Bio-medical understanding.

Some PHC clients and all PHC workers expressed understandings about meaning of hypertension related to biomedical views of raised blood pressure as measured by some medical equipment.

“No, the only name I know for hypertension is hypertension when the doctor measures it with a machine” (cp4:I)

However, PHC workers explained the meaning in more definite terms using cut-off points for abnormal blood pressure measurement. But, different cut-offs for diagnosis of hypertension were mentioned by two senior PHC workers.

Notably, during the focus group discussion for PHC workers a discussion took place over the issue of blood pressure cut-off point for diagnosis of hypertension and all arrived at a consensus that they needed to look up in the books for the acceptable cut-off point.

“Apart from hypertension, it is also known as high blood pressure, increase in your BP that is the blood pressure is more than 160/100, or 160/110 that is hypertension…”(wp4:I)

“You see, when the systolic pressure rises from the range 100 to 140, that person is free. So if, the diastolic pressure too from 60–90, it is expected that, that person doesn’t have any cause for alarm so, if the systolic pressure is above 140, that is where we say the blood pressure is high now and we try to explain things to them”(wP1:I)

All PHC clients who expressed biomedical views also expressed other views about meaning of hypertension and all were diagnosed hypertensive clients. All of those who did not express biomedical views of meaning were not known to be hypertensive.

Cultural perceptions.

This study involved participants from twenty-one ethnic groups. Three (3) diagnosed hypertensive participants who gave the ethnic/cultural names for hypertension explained their meanings in terms of stress and biomedical related complications.

“In Yoruba, we call it Ejeriru. The meaning is that, when you over labour the body, the way the heart pumps out blood, is too high and the temperature will go high and all the body will collapse, and that part of the body, will be functionless either the leg, hand or the whole body”(cp9:fg)

“Like in my own language, Igbo, we call it ‘‘ogbaramgbanyi-enu” i.e. high BP high blood pressure.It means someone who is over thinking has something disturbing or worrying him, that causes him may be, sleepless nights and all that and sometimes the person starts misbehaving at times it leads to paralysis or stroke”. (cp8:fg)

Other ethnic understandings of hypertension elicited from this study did not relate to stress or biomedical complications but were verbatim translations of the native/ethnic/cultural names for hypertension. They include perceptions like; “the blood volume is going high”, “climbing blood”, “blood shooting up” and “a dangerous ailment that is incurable”. These perceptions were elicited from Igbo, Tiv, Hausa and Esan-edo ethnic groups respectively.

“We call it ‘‘ogbaramgbanyi-enu” it means somebody’s blood level is going high” (cp30:I).

“Hypertension…some locals call it bubun jini, but the enlightened ones would say; hawan jinni. It means Climbing blood (literally) but it means hypertension” (wp20:I).

“Well generally in Hausa we call it hawan jini. It means the blood is shooting up”(cp8:I)

“In my dialect we have a name for it. It is called, ‘Ujagbe’. It means something that is a dangerous ailment that is un-curable”(cp21:I).

It was noted that among the Igbo ethnic group, different meanings were given to the same ethnic names for hypertension.

“Like in my own language, Igbo, we call it ‘‘ogbaramgbanyi-enu” i.e. high BP high blood pressure.It means someone who is over thinking has something disturbing or worrying him, that causes him may be, sleepless nights and all that and sometimes the person starts misbehaving at times it leads to (paralysis) paralyze or stroke”. (cp8:fg)

“We call it ‘‘ogbaramgbanyi-enu” it means somebody’s blood level is going high” (cp30:I).

There was also overlap between the Yoruba ethnic understandings and Hausa ethnic understandings as participants belonging to these groups expressed similar meanings to different native names.

“Well in Hausa we call it hawan jini. It means the blood is shooting up”(cp23:I)

“I don’t know any other name but the Yourba call it ejeriru which means blood shooting up”(cp28:I)

All these beliefs were expressed by both diagnosed hypertensives and patients not known to be hypertensive alike. There was no indication of any distinction in beliefs between diagnosed hypertensives and participants not known to be hypertensive.

Stress.

Some PHC clients expressed the understanding that hypertension simply meant stress. Stress was colloquially termed “thinking too much” or “thinking” which is caused by negative circumstances in life.

“It means when you are thinking, like when something is disturbing you and you are thinking too much of how to get out of that problem and then that thinking enters your blood and make your blood pressure to rise”(cp10:I)

“It means someone who is over thinking has something disturbing or worrying him, that causes him may be, sleepless nights and all that…”(cp5:fg).

Among PHC workers, stress was only mentioned as a cause of hypertension and not understood to mean hypertension.

Stress.

Stress was the most prominent belief expressed in this sample as the cause of hypertension. Majority of participants (PHC workers and clients) expressed stress as the cause of hypertension. There was no specific difference in the beliefs about stress amongst diagnosed hypertensives and those not known to be hypertensive. It is also of note that there was no difference in the aetiology of stressors identified by men and women in this sample. Generally, stressors identified in this sample refer to thinking too much about life circumstances such as poverty, health related problems, relationship problems, loss of a loved one, unemployment, family responsibilities and financial demands or anything that reduces the amount of sleeping time.

“When you are anxious about something and you are not getting it, eventually, it can result to hypertension” (cp7:fg)

“Yes if one over thinks about something in the sense that it affects your sleep. You don’t sleep well it affects the brain. Your brain doesn’t rest, neither does it get adequate rest. It can lead to high B.P”(wP2:fg).

One PHC client disagreed with the fact that being biologically old in age may be a risk factor for hypertension but felt that most hypertension in old age was as a result of stress in old age.

“It depends on the person because most old people stress themselves to the extent that they will not have time to relax and some other people they have time to relax because their children do everything for them, so they don’t have anything to think about. It is when they start thinking about maybe the wellbeing of their children which is not okay and that might lead to hypertension”(cP29:I)

Most PHC workers who said stress was a cause of hypertension had practical examples among their clients to back up their claims.

“Maybe, all the time, you are busy doing this or that, thinking of this or that all through the night, you don’t sleep, you are having insomnia, it could lead to hypertension too”(wp1:I).

“It is not just my opinion but from what I have learnt and experienced, it is caused by too much thinking, stress. People don’t have a history for rest” (wP14:I).

Bio-medical causation.

Most PHC clients and all PHC workers believed that biomedical identified risk factors such as excessive salt intake, lack of exercise, excessive fat consumption, smoking and aging could be a cause of hypertension. However, for PHC workers some specifically used the word “causes” while others were more cautious preferring to use the word “predisposing factors” for hypertension.

“I don’t think salt causes hypertension. It is just a predisposing i.e. a contributing factor”(wp5:fg)

“Smoking can make the blood pressure to increase”(wp22:I)

“Yeah because I believe that too much fat will block some blood vessels and that can cause it”(wp23:I)

There were no differences found in beliefs between clients known to be hypertensive and those that are not known to be hypertensive.

However, some PHC clients who believed that biomedical risk factors could trigger hypertension disagreed with some known biomedical risk factors. Some of the disagreements were based on personal experiences or experiences of people in their social network.

“Because as for myself I don’t sit in one place, I am always about but yet I still have it”(cp11:I)

“Why I will not agree with that is because my mother who died at the age of ninety five (95) did not have hypertension so, I don’t believe that”(cp21:I)

One PHC client who didn’t agree with the fact that alcohol could be a cause of hypertension thought so because of the ability of alcohol to reduce “thinking” or stress.

“If you take alcohol, you feel relaxed, so you don’t think”(cp31:I).

All PHC workers also expressed beliefs that hypertension could be genetically inherited and that it could occur as a result of complications from other medical conditions. However, this was not the case with PHC clients. Some believed it could be inherited while others did not. Most of the PHC client who expressed agreement or disagreement with heredity as a cause of hypertension did so on account of personal experiences. For most of these participants, these did not affect other held beliefs as most of them still thought that other biomedical risk factors could cause hypertension.

“…. one my bosses, she has an eye problem and she told me that her dad had it … Her dad and mum had it and now one of her children is facing it. So likewise hypertension, it can be caused by heredity”(cP6:I).

“…Like I told you earlier, that I don’t think I inherited it from my parents. Maybe, in a way, I contributed negatively either my lifestyle or diet”(cP20:I)

Regarding salt intake, there were two camps in the focus group discussion. Some PHC workers specified that salt was more dangerous than some certain types of food seasoning while others disagreed.

“I have observed that people in the North, hardly suffer from hypertension but in the East, you see a lot of adults with it because of the kind of food they eat. The Northerners tell me that they don’t cook with salt, instead they use magi in place of salt. You can see them using up to ten (10) to fifteen (15) cubes of magi for cooking soup but in the East, we don’t use maggi and some of our local foods, require raw salt and you know that raw salt is more dangerous than cooked salt”(wp3:fg).

“I don’t agree with taking only maggi. As she has rightly said, the major ingredient in maggi is salt so I do not agree with taking only maggi if there is no salt, there should be no maggi too”(wP7:fg).

Drug abuse.

Both PHC clients and workers expressed the idea that addiction to illicit drugs like cocaine and cannabis could cause hypertension.

“Yes. In those who are involved in social vices, like; drugs, drug addict, someone who takes a lot of alcohol too. All these ones are prone to hypertension” (wP11:I).

Divine destiny.

Two PHC clients felt that sometimes the cause of hypertension may not be attributable to any physical cause but the divine will. It is important to note that these participants still expressed beliefs about other causes of hypertension such as stress.

“There are two types; one that comes from over-thinking and vexing, the other comes naturally from the air divinely” (cP27:I)

Symptoms of hypertension.

All PHC workers reported at least one symptom of hypertension. This was based on their experiences of managing patients with hypertension. The most common symptoms mentioned were headaches, palpitations, dizziness, blurred vision. Among PHC clients the commonest symptoms mentioned were palpitations and dizziness

“I will tell the person the signs and symptoms of hypertension some are headache, dizziness and some will have palpitations”(wP15:I)

A few PHC clients said they didn’t know what effects hypertension could have because they did not have the disease. All of the five participants who said this were not known to be hypertensive.

“Well, since I don’t have it, I don’t think I can’t say much about it” (cP6:I)

However, some clients not known to be hypertensive still gave their opinion on the effects of hypertension based on experiences of those in their social network.

“Yes, my sister. Sometimes she dey say her eye dey turn (feels dizzy) and her heart dey beat fast (palpitations). When she starts to feel like that, she has to go to the hospital to run some tests”(cP3:I)

Some PHC workers also believed that hypertension could result in weight loss and sleeplessness and would tell their clients to watch out for these signs among others as mentioned above.

“Sometimes, if you have hypertension, you lose weight, and experience headache, your blood pressure is checked or you are sent to the laboratory to know what is there”(wP18:I).

Only few PHC workers mentioned that hypertension could be asymptomatic. Most of those who said these were high level cadre health care workers like doctors, nurses and senior community health extension workers.

Illnesses caused by hypertension.

Most PHC workers reported that hypertension could result in other health problems if not well managed. The most common illness reported was stroke, eye problems, hypertension in pregnancy related complications and sudden death.

“I fear these two things; having stroke (paraplegia)” and then sudden death. Those are the things that scare me about hypertension”(wp3:fg).

Poverty.

The idea of hypertension making one poor was expressed by only diagnosed hypertensive PHC clients who have been on hypertensive medications for a long time.

“I can’t just say because if I see the situation I am in now, I can’t pay for my drugs, I can’t eat good food, these are the major problems I have faced”(cP24:I)

Solitude.

One PHC client not known to be hypertensive expressed the idea that he has observed that hypertensive patients usually like to stay in serene locations at all times as they may not want to be disturbed. It is not clear whether the participant viewed this as a positive or negative outcome. However, during the focus group discussions with PHC clients, this idea was disputed by most diagnosed hypertensive participants.

“Well people that have hypertension, they do not like staying around places that are disturbed, they always want to be where it is quiet” (cP6:I).

Cure versus manage.

There was a general consensus amongst all PHC workers that hypertension can be managed and not cured. However, PHC clients’ response on whether hypertension would last for a short or long time was variable. A few believed that hypertension could be cured while many thought that it could only be managed. There was no relationship noted between the beliefs about the cause of hypertension and curability. Many who thought hypertension could be managed were influenced by personal and shared experiences.

“I heard some people say that on its own after a while it vanishes” (cP30:I)

“You know one thing I don’t believe this thing has a remedy or a cure… (cp31:I)

Spiritual help.

Only a few PHC workers thought that spiritual forces could help in the treatment of hypertension. Most of those who prescribe spiritual help for their clients specifically recommend it as means of alleviating negative life circumstances that can lead to thinking too much and in turn hypertension. There was no relationship between health worker cadre and recommendation of spiritual help.

“Any issue you know you cannot handle, don’t think about it but pray and hand it over to God” (wP9:I)

However, although most PHC clients believed spiritual help was useful, they all thought it should be combined with other treatment modalities. However, one hypertensive female PHC client believed that God would heal everybody in the future.

“God will heal everybody someday”(cP17:I)

Therapeutic agents.

Therapeutic agents refer to beliefs about the use of some external agents such as orthodox drugs or herbal medications. Most PHC workers believed that you needed some form of therapeutic agent to bring down blood pressure. Orthodox medications were believed to be effective if strictly adhered to. As for herbal medications while majority will not recommend it, a few PHC workers would still prescribe it for their clients. In addition, most PHC workers would not recommend taking herbal medications together with orthodox medication as it could cause adverse reactions. Those who prescribe herbal medications do it based on positive experiences in the past. One PHC worker said:

“I used to be one of those that is totally against herbal medication but I just noticed of recent, on the herbal medication that was given to a hypertensive patient with a case of obesity and I think they were just natural roots given to her to keep boiling and drinking. Of a truth, she did as she was told and she involved herself in exercise as well. The obese nature dropped drastically which the patient continued taking those herbs for almost three weeks or so and it dropped and the person continued with the exercise….” (wP2:Fg)

However, half of PHC clients believed that orthodox drugs alone as prescribed by a doctor was effective in treating hypertension but only a few believed that using herbal medications alone could be effective. Some of the participants who believe that herbal medications alone could be effective thought that you needed a doctor to make a diagnosis before using herbal medications.

“You can take herbs when you know what the problem is. When you know what you are having it is then you can start taking herbs instead of taking anything when you don’t know the problem”(cP2;I).

A few PHC clients believed that you could use both herbal and orthodox medications together.

“Yes they should take both. You can use the herbal for a start then the orthodox medicine”(cP7:I)

Life style modification.

All of the PHC workers and most PHC clients believed that life style modification was a key element in the treatment of hypertension.

“Yes, number one, you have to assure them; two, you have to sensitize them .i.e. you do community health education and mobilization, and that they should be able to take their drugs constantly” (wP12:I).

“The kind of food you eat matters a lot because it goes into the body so, if you take in too much salt, fats, can lead to it. You will reduce some kind of food intake that is what I think apart from the drugs”(cP29:I)

However, only about half of the PHC workers reminded their patients regularly about modification of life style habits during consultation.

Stress management.

Since majority of PHC clients thought that stress was a cause of hypertension, many thought that stress management i.e. not thinking too much and taking a rest was a personal remedy for hypertension. However, the idea of stress management was not particularly expressed by PHC workers of any cadre.

“First I would call it a personal remedy. You should try and reduce your thinking, then maybe stay away from things that cause you to think, stay away from problems although you I don’t think you can escape problems but you can just try to help yourself then constant check-up”(cP7:I).