot. I told her there is no use in having oily foods; control it. But it is the same. Nothing has changed. (Husband of P03: 35-40Y, PHC level)
Hence, participant behaviours were guided by their entrenched lifestyles which are not easily modified.“I know everything... it will harm my pressure as well, but I am drinking (alcohol). It is like my challenge. I am taking medicine and taking alcohol, as well. It’s all due to my habit.” (FGD2- 09: 55-60Y, Tertiary Level)