Discussion
Several barriers and facilitators affecting hypertension management in urban Nepal were explored to inform the implementation of comprehensive approaches to hypertension management intervention. The major facilitators were, knowledge about risk factors and control measures motivating patients to adopt healthy lifestyle at individual level, family support at interpersonal level, availability of hypertension services at health system level and gender role enabling men to adopt healthy lifestyles at community level. Several important barriers were identified such as inadequate knowledge affecting medication adherence at individual level, peer pressure and poor family communication at interpersonal level, distrust in primary healthcare providers at the health system level and misconceptions regarding treatment at the community level. These findings have implications for future community interventions seeking to engage patients and families for hypertension control in Nepal and in similar LMICs, and we discuss these below.
We found that the individuals with adequate knowledge on hypertension were motivated to adopt healthy lifestyles and adhere to medication, which is also reported by previous studies from Nepal27 28 and LMICs.29–33 Consistent with findings from previous studies, motivation to adopt healthy lifestyles waned after starting medication in part due to insufficient knowledge about treatment measures.27 30 31 34 Patients and families could benefit from understanding the value of antihypertensive medication, and medication in tandem with lifestyle measures giving the best health benefit. Receiving information is insufficient to adopt healthy behaviours for blood pressure control.35 36 Paulo Freire’s empowering education approach37 engaging families over a period of time to critically analyse problems and its causes to develop and implement prioritised behavioural actions have been successful in managing chronic conditions.38
Intersections of age, gender and income affect patients’ ability to manage hypertension.39 We found that elderly patients refrained from physical activity equating it to vigorous exercise, while female patients were unable to allocate time. In Nepal, women are primarily responsible for unpaid housework (cooking, cleaning, washing, shopping) spending on average 268 min per day in comparison to 56 min per day spent by men.40 Tailoring physical activity to patient capacity may boost confidence in incorporating physical activity to control blood pressure.41
Adherence to antihypertensive medication is one of the keys to effective management of hypertension.42–44 Non-adherence to antihypertensive medication increases the risk of complications such as cardiovascular diseases (heart failure, myocardial infarction and stroke), which are increasing in Nepal.45 The cultural belief that medicines are mainly for curing severe diseases and not for reducing high blood pressure, an asymptomatic condition46 has created delays in initiation and discontinuation among those who initiated in our study.
A strong belief in home remedies such as eating bitter food to reduce blood pressure delayed or caused discontinuation of medication. Previous studies have also reported preference for home remedies to manage hypertension and other chronic conditions in Nepal27 28 and LMIC.31 32 47 Preference for home remedies is due to their easy availability, perceived safety and endorsement from family and friends.27 Misconception found in our study may be due to the high proportion of illiterate patient participants. Illiterates usually have poor access to information and knowledge,48 impending timely treatment and control of hypertension and its complications.29 Increased knowledge on the benefits of medication could counteract the negative consequences of misconception.
Our study found patients receiving family support were able to adopt healthy lifestyles. Family support in ensuring recommended diet was also reported in a previous study from India.49 It is an important factor for patients’ blood pressure control.32 Improved interaction and providing authentic information to patients and family could enhance hypertension control. For example, family reminding patients to take medicine is known to improve adherence in South Asian countries.34 However, the changing attitudes towards elderly and declining intergenerational support in Nepal50 highlight further research on family’s role in providing hypertension care. Also, families may be forced to prioritise the needs of breadwinners as opposed to elderly.51 The adult children and spouses as caregivers can be key stakeholders in the intervention, and they can play an active role in helping patients in monitoring blood pressure and adhering to medication and healthy behaviours.
The health system’s inability to identify poor obstructed socioeconomic access to hypertension care. Poor patients may not have the financial resources to seek care and medicines.52 53 Reliable estimates of poverty are the basis for inclusive healthcare. Also consistent with previous studies from LMIC,34 54 55 patients distrusted the competency of primary healthcare providers. When patients doubt the quality of healthcare, they self-refer overcrowding the tertiary care.56 The cost of travel and high fees at the tertiary care burden patients from low socioeconomic status.56 Studies from Nepal have shown patient discontinue treatment due to high cost of medicine and diagnostic tests.27 Hypertension services in the public primary healthcare facilities are free, therefore ensuring uninterrupted supply of antihypertensive medication, and training healthcare providers on treatment protocols can improve access. Trained primary healthcare providers can personalise counselling based on patients’ blood pressure measurements,43 and regular positive interaction can help instate trust in the primary-level care.
Positive patient–provider interactions are important for hypertension management.57 Our study identified poor patient counselling negatively affected patient follow-up. The high volume of patients in LMIC health centres is not conducive for positive patient–provider interaction35 in lack of healthcare provider time and space. Patients not receiving counselling are likely to be non-adherent to treatment and routine follow-up.28 29 35 36 In Nepal, the female community health volunteers have traditionally channelled health information to the community.58 Female community health volunteers may find participatory discussion difficult to implement,59 but there is a possibility to leverage on the existing approach to bridge patient–provider communication gap by recruiting trained nurses for a comprehensive approach to hypertension management. Flexible and tailored approaches considering individuals’ and family context are important when developing and implementing hypertension intervention.
Our results provide insights which can be applied globally. Research from other LMICs also show that adequate knowledge on hypertension services motivates patients to adopt treatment measures,30–33 and that addressing misconceptions29 46 and continued family support34 49 contribute to sustained behavioural changes. Rebuilding trust in primary healthcare providers34 49 55 is critical to ensure access to services for marginalised communities.56 Figure 2 highlights the recommendations drawn from our findings to guide future implementation of similar interventions in LMICs.
Figure 2Overcoming barriers to hypertension control—future perspective.
Strengths and limitations
The study’s main strength was collecting the perspectives of different stakeholders: hypertension patients, family members, private and public healthcare providers and municipal and ward officials to gain a comprehensive understanding of hypertension management in the community. Mixing different methods of data collection provided opportunities for clarification and triangulation of findings. The iterative process in data collection to achieve code saturation to gain comprehensive understanding of a range of new issues is expected to provide better internal validity. All focus groups and interviews were conducted by the authors (SaB and SwB) from similar cultural backgrounds as the participants. There were some limitations too. The heterogeneous (various socioeconomic background) sampling prevented us from understanding the intersection between evolving family roles, social class, gender, ethnicity, but we expect the participatory discussion during the intervention will allow further exploration. The findings are from a sample within one municipality and may not be generalisable to rural Nepal. Nevertheless, findings can be relevant for urban municipalities in similar low resource settings hoping to successfully manage hypertension.
Conclusion
Our study revealed the complexity of managing hypertension in urban Nepal. Inadequate knowledge and misconception on hypertension and medication affected adherence to treatment measures. Empowering families with knowledge on hypertension and its management was vital to optimise family support in home management of hypertension. The findings were and can be used in designing and implementing interventions to overcome the individual, interpersonal, health system and community barriers in managing hypertension.
Patient and public involvement
Participating hypertension patients, their family members, healthcare providers and municipal representatives were informed about the objective of the study and its implication. However, they were not directly involved in developing research questions and study design. The results of this study were discussed with the municipal representatives when developing the home visit manual.