Self-Management Strategies in Outpatients with Hypertension under Treatment in Rural Communities

1. Introduction

For centuries, communicable diseases have been responsible for the greatest worldwide burden of premature death. Following the Second World War, medical research achievements in the development of efficient and inexpensive vaccinations and the increased availability of antibiotics decreased the toll of communicable diseases even more [1]. Non-communicable diseases (NCDs) such as cardiovascular disease (CVD), diabetes, chronic-obstructive pulmonary disease (COPD), and cancers have emerged as an emerging pandemic with a major threat to the government. These diseases undermine health gains while imposing a heavy economic burden on governments and households worldwide in recent years [2, 3]. For example, according to the World Health Organization (WHO), NCDs are the leading cause of mortality worldwide, accounting for 71% of all deaths, with CVD accounting for the majority of deaths, with around 17.9 million people dying each year, followed by cancer, respiratory illnesses, and diabetes [4]. NCDs are the second leading cause of mortality in much of Sub-Saharan Africa (SSA), accounting for 2.6 million deaths [5]. Because of the rapidly expanding epidemic of NCDs, SSA is facing a double burden of NCD and communicable illnesses in a disadvantaged environment characterized by ill-health systems [6].

It is noted that CVD mortality rates are low in SSA as compared to high-income countries; however, the deaths due to CVD has doubled in the past three decades in SSA [7]. Certain risk factors, including hypertension and diabetes, are the key modifiable risk factors for poor CVD outcomes, such as stroke, the leading cause of death globally [7]. According to a study by Kearney et al. [8] using published literature from January 1, 1980, to December 31, 2002, the prevalence of hypertension was predicted to increase by about 60% to a total of 1·56 billion in the year 2025 [8]. The risk of hypertension in the semi-urban and rural areas of South Africa increases with age. It recorded 36% and 40% among the 56+ year population in semi-urban and rural areas, respectively [9]. Globally, including SSA, certain risk factors such as physical inactivity, family history of hypertension, unhealthy diets, waist-to-hip ratio (WHR), the harmful use of alcohol, and being diabetic are associated with hypertension [9, 10, 11]. Additionally, studies in Africa have shown that socio-economic status (SES), such as household wealth status and high BMI (overweight/obesity) is associated with hypertension [12, 13].

NCDs management includes diagnosing, screening for, and treating these illnesses and providing those in need with access to palliative care [4]. Undiagnosed hypertension in a rural district remains a concern. A large proportion of the hypertensive population remains undiagnosed, untreated, or inadequately treated in developing countries with most coming from lower socio-economic status (SES) than people with higher SES [12, 14]. If left undiagnosed and untreated in rural communities, this might increase the risk of a cardiovascular event, such as heart attack, stroke, enlarged heart, or kidney damage that may occur due to high blood pressure [11].

Most recent studies showed that community members had good (14%) or intermediate (74.3%) knowledge of hypertension, and only 11.8% of the population had poor knowledge even its risk factors [11, 15]. Lifestyle characteristics have direct correlations to hypertension risk, and modifying lifestyles in a favorable direction can significantly reduce hypertension risk [16]. However, poverty was highlighted as a key risk in this group, restricting healthy lifestyle choices and timely access to health treatment [15].

NCD management interventions are essential for achieving the global target of a 25% relative reduction in the risk of premature mortality from NCDs by 2025, and the sustainable development goal target of a one-third reduction in premature deaths from NCDs by 2030 [4]. Disease self-management, or patients’ capacity to use disease information and engage in strategies that assist them in maintaining their health, helps lower death and hospitalization rates [17, 18]. Therefore, this chapter is aimed at exploring the knowledge of self-management and strategies in outpatients with hypertension under treatment in rural communities. We discuss risk factors for hypertension and discuss self-management strategies used by patients in rural communities.

2. Methodology

The study adopted a Mixed-Methods Research (MMR) approach, known as explanatory sequential design, advocated by Edmonds and Kennedy [19]. The study used a household administered data collecting tool in which quantitative data (QUAN) were collected through the non-laboratory INTERHEART risk score tool and qualitative data (QUAL) were obtained through semi-structured interviews. The data collection tool was distributed. The population eligible for this study was people staying in those selected rural communities and 18 years and above. Only 1224 completed the data collection tool with the assistance of community health workers (CHWs) using the non-laboratory INTERHEART risk score tool. For qualitative, participants were selected and interviewed until data saturation was reached. These respondents provided the qualitative data set that sought to explore the knowledge of self-management and strategies in outpatients with hypertension under treatment in rural communities. For quantitative data, frequencies were generated using the Statistical Programme for Social Sciences (SPPS version 26.0), and eight Steps of Tesch’s inductive, descriptive open coding technique were used for qualitative data [20].

3. Quantitative phase

This section presents the demographic information of participants followed by risk levels findings. A standardized INTERHEART questionnaire instrument was employed in the study and 1244 individuals from a rural community in South Africa's Limpopo region responded (Table 1).

Of the 1244 participants, the majority were females (75%). In the majority of, participants their waist to hip ratio was less than 0.873 (54%). The median age of the participant was 48 years old. Regarding CVD risk factors status, 66% of adults in the rural area have hypertension while only 14% were diabetic, shown in Figure 1. Hypertension is more prevalent in rural communities than diabetes [21, 22]. However, there is substantial overlap between diabetes and hypertension, reflecting substantial overlap in their etiology and disease mechanisms [21]. Hypertension and diabetes are two of the leading risk factors for atherosclerosis and its complications, including heart attacks and strokes [23]. Making certain lifestyle changes (quit the smoke, drinking alcohol only in moderation, limiting salt intake, and eating a diet with low sugar but plenty of fruits, vegetables, fish, healthy fats, and whole grains) cannot only reduce complications from diabetes but can also greatly reduce your risk of high blood pressure [23]. The majority of the participants were non-smokers (89%) with 25% and 8% being hypertensive and diabetes, respectively.

Table 2 summarizes the quantitative data on the characteristics of rural community members in South Africa for hypertensive and non-hypertensive patients. Most participants in the study were females. Factors such as being female, hypertensive, and having comorbidity were associated with high risk developing coronary heart disease in the elderly than in younger patients [24]. The majority of the 175 (25%) hypertensive individuals in the study were at moderate risk of developing coronary heart disease.

4. Qualitative phase

Thematic analysis was applied to derive themes for discussion in this section. The following themes emerged: (1) paradoxical description of self-management strategies and (2) unforeseen painful life experiences.

5. Integration phase

Integration of the QUAN and QUAL results revealed that most of the patients are engaging in eating a healthy balanced diet (Table 3). QUAN results pointed out that more than 61% of outpatients were consuming enough fruits and vegetables daily but still eating meat and salty food one or more times a day and physical inactivity. Combining the eating plan and a lower salt consumption could provide the most effective and may reduce hypertension risk [35]. It is observed that patients still consume high salts and a lot of meat on daily basis, however, some reported that they avoid eating beef meat as compared to chicken meat and also, try to use a small amount of salt and sugar. Patients adhere to treatment and medication instructions and medical follow-up visits at the health facility as other self-management ways of hypertension. The proper use of antihypertensive medications is a critical component of hypertension management [36]. Knowledge of hypertension and its treatment, socio-demographics, treatment views, and patient-provider interaction may contribute to poor drug adherence [36]. Poor adherence might worsen diseases and increase the likelihood of cardiovascular events such as heart attack or a stroke. Most hypertensive patients in rural areas are adherent to medication and clinic visits, however, about 39% of patients were at a high risk of coronary heart disease.

It is observed that about 33% felt work or home life stress. A stressful situation leads to a surge of hormones and temporarily increases your blood pressure. Although stress does not directly cause hypertension, it does trigger a rush of hormones and momentarily raises your blood pressure, which may later develop into hypertension [37]. Some hypertensive patients reported managing their emotions by avoiding stress, overthinking, and becoming angry as a self-management strategy. Most patients, especially pensioners and the elderly, perform household duties every morning and clean the yard, which they believe is adequate because they have large yards. Risk behaviors such as smoking and alcohol use have direct correlations to hypertension risk, and avoiding such risk behaviors can significantly reduce hypertension risk [9, 10, 11]. Due to religious interventions, some patients eat healthy foods and avoid smoking and alcohol.

6. Conclusion

Hypertensive patients residing in rural communities seem to lack sufficient knowledge concerning hypertension self-management strategies. Additional efforts are needed in rural communities to promote hypertension and self-management measures through educational programs such as encouraging patients to engage in increased physical activity and a healthy diet.

Acknowledgments

The authors would like to thank all participants, notably community health workers, professional nurses in clinics, SPICES research participants, the University of Limpopo, and the Limpopo Provincial Department of Health. Finally, we would like to express our gratitude to the European Commission for sponsoring this initiative.