Vol X: Knowledge, Attitudes and Practices related to Hypertension in Low- and Middle-income Countries: a Systematic Review

This article is part of the MJGH’s 2021 Spring Issue.

Authors: Maha Asad¹, Gary Wang², Louise Pilote³

¹Global Health Programs, Faculty of Medicine, McGill University

²Faculty of Medicine, McGill University

³McGill University Health Centre, Centre for Outcomes Research and Evaluation

This study aimed to collect and analyze qualitative data on knowledge, attitude and practice (KAP) towards hypertension (HTN) among adults in low and middle-income countries (LMICs), in order to better inform future research or policy interventions. Studies were included in the review if they examined HTN KAP of adults located in LMICs as defined by the World Bank, using qualitative methods. The databases searched were MEDLINE, CINAHL, Embase, Scopus, Global Health, and LILACS. Data was collected on participants’ knowledge of HTN causes, symptoms, and risk factors, sources of HTN information, beliefs and practices regarding checking blood pressure regularly, perceived importance/danger of HTN, and behaviour concerning HTN modifiable risk factors. A total of 16 qualitative studies were included from ten countries. Overall, there were numerous cultural and psycho-social understandings, both correct and incorrect, of HTN. Social support from community and family members were a crucial aspect of HTN KAP, as the most common source of HTN information and a factor in decisions regarding blood pressure checks and lifestyle changes. Urbanicity was perceived to worsen HTN outcomes through heightened social stress, physical inactivity, and other barriers, which also differed according to sex. In general, this review has two important implications. First, community- and gender-based initiatives are needed to address barriers to lifestyle changes related to HTN risk factors. Second, growth and development in LMICs must mitigate these barriers at their root causes of poverty and inequality. Possible limitations include the generalisation of findings due to the heterogeneity of included studies, and the LMIC classification due to wide inequalities in some high income countries, both of which highlight the need for further qualitative research in low-resource settings.

Introduction

Rationale

Hypertension (HTN) is a major public health issue and a leading cause of death and disability across the world. HTN is responsible for an estimated 7.1 million deaths and 64 million disability-adjusted life-years (DALYs) lost annually worldwide.(20) However, a greater proportion of the global hypertension burden is on developing countries due to disparities in awareness, treatment, and control.(6) While the estimated prevalence in developing countries (~32%) does not differ dramatically from that of developed countries (~29%), these disparities can be attributed to limited resources and lower investment in education and health, in combination with greater population growth and stage in the epidemiological transition.(7) Accordingly, there is a difference in the rate at which prevalence is changing; while prevalence decreased by 2.6% in higher-income countries (HICs) from 2000-2010, it increased by 7.7% in lower- and middle-income countries (LMICs).(21) There are also wide variations of HTN prevalence within LMICs characterised by high levels of inequality.

It is possible that social and cultural factors related to dynamics of inequality and poverty could account for poor HTN outcomes (including low access and adherence to medications and a general lack of awareness and control) in the developing world.(19) Under these circumstances, understanding the context and background of HTN through the beliefs and perceptions among lay persons is crucial. Any intervention strategy aiming to improve HTN among adults in LMICs should consider the determinants of HTN found in lifestyle and behavioural choices, taking socio-cultural contexts into account.

In line with the third UN Sustainable Development Goal (SDG) of ensuring healthy lives and promoting well-being for all at all ages, ameliorating the disproportionate burden of HTN in LMICs would have significant impact on the indicator which looks at the mortality rate attributed to cardiovascular disease, cancer, diabetes, or chronic respiratory disease.(8) An effective management program which addresses a possible lack of accurate KAP may be able to overcome certain barriers to treatment and public health through education and lifestyle intervention initiatives. It may also pave the way for necessary collaborations with government health authorities, healthcare providers, and community stakeholders.

We thus conducted a systematic review that aims to assess knowledge, attitude and behaviour towards hypertension among adults in low and middle-income countries. Specifically, we aimed to collect and analyze qualitative measures of adults ‘knowledge, attitudes, and practices (KAP) concerning HTN and its risk factors, describe relevant trends, and advise how conclusions can be utilised in devising future intervention or education programs.

Methods

Information Sources

An initial search of PubMed, Google Scholar, and the McGill Library WorldCat search engine confirmed a lack of breadth in the general literature on the influence of KAP on HTN prevention and management in LMICs. A search strategy was then devised for each database in order to address the specific research question regarding KAP in a systematic review. The final search strategy was peer-reviewed by an associate librarian at McGill University specializing in epidemiology and global health related topics.

The review author searched the following electronic databases in July 2019 for eligible studies: MEDLINE (Ovid, 1950 onwards), CINAHL, Embase, Scopus, Global Health, and LILACS. Preliminary manual searches were also conducted by reviewing the references listed in studies that seemed most relevant.

Search

The following key search terms were used in all selected databases: “hypertension”, “blood pressure”, “knowledge”, “attitudes”, “practices”, “low income countries”, and “developing countries”. Search syntax was adapted from strategies available from existing systematic reviews in the Cochrane database.(10,11) The complete draft search strategy for Ovid MEDLINE is shown in Appendix 1.a.

Database searching was done by the lead author (MA), after which the records identified were screened for eligibility by title and abstract by two authors (MA, GW). This was done on Rayyan QCRI, a web application for performing systematic reviews, in a blinded manner. The included articles were then screened by full-text by both authors, noting reasons for exclusion of each article. Throughout the screening process, disagreements were resolved through discussion and consensus (LP). The selection process is outlined visually in a PRISMA flow diagram below (See Figure 1).

Data collection process

The qualitative analysis software NVivo was used to extract text from included studies according to nodes that corresponded to KAP variables. After PDF files of each study were uploaded to the software, reviewers examined each article and assigned text (mainly quotes and results from studies) to the relevant coded node. Each reviewer then exported their nodes and data within them, and the lead author compiled them into one document in order to easily highlight conflicts. Both reviewers communicated on these contradictions until consensus was reached. Then, identical or similar data in each node were grouped and condensed by the lead author. The contributing author (GW) regularly reviewed the paper throughout the editing process.

The following data items refer to the “nodes” in NVivo. For the “knowledge” aspect of KAP, data was extracted on 1) participants’ definition of HTN, and their knowledge of HTN causes, symptoms, and risk factors, and 2) participants’ sources of HTN information. For the “attitudes” aspect, data was collected on 1) participants’ beliefs about checking their BP regularly, and 2) how important and/or dangerous they perceive HTN to be. Lastly, data was extracted on “practices” in terms of 1) participants’ conscious behaviour concerning HTN modifiable risk factors (ie. diet, exercise, tobacco/alcohol consumption, stress), and 2) whether or not they have their BP checked regularly.

Results

A summary table of the 16 included studies can be found in Appendix 1.b, including information on study population and location. Risk of bias within each study was assessed by the principal reviewer following the full-text review to ensure results would not be impacted. Data from included studies were analysed according to the data items, or “nodes”, used in NVivo. The difference in results between urban and rural participants was also summarised in order to highlight important aspects of the relationship between the two.

Knowledge of HTN definition, causes, and consequences

The definition of HTN given by study participants varied in its accuracy. In all studies, participants were able to identify causes of HTN in terms of dietary factors, exercise, and/or stress, however they also held several misconceptions about the specificities as well as other causes (See Table 2). Finally, the consequences mentioned were mainly characterised by explicit symptoms, while very few were able correctly identify complications such as stroke. Overall, there seemed to be multiple understandings (a mix of correct and incorrect) of HTN with no one overriding belief; there were a variety of significant cultural and psycho-social perceptions in addition to biomedical understandings.(2)

Sources of HTN Information

The most common place to get information about HTN across included studies was from lay sources, such as the family, neighbours, and community.(2,3) In settings where there is a lack of stigma associated with the disease, communication of information about lifestyle changes, medication adherence, and options for care is encouraged.(3,7) Having prior knowledge of the disease was also often linked to having a prior experience of HTN among family community members.(7)

The media was the most cited source in one of the included studies(1), and its various forms were mentioned by several others. For example, participants specified radio and television campaigns/ads about HTN as sources(1,9), as well as drug advertisements by doctors.(6) Participants also mentioned the need for government campaigns, as some had previously seen such campaigns for TB and AIDS, and believed that one for HTN would be useful.(5)

Health staff such as doctors and health counsellors were another common source of information, particularly for dietary instructions.(1) However, many “complained that doctors do not explain enough about high blood pressure” because of barriers such as “limited consulting time”.(14,15) Others mentioned the transportation/financial cost of going to a health facility, the inability to read in English/local languages, or having no relative or friend with HTN as hindrances.(9) In particular, the false perception that HTN is “excess blood” is “facilitated partly by how HTN is translated by health professionals to community members into the local languages”.(9) Otherwise, participants mentioned that occasional free health screening exercises organised by churches and NGOs were helpful in providing HTN information.(6) A few participants also reported consulting herbal medicine peddlers, justifying the use of plants for medicine from verses of the bible.(1)

Finally, some participants were oblivious to the need for correct information on HTN. Claiming that they were best ones to decide on treatment options, they sought support from family, peers, neighbours or healthcare professionals only if they felt that they needed to.(12) While many participants held misconceptions that would require some guidance, it is important to clarify that in fact some lay perceptions included technical concepts about HTN due to the wide reach of public education on chronic diseases in some areas, especially through mass media.(13)

Attitudes and practices toward checking blood pressure regularly

While many participants acknowledged the need to regularly check their blood pressure, there was still a presence of negative attitudes and/or incorrect information, and in some participants, a preference for traditional methods (See Table 3).

Perceived importance/danger of HTN

As previously mentioned concerning blood pressure checks, the perceived importance or danger of HTN was related to some participants’ priority on other daily needs and illnesses with more prominent symptoms. Still, HTN was taken very seriously by most participants, sometimes due to stigma or misconceptions surrounding the disease (See Table 4).

Practices regarding HTN modifiable risk factors

Most participants recognised that lifestyle adjustments are needed for self-management, which are highlighted in Figure 5. In general, there was an eagerness among participants to adopt healthy lifestyle measures, even if they were unaware of them.(11) One aspect of this came from previous negative experiences with medication and doctors, leading to the belief that medicine alone is not sufficient to control HTN, and that one must eat right and self-manage.6 Despite being aware of lifestyle changes, participants also described several barriers they faced that discouraged them from adhering to such modifications (See Table 5).

Urban vs Rural Results

Knowledge of HTN among urban participants was similar to the rural-dwelling study population, though the definition of HTN given was different across ethnic groups. For instance, in some languages, the term for HTN existed but was not properly used.(5,14) The causes of HTN described by urban-dwelling adults resembled those of rural-dwelling adults, but were in some cases more linked to urbanicity. Social aspects such as “unemployment, raising prices, insecure livelihood, disharmony in the community, and other urban related issues” were a prime factor.(5) Urban stressors also differed depending on gender; men tended to mention work related issues, while women were more concerned with familial issues.(15) Although stress factors were seen by many as unavoidable, it was believed by some urban participants that exercising and dietary changes can help in stress management.(16)

Also contrasting rural beliefs, alcohol in one urban case was not believed to cause HTN because “it makes you relaxed”.(2) In terms of sources of HTN info, there was more difficulty for rural participants in attaining accurate information. One pointed out how “there are many people at the rural areas still who don’t dare to go to the doctors. Many people can‘t go for money. Many people don‘t know where to go”.(7) Finally, concerning attitudes towards BP checks, there was a perception in one study that educated families (often associated with urban areas) would take the initiative to visit health care facilities, while those from uneducated families (more associated with rural areas) tended not to.(8)

Discussion

Main findings

To the authors’ knowledge, this is the first qualitative systematic review on knowledge, attitudes, and practices (KAP) of hypertension (HTN) in low- and middle-income countries (LMICs). There are several interrelated themes that arise from these results which have important implications for any relevant policy development or intervention work.

First, the nuances revealed on urban and rural KAP have an interesting correlation with the hypothesis suggesting a higher prevalence of HTN in urban settings compared to rural settings, attributable to behavioural factors such as unhealthy diet, physical inactivity, and obesity.(21) It is likely that urbanisation and globalisation will cause lifestyle changes in many developing countries, and the lower prevalence of hypertension in rural areas will be gradually replaced by a higher prevalence.(17) The results correlate with this as various causes of HTN and practices towards modifiable risk factors stemmed from social, economic, or cultural determinants related to urbanicity. Underlying the results was a negative attitude among most participants that urbanisation and globalisation are partly to blame for HTN in their community, through increasingly unhealthy diets (“commercial” foods), pollution, higher costs, psychological and social stress, and physical inactivity.

The social stress aspect of urban risk factors is related to another dominant theme; the importance of having strong social support, for both HTN prevention and treatment. The community and family network proved to be an indispensable source of HTN information and/or advice, which in turn influenced practices regarding adherence to lifestyle changes related to risk factors, as well as getting blood pressure checked. A lack of social support for someone with HTN was a large concern, as this could lead to tensions or conflicts within the family and/or community. Stigma or misconceptions in the community surrounding HTN further heightened this psychosocial stress — from fear of being labelled as a “sick person” to unwillingness to seek treatment due to a clinic being associated with HIV treatment. A note should also be made about the gendered nature of some of these results; the experiences and attitudes of women and men were often tied to gender roles. For instance, women were more concerned about the effect of HTN on their family and relationships with others, while men focused more on the physical and sexual weakness, the resulting financial burden, and the community stigma that all of this implied.

Thus, this review confirms the importance of gender-specific and community-based HTN interventions that purport to address KAP towards modifiable risk factors. In the WHO’s Global Brief on Hypertension, one of the most important components of any country initiative is the reduction of risk factors in the population.(18) However, past interventions have often given unrealistic recommendations for people living in low-income countries, such as to increase physical activity or avoid mental stress.(17) As this review demonstrates, such behavioural changes are deeply rooted in socio-cultural and community factors which must be taken into account. Solutions such as public awareness programmes about diet and physical activity should undertake community consultations before implementation, in order to effectively engage and reduce misinformation among the target population.

While these results can be used to inform future policy development and research initiatives, they also bring to mind some more concrete fixes that could improve access to hypertension information and management, especially in rural areas and developing urban areas. For instance, much of the correct information regarding hypertension definitions and beliefs has likely been lost in translation, between local or native languages and dominant or formal languages used in trials or campaigns. In addition, ameliorating the financial and physical barrier to seeking hypertension treatment would make a great difference for rural dwelling adults, for whom the cost or distance of travelling to a clinic was a major deterrent. Many participants had a positive attitude towards having their blood pressure checked but simply found the process to be too difficult or inconvenient. Increasing the accessibility of blood pressure (BP) measuring cuffs in pharmacies or introducing remote home-monitoring devices could greatly increase BP monitoring rates in low-resource communities, which in turn can have positive effects on self-management behaviours and knowledge.(24) These are also solutions that should intertwine with urban development and growth to ensure that improved access to clinics and health infrastructure mitigates the relatively higher urban HTN prevalence.

Limitations

While this review provides a rich qualitative insight into HTN in developing countries, a possible limitation in generalising the findings is the heterogeneity of the included studies in terms of participants’ characteristics (ethnicity, age, etc). There is also heterogeneity in the definition of hypertension used in different countries. Another limitation relating to the study selection process could be the LMIC classification, as there are areas within high income and upper-middle income countries (e.g. Brazil) that have such wide inequalities within them that the socio-economic conditions in their lower-income areas are very similar, if not identical, to those in LMICs. This highlights the need for further qualitative research in low-resource settings, at both the national and regional scale.

Conclusions

In order to produce efficient, inclusive, and successful strategies to tackle the growing prevalence of HTN in LMICs, education and awareness-building initiatives targeting behavioural change should be promoted, but through a gendered and community-level lens. It is through this first step of culturally and socially sensitive interventions that a population’s knowledge, attitudes, and practices will likely improve and help reduce the prevalence of HTN. As LMICs face an ever-growing double burden of infectious disease and non-communicable diseases, it is becoming crucial to address the complex barriers to behavioural changes that exist at both the institutional and individual levels. More generally, the impact of urbanization and globalization also plays a large role in shaping such future work, which involves “capitalizing on the positive aspects of urbanization by understanding the factors responsible for urban health and preventing the distortions of development outweighing the benefits.”(20) Growth and development in LMICs must mitigate these barriers to behavioural changes at their root causes of poverty and inequality.

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Appendix 1

1.a. Search strategy

Database: Ovid MEDLINE(R) ALL <1946 to July 10, 2019>

Search Strategy:

—————————————————————————————–

exp hypertension/ (246147)
hypertensi*.tw. (408333)
exp blood pressure/ (282765)
((elevat$ or high$ or rais$) adj3 (diastolic or systolic or arterial or blood) adj pressure).tw. (30980)
bloodpressure.tw. (42)
(knowlege or attitudes or practice*).tw. (877333)
Health Knowledge, Attitudes, Practice/ (103941)
((survey* or questionnaire* or interview* or qualitative) adj3 (hypertensi* or “blood pressure” or bloodpressure)).tw. (1631)
((understand* or comprehen*) adj6 (hypertensi* or “blood pressure” or bloodpressure)).tw. (2108)
((perception* or aware* or perspective* or view or views or belief*) adj3 (hypertensi* or “blood pressure” or bloodpressure)).tw. (1955)
((behavi* or decision*) adj3 (hypertensi* or “blood pressure” or bloodpressure)).tw. (1501)
Developing Countries.sh,kf. (83634)
((developing or “less* developed” or “under developed” or underdeveloped or “middle income” or “low* income” or underserved or “under served” or deprived or poor*) adj (countr* or nation? or population? or world)).ti,ab. (91626)
(low* adj (gdp or gnp or gross domestic or gross national)).ti,ab. (233)
(low adj3 middle adj3 countr*).ti,ab. (13289)
(lmic or lmics or third world or lami countr*).ti,ab. (6495)
transitional countr*.ti,ab. (155)
(Afghanistan or Angola or Bangladesh or Benin or Bhutan or Bolivia or Burkina Faso or Burundi or Cabo Verde or Cambodia or Cameroon or Central African Republic or Chad or Comoros or Congo or Cote d’Ivoire or Ivory Coast or Djibouti or Egypt or El Salvador or Eritrea or Ethiopia or Gambia or Georgia or Georgia Republic or Georgian Republic or Ghana or Guinea or Guinea-Bissau or Haiti or Honduras or India or Indonesia or Kenya or Kiribati or Korea or Kosovo or Kyrgyz Republic or Kyrgyzstan or Kirghizia or Kirghiz or Kirgizstan or Lao PDR or Laos or Lesotho or Liberia or Madagascar or Malawi or Mali or Mauritania or Micronesia or Moldova or Mongolia or Morocco or Mozambique or Myanmar or Nepal or Nicaragua or Niger or Nigeria or Pakistan or Papua New Guinea or Philippines or Rwanda or (Sao Tome adj Principe) or Sao Tome or Senegal or Sierra Leone or Solomon Islands or Somalia or South Sudan or Sri Lanka or Sudan or Swaziland or Syrian Arab Republic or Syria or Tajikistan or Tanzania or Timor-Leste or East Timor or East Timur or Togo or Tunisia or Uganda or Ukraine or Uzbekistan or Uzbek or Vanuatu or Vietnam or Viet Nam or (West Bank adj Gaza) or West Bank or Yemen or Zambia or Zimbabwe).ti,ab,tw,kf. (529335)
1 or 2 or 3 or 4 or 5 (663813)
6 or 7 or 8 or 9 or 10 or 11 (946341)
12 or 13 or 14 or 15 or 16 or 17 or 18 (632219)
19 and 20 and 21 (1349)