The aim of this study was to explore and compare explanatory models (EMs) of hypertension in nativeDutch, first-generation Ghanaian and African-Surinamese (Surinamese) hypertensives in Amsterdam, the Netherlands. Through semi-structured interviews, we elicited accounts of the nature, causes and consequences of hypertension in a purposive sample of 46 patients (aged 35-65 years, treated for hypertension in general practice 41 year). All three groups had difficulty in describing hypertension. All groups mentioned culturally specific nutritional habits as possible causes of hypertension (Dutch liquorice; Ghanaians fufu; Surinamese salty diet). Most respondents, particularly those of Ghanaian and Surinamese background, perceived stress as the main cause of hypertension and experienced symptoms of hypertension. Many Ghanaian and Surinamese respondents attributed hypertension to migrationrelated factors: changes in diet or climate, stress owing to adaptation to the Dutch society or obligations towards family in their homelands. Many immigrants felt a return to their homeland could cure hypertension and were concerned about the consequences of hypertension. Half of the Dutch and almost all Ghanaian and Surinamese respondents believed uncontrolled hypertension could cause immediate damage. Some Ghanaians expressed reservations sharing their concerns with community members because it might cause social stigma. Few respondents associated hypertension with obesity, even though many were overweight. Confirming findings from UK and US studies, this study reveals that EMs of hypertension in patients from three ethnic groups differ from the common medical perspective. These differences are greater for patients from migrant groups. Our findings can be useful in developing patientcentred hypertension interventions, particularly in new migrant populations.

ObjectivesTo evaluate the effect of a practice-based, culturally appropriate patient education intervention on blood pressure (BP) and treatment adherence among patients of African origin with uncontrolled hypertension.MethodsCluster randomised trial involving four Dutch primary care centres and 146 patients (intervention n = 75, control n = 71), who met the following inclusion criteria: self-identified Surinamese or Ghanaian; ≥20 years; treated for hypertension; SBP≥140 mmHg. All patients received usual hypertension care. The intervention-group was also offered three nurse-led, culturally appropriate hypertension education sessions. BP was assessed with Omron 705-IT and treatment adherence with lifestyle- and medication adherence scales.Results139 patients (95%) completed the study (intervention n = 71, control n = 68). Baseline characteristics were largely similar for both groups. At six months, we observed a SBP reduction of ≥10 mmHg -primary outcome- in 48% of the intervention group and 43% of the control group. When adjusted for pre-specified covariates age, sex, hypertension duration, education, baseline measurement and clustering effect, the between-group difference was not significant (OR; 0.42; 95% CI: 0.11 to 1.54; P = 0.19). At six months, the mean SBP/DBD had dropped by 10/5.7 (SD 14.3/9.2)mmHg in the intervention group and by 6.3/1.7 (SD 13.4/8.6)mmHg in the control group. After adjustment, between-group differences in SBP and DBP reduction were −1.69 mmHg (95% CI: −6.01 to 2.62, P = 0.44) and −3.01 mmHg (−5.73 to −0.30, P = 0.03) in favour of the intervention group. Mean scores for adherence to lifestyle recommendations increased in the intervention group, but decreased in the control group. Mean medication adherence scores improved slightly in both groups. After adjustment, the between-group difference for adherence to lifestyle recommendations was 0.34 (0.12 to 0.55; P = 0.003). For medication adherence it was −0.09 (−0.65 to 0.46; P = 0.74).ConclusionThis intervention led to significant improvements in DBP and adherence to lifestyle recommendations, supporting the need for culturally appropriate hypertension care.Trial RegistrationControlled-Trials.com ISRCTN35675524

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Patients have explicit expectations on diagnosis, instructions, and interpersonal management. New strategies need to be developed in order to meet patients' expectations better. Practice guidelines should pay more attention to the best way of discussing the causes and diagnosis with the patient and should involve them in the decision-making process.

For Surinamese diabetes patients, cooking and eating practices are related to deeply rooted cultural beliefs and values. The wish to maintain one's Surinamese identity may pose difficulty for patients' adherence to dietary guidelines, as these are perceived as being based on 'Dutch' habits. This suggests that immigrants with a long duration of residence in the host country like the Surinamese, who are seen as well integrated might benefit from culturally sensitive diabetes education that is adapted at surface and deep structure.

BackgroundUniversal health care coverage has been identified as a promising strategy for improving hypertension treatment and control rates in sub Saharan Africa (SSA). Yet, even when quality care is accessible, poor adherence can compromise treatment outcomes. To provide information for adherence support interventions, this study explored what low income patients who received hypertension care in the context of a community based health insurance program in Nigeria perceive as inhibitors and facilitators for adhering to pharmacotherapy and healthy behaviors.MethodsWe conducted a qualitative interview study with 40 insured hypertensive patients who had received hypertension care for > 1 year in a rural primary care hospital in Kwara state, Nigeria. Supported by MAXQDA software, interview transcripts were inductively coded. Codes were then grouped into concepts and thematic categories, leading to matrices for inhibitors and facilitators of treatment adherence.ResultsImportant patient-identified facilitators of medication adherence included: affordability of care (through health insurance); trust in orthodox “western” medicines; trust in Doctor; dreaded dangers of hypertension; and use of prayer to support efficacy of pills. Inhibitors of medication adherence included: inconvenient clinic operating hours; long waiting times; under-dispensing of prescriptions; side-effects of pills; faith motivated changes of medication regimen; herbal supplementation/substitution of pills; and ignorance that regular use is needed. Local practices and norms were identified as important inhibitors to the uptake of healthier behaviors (e.g. use of salt for food preservation; negative cultural images associated with decreased body size and physical activity). Important factors facilitating such behaviors were the awareness that salt substitutes and products for composing healthier meals were cheaply available at local markets and that exercise could be integrated in people’s daily activities (e.g. farming, yam pounding, and household chores).ConclusionsWith a better understanding of patient perceived inhibitors and facilitators of adherence to hypertension treatment, this study provides information for patient education and health system level interventions that can be designed to improve compliance.Trial registrationISRCTN47894401.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-014-0624-z) contains supplementary material, which is available to authorized users.

General rightsIt is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), other than for strictly personal, individual use, unless the work is under an open content license (like Creative Commons). Disclaimer/Complaints regulationsIf you believe that digital publication of certain material infringes any of your rights or (privacy) interests, please let the Library know, stating your reasons. In case of a legitimate complaint, the Library will make the material inaccessible and/or remove it from the website. Please Ask the Library: http://uba.uva.nl/en/contact, or a letter to: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam, The Netherlands. You will be contacted as soon as possible. Abstract ObjectivesTo explore and compare how Ghanaian, African-Surinamese (Surinamese), and WhiteDutch patients perceive and manage antihypertensive drug treatment in Amsterdam, Netherlands. MethodsQualitative study was conducted using detailed interviews with a purposive sample of 46 hypertensive patients without comorbidity who were prescribed antihypertensives. ResultsPatients in all the ethnic groups actively decided how to manage their prescribed antihypertensive regimens. In all the groups, confidence in the doctor and beneficial effects of medication were reasons for taking prescribed antihypertensive dosage.Particularly, ethnic-minority patients reported lowering or leaving off the prescribed medication dosage. Explanations for altering prescribed dosage comprised disliking chemical medications, fear of side effects and preference for alternative treatment.Surinamese and Ghanaian men also worried about the negative effects of antihypertensives on their sexual performance. Some Ghanaians mentioned fear of addiction or lack of money as explanations for altering prescribed dosage. Surinamese and Ghanaians often discontinued medication when visiting their homeland. Some respondents from all ethnic groups preferred natural treatments although treatment type varied. ConclusionPatients' explanations for their decisions regarding the use of antihypertensives are often influenced by sociocultural issues and in ethnic-minority groups also by migration-related issues. Self-alteration of prescribed medication among Surinamese and Ghanaians may contribute to the low blood pressure (BP) control rate and high rate of malignant hypertension reported among these populations in the Netherlands. This study provides new information, which can help clinicians to understand how patients of diverse ethnic populations think about managing antihypertensive drug treatment and to address ethnic disparities in medication adherence and BP control.

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