Development of a cardiovascular health education program for primary care patients with hypertension in rural Nigeria: a qualitative study

Background: Patient-centered, culturally tailored cardiovascular health education has the potential to improve hypertension self-management. Despite the high prevalence of hypertension in Sub Sahara Africa, this type of health education is hardly available in this region. Objective: To describe how we developed and evaluated a culturally adapted Cardiovascular Health Education Program for insured hypertensive patients in rural Nigeria. Methods: Applying concepts of “cultural adaptation”, we took a hypertension education program from Europe as a starting point for program-development. First, we collected information on socio-cultural perspectives on hypertension care through a literature review and qualitative interviews with 40 hypertensive patients and 15 healthcare professionals/insurance managers in Kwara State Nigeria. Second, we used this information to adapt the content (deep structure) and the form (surface structure) of the European program to the unique patient population and circumstances of a primary care clinic in Kwara. Third, we evaluated the adapted program among 149 hypertensive patients from this clinic. Results: The interviews offered insight into patient perspectives on hypertension, socio-cultural and environmental inhibitors and facilitators for medication/ behavioral self-management (e.g. exercise) and on healthcare professional perspectives on optimal education delivery platforms – group counseling, posters, audiovisuals. These insights were used to adapt elements (e.g., educational tools, content) of the existing educational program. The adapted program has been shown to strengthen medication adherence and consequently blood pressure control among the targeted population. Conclusion: A culturally tailored Cardiovascular Health Education Program, developed by using a qualitative research approach, offered an effective means for educating patients about blood pressure control in a rural primary care setting in Africa. Implications: Our description of the program and the process by which it was developed offers a practical framework for developing cardiovascular health education for other patient populations in Africa. Correspondence to: Aina O Odusola, Department of Global Health, Academic Medical Center, University of Amsterdam, Amsterdam Institute for Global Health and Development, Trinity Building C, 3rd Floor, Pietersbergweg 17, 1105 BM Amsterdam Zuid Oost, The Netherlands, Tel: +234(0)8033330214; Fax: +31(20)5669557; E-mail: f.odusola@gmail.com


Introduction Background
Hypertension is highly prevalent in sub Saharan Africa (SSA) [1] and raised blood pressure is one of the leading risk factors for cardiovascular disease (CVD) and related premature death in the region [2]. In Nigeria, the estimated hypertension prevalence (systolic blood pressure (BP) ≥ 140 mmHg or diastolic BP ≥ 90 mmHg) is 28.9% among people aged 15 years and older [3]. It is well established that long-term treatment, which includes behavioral adaptations (e.g., weight control, reduced salt intake, regular exercise, smoking cessation and moderate alcohol use) and pharmacotherapy if needed, reduces BP and, concomitantly, the risk of developing CVD and other hypertension-related complications [4]. However, BP control rates are low in SSA [5]. Unfortunately, many people in the region have no access to affordable hypertension care in their communities. In addition, in settings where affordable care is available, poor compliance can compromise treatment outcomes [6][7][8]. Indeed, adequate hypertension management is challenging in SSA and multiple interventions are needed to improve both access to-and compliance with quality care [9].
A review of community-based interventions for CVD prevention in low-and middle income countries suggests that patient education can have a positive effect on treatment adherence and BP control among patients with hypertension [8]. The literature provides ample information on health education programs to support hypertension self-management for patients living in high income countries [10]. However, information on suitable educational programs for patients with hypertension in low resource countries is not available [11]. To fill the gap, in this paper we describe the formative phases by which we developed a cardiovascular health education program (CHEP) that is designed for insured primary care patients with hypertension in Kwara State, Nigeria. By positively influencing patients' perceptions of hypertension and medication, the developed program has been shown to strengthen medication adherence, and consequently BP reduction among the affected population [12].

Context
Kwara State was the fourth poorest State in Nigeria at the time of this study [13]. The majority of the population lives in rural areas and works in agriculture, fishery or (petty) trading. About one third of the population is illiterate. The main ethnic groups in the State are Yoruba and Nupe. Islam and Christianity are the main religions. In 2007, a subsidized health insurance program, the Kwara State Health Insurance (KSHI), was introduced in three rural regions in Kwara, where about 20% of the population lives below the poverty line of 2 USD per day [13]. KSHI provides coverage for consultations, diagnostic tests and drugs for all conditions, that can be managed at a primary care level, including hypertension, and limited coverage for secondary care services. In December 2014, about 67,000 people were enrolled in KSHI. Enrollees paid approximately 8% of the yearly premium of 30 USD themselves, while the Kwara State Government and the Health Insurance Fund subsidized the remaining 92% [14].
In 2010, hypertension was identified as the most important risk factor for CVD in rural Kwara, with a prevalence of 21% among the population aged ≥18 years and low levels of awareness (8%), antihypertensive treatment coverage (5%), and BP control (3%) among those with hypertension [15]. As part of its quality improvement program KSHI introduced WHO guidelines for CVD risk management, including hypertension care in contracted primary care clinics [16] and offered them new equipment, organizational support and training to facilitate implementation [17]. But because clinical guidelines offer little guidance on methods for patient education, CHEP was developed to support KSHI's initiative to improve the quality of CVD prevention care in Kwara [18].

Concepts underlying the development of CHEP
According to common sense models of health behaviour [19,20], patients' perceptions of a health problem (e.g., hypertension) and its treatment are an important determinant of treatment adherence. These perceptions can be rooted in individual experiences but also in the broader social, cultural, economic or environmental context of patients' lives. This was also highlighted in recent reviews of studies of patient perspectives on hypertension [21,22]. It is well recognized that "patient-centred" health education can play an important role in promoting adequate hypertension self-management, and particularly education that addresses patient perceptions on hypertension (e.g., its causes, symptoms, duration, severity, and consequences), the recommended treatment and their own ability to use medication and implement the recommended behavioural changes [10,23]. The five A's approach (Ask, Advise, Assess, Assist, and Arrange) is an example of a widely used "patient-centered" approach for supporting hypertension self-management [10]. However, several authors have emphasized it is also vital that educational interventions are "culturally sensitive" and that deep-rooted cultural norms (e.g., beliefs and traditions) and structural factors (e.g., socioeconomic status, health literacy) influencing behaviours of target groups are considered when developing such interventions [24][25][26]. In doing so, intervention developers must ensure that both the form in which health promotion interventions are delivered (the surface structure) and their content (deep structure) acknowledge customs, socio-demographic characteristics, and social, cultural and environmental values of the targeted population groups [25,26]. Our work drew upon a practical protocol for hypertension education developed by Beune et al. [27] to support treatment adherence and BP control among Afro-Surinamese and Ghanaian primary care patients with hypertension in the Netherlands. This protocol includes a generic "patient-centred" part, based on the method of the five A's [10] and a "culturally adapted" part, based on a framework proposed by Kleinman. The protocol allows educators to address both individual and cultural specific perspectives on hypertension self-management.

Design
Cardiovascular Health Education Program (CHEP) was developed in two phases: a formative phase and a construction phase. The goal of the formative phase was to collect information from available literature and from qualitative interviews with 40 primary care patients with hypertension and 11 health care professionals from the participating hospital and 4 health insurance managers from the Kwara State Health Insurance (KSHI) program. The goal of the construction phase was to review information that emerged in the formative phase and to supplement the protocol and materials developed by Beune et al. [27] with information collected during the formative phase, so as to make the program and educational materials relevant to patients in Nigeria.

Participants and setting
The study setting was a busy primary care hospital that participated in the KSHI program in (rural) Kwara State. As common in most parts of rural Africa, at that time rural Kwara similarly experienced an acute shortage of healthcare personnel. During the study period (July 2010 to December 2010) the hospital was managed by an experienced general practitioner assisted by 2 other doctors, 10 nurses, 4 laboratory technicians, 3 pharmacy staff and 4 health information administrative staff. At the same time about 400 hypertensive patients were enrolled in the insurance program and accessed hypertension care in the hospital.
Participants for the perception (interview) studies used in developing the education program include: 40 insured hypertensive patients (16 males and 24 females) for the patients' perspectives study; 2 medical doctors, 2 nurses, 2 laboratory staff, 4 health information (records) staff and 1 pharmacy staff for the healthcare professionals' perspectives study; and 4 KSHI managers (all medical doctors) for the health insurance managers' perspectives study.
Details of the specific methods employed in the interview studies are reported elsewhere [28,29]. For the literature review a narrative approach was used.

Data management and analysis
Data management and analysis of the qualitative interviews was based on grounded theory and supported with MAXQDA software.

Ethics
Ethical approval (Ref: UITH/CAT/189/13/13) was obtained from the University of Ilorin Teaching Hospital on 30 th August 2010. Prior to commencement of the study informed consent was obtained from all study participants.

Formative phase
Surface structure: The information gleaned from the literature provided little information about the best form for educational programs for the priority group of CHEP. However, interviews with health care professionals provided some relevant insights. They suggested various educational forms or strategies for enhancing patients' hypertension self-management capacities that are suitable within rural contexts in Africa where financial resources and health care personnel are limited: periodic group education led by trained nurses or paramedics (in addition to individual consulting room education); cardiovascular health clubs for patients to stimulate regular exercise and healthy dieting; the use of well known "positively living" community figures and peers as educators; involvement of patients' family members in education to ensure necessary social support for hypertension management; the use of local languages or interpreters in education; the use of pictorial and audiovisual materials (audiovisuals, posters, pictures, pamphlets) to reinforce learning, especially for illiterate patients. Moreover, the professionals emphasized that the organization of educational events during religious holidays, Muslim prayer hours and market days should be avoided. They also viewed the use of a "contact tracing system" to remind patients of their scheduled clinic visits as an educational tool.
Deep structure: In order to develop the content of CHEP we sought "in-depth" information on how patients' "explanatory models" of hypertension (understandings of the causes, mechanisms or pathophysiology, course of illness, symptoms) and its treatment relate to their daily hypertension self-management behaviours. To this end we conducted a qualitative interview study to investigate perceptions on hypertension and its management among primary care patients with hypertension in Kwara State [27] and reviewed similar studies from Nigeria on this topic [30,31]. Table 1 summarizes some of the main themes that emerged from the study and the literature, the selfmanagement coping strategies employed by patients and the specific educational teachings which the CHEP trainers used to address foci of insufficient hypertension knowledge that emerged from patients' perceptions. These themes illustrate that poor knowledge, cultural beliefs and customs and contextual factors may hamper adherence to treatment among patients, but that the local context also provides specific possibilities for harnessing adherence. To enhance the cultural sensitivity profile of the intervention we selected from the interview data aspects of the people's culture, practices and beliefs with clear health benefits. For example participants were taught to use suitable local salt substitutes in place of salt, and the healthier vegetable oil in place of red palm-and groundnut oils in preparing their meals. We encouraged consumption of fruits and vegetables which are cheap and abundantly available in the community, and re-orientated participants on perceived prejudiced cultural practices about local stimulants, tobacco and alcohol. To achieve physical fitness with less difficulty we encouraged the use of locally available environmental materials and cultural practices that are user-friendly to get enough exercise daily. Examples of these include: performance of usual household chores involving low-and medium level physical activities, brisk walking to-and from farm/other locations, farming/gardening activities, cultural and religious activities e.g., dancing, clapping, singing, drumming etc. and if feasible other more conventional exercise types like swimming, spot jogging and cycling to-and from farm/other destinations. Furthermore, participants were enlightened and trained on new strategies to achieve consistent use of prescribed medication to improve self-management capacities. To promote attractiveness and acceptance of the intervention by participants the physical activities were practiced within training sessions and thereafter set as goals to be achieved at home in between training sessions. Moreover, an audiovisual on environmentally possible user-friendly exercise regimes starred by familiar peers was viewed by participants at the beginning of each training session (Table 1).

Construction phase
CHEP: Based on the formative phase, we developed a final protocol for CHEP with the following overall objectives: 1) To enhance patients' understanding of hypertension and its treatment/management.
2) To raise patients' awareness and confidence on how they can manage hypertension in their daily lives.
3) To raise patients' awareness and confidence on how they can cope with the challenges in managing hypertension in the long run.
In order to achieve these objectives we developed a final program for cardiovascular health education that consisted of three sequential modules for group-based educational sessions. Table 2 provides an overview of the specific objectives and the proposed content and educational tools for each of these modules/sessions. The CHEP trainings were facilitated by a medical doctor (the researcher) and a trained nurse who is a native of the local community and had undergone prior training in CVD prevention strategies ( Table 2).

Translation of findings from formative phase into CHEP
CHEP was inspired by the three modules of the culturally adapted hypertension education (CAHE) program developed by Beune et al. [27]. The overall-and specific objectives of the educational sessions of CHEP as listed above are similar to those of CAHE (Supplementary file). However, based on information from the formative phase, several changes were made to components of CAHE, so as to adapt the program to the Nigerian socio-cultural context (Table 3).
Firstly, rather than individual counseling, which was used in CAHE, CHEP used group-interviewing, group-discussions and group-education as the main educational tools. Secondly, to reinforce education about medication use and lifestyle adaptations, CHEP used posters with images, a video film and physical exercise sessions at the clinic's compound. Instead, CAHE used a booklet containing written information. Given the low literacy rate of the priority groups of CHEP, pictorial information and practical exercises were deemed more appropriate. Finally, in order to ensure cultural sensitivity, we designed the form (surface structure) and the specific content (deep structure) of CHEP by using findings from the interviews held during formative phase as illustrated in Table 3 Uses alcohol and tobacco products for socio-cultural reasons (e.g. to stimulate work, relieve stress etc) despite awareness of hypertensive status Enlighten on the dangers of alcohol and tobacco to cardiovascular health despite perceived cultural usefulness; risks outweigh benefits Religion and gender perspectives discourages use Exploits religious and gender abhorrence of stimulants use to limit or quit use of alcohol and tobacco products Capitalize on existing cultural and religious abhorrence of these unhealthy social habits to further reinforce behavior change message Social support for hypertension management Family, peers, local leaders, media are potential sources of supports -Helpless about inadequate support from family and community which hampers clinic visits, regular medication use and behavioral changes -Exploits support from family with regards to cooperation on dietary prescriptions like low salt diet -Exploits support from community and religious leaders who routinely reinforce counseling on regular pills use and healthy behavior -Encourage participants to seek adequate support from family members in following prescribed treatments -Invite family members of patients and solicit their supports and cooperation to help patients achieve treatment adherence -Exploit the opportunities presented through potential roles of community leaders and religious organizations in additional counseling on pills adherence and healthy behavior An overview of the key information that was provided to CHEP trainers about commonly held patient perspectives that may either hinder or enable adherence to treatment is also shown in Table 1. This information was used by the educators to facilitate training on specific topics such as what hypertension is, or what can encourage appropriate medication, dietary or behavioral adaptations.

Evaluation
CHEP was implemented for a group of 149 primary care patients who were not sufficiently adherent to treatment recommendations or had BP above target after they had received guideline-based treatment for at least one year in the context of KSHI program. In a previous published report of a pretest/posttest study, we have shown that the developed program CHEP was able to strengthen medication adherence, in particular by positively influencing patients' perceptions of medications [12].

Discussion
CHEP is an educational program that was designed specifically for primary care patients with hypertension in Nigeria, with the aim to enhance their understanding of hypertension and better disease self-management. The rationale for developing this program was based on research which has demonstrated that a poor understanding of hypertension or aspects of the treatment may hamper adequate BP control among patients with hypertension, even if they receive affordable guideline-based treatment [12]. Rather than relying solely on information from healthcare providers on what patients need to know to manage hypertension, CHEP was developed using a formative approach that also considered data from qualitative interview studies on affected patients' perspectives regarding inhibitors and facilitators for managing hypertension. An existing educational program for patients in Europe, CAHE [27] that combines principles of patientcenteredness and cultural sensitivity, was taken as point of departure in developing CHEP. Notions from Resnicow (1998) on cultural adaptation of health education were employed to adapt the program to fit the patient population in the program area.
CHEP provides a framework for cardiovascular health education for patients with hypertension in Nigeria. However, the majority of the population investigated in the formative interview study had health insurance (100%), a low level of formal education (92%), was of Nupe or Yoruba origin, practicing either Christianity or Islam and did not suffer from hypertension-related complications or co-morbidity [27]. Therefore, CHEP may not have addressed the concerns of all hypertensive patients in Nigeria, including those from other social strata and ethnic and linguistic groups or patients treated in tertiary care hospitals. Future formative studies are needed to develop and test the CHEP framework among larger populations. Our initial evaluation in a non-controlled study suggests that CHEP can be implemented in rural primary care practices in Nigeria and that it can lead to a decrease in patients' concerns about medication use and an increase in medication self-efficacy, and, concomitantly, better medication adherence [12]. There is a potential to further test the impact of CHEP on treatment adherence and BP control in future using randomized studies.

Conclusion
This paper provides a detailed description of the development and design of a program for cardiovascular health education that is applicable to patients with hypertension in rural Nigeria. The strength of the program is that it was developed based on "patient-centered" and "culturally-sensitive" approaches to health promotion using qualitative interviews with stakeholders. The program and formative process for developing CHEP described in this paper offer a framework for developing or adapting similar educational programs for other patient populations with high risk of CVD in Africa. Even though we have shown that the developed program was able to strengthen medication adherence, in the next phase CHEP will need to be evaluated in rigorous controlled studies.

Group session 3 (CHEP-3) (week 15)
Overall objectives To enhance patients' understanding of hypertension and its treatment/management To raise patients' awareness and confidence on how they can manage hypertension in their daily lives To raise patients' awareness and confidence on how they can cope with the challenges in managing hypertension (in the long run)

Session objectives
To elicit participants' ideas about hypertension and treatment; inform them about medical perspective; reach consensus; and establish treatment objectives for next session -CHEP-2 To explore daily challenges participants face in managing hypertension; how they currently cope with the identified challenges; inform them on how they may cope better; and establish objectives for next session -CHEP-3 To explore daily challenges participants face in managing hypertension; how they currently cope with the identified challenges, inform them on how they may cope better; and establish how they can continue to deal with the challenges in future • What challenges do you face? • How did you cope?

2.3: Weight reduction/exercise group discussion (15 minutes)
• What challenges do you face? • How did you cope?

2.4: Attending your follow-up appointments regularly as advised group discussion (15 minutes)
• What challenges do you face? • How did you cope? • Set 3 goals on what you want to achieve before your next CHEP visit to keep your blood pressure controlled (e.g. reduce salt consumption, increase physical activity through exercise)

3.1: Medication use: group discussion (15 minutes)
• What challenges do you face? • How did you cope?

3.2: Dietary advice/salt: group discussion (15 minutes)
• What challenges do you face? • How did you cope?

3.3: Weight reduction/exercise group discussion (15 minutes)
• What challenges do you face? • How did you cope?

3.4: Attending your follow-up appointments regularly as advised group discussion (15 minutes)
• What challenges do you face? • How did you cope?

3.5: Audiovisual 'Living positively with hypertension': Instruction (25 minutes)
• View and discuss video "living positively with hypertension" and some patientcentered exercise regimes to help coping (35 minutes) 3. 6  Exercise classes at health facility Use of common daily activities as forms of exercise Table 3. Adapted components of the cardiovascular health education program