Knowledge , beliefs and attitudes of community health workers about hypertension in the Cape Peninsula , South Africa

Abstrak This article explores the perceptions and attitudes of community health workers (CHWs) about hypertension. The level of knowledge of hypertension, as well as their personal attitude towards this is crucial in the style and quality of their interventions. CHWs, whose role in health promotion is being increasingly recognised, can help contain or reduce the prevalence of hypertension by influencing the community to adopt healthy lifestyles. Forty-three CHWs employed by Zanempilo in two study areas, Sites B and C in Khayelitsha in the Cape Penin­ sula, South Africa, were included in the study. Firstly, focus group discussions were conducted with 17 purposively selected CHWs to explore attitudes, beliefs and perceptions of hypertension. Secondly, interviews were conducted to assess their basic knowledge about causes, prevention and control of hypertension. The focus group discussions revealed that CHWs were un­ certain about the causes of hypertension. They also found it difficult to grasp the fact that people without risk factors, such as overweight or a family history of hypertension, could be hypertensive. Many CHWs be­ lieve in traditional medicines and home-brewed beer as the best treatment for hypertension. They believe that people who take medical treatment become sicker and that their health deteriorates rapidly. Risk factors of hy­ pertension mentioned during the structured interviews include inheritance, lack of physical activity, consuming lots of salty and fatty food. Conclusions drawn from the findings of the CHWs’ responses highlighted their in­ sufficient knowledge about hypertension as a chronic disease of lifestyle. Meanwhile they are expected to play a role in stimulating community residents’ interest in the broad principle of preventive health maintenance and follow-up. Data obtained from this research can be used for the planning of health-promotion programmes. These should include preventing hypertension and improving primary management of individual sufferers. Because of their working relations and close link with CHWs, com­ munity nurses in primary health-care facilities need to recognise these beliefs and attitudes since these may differ from their own. Hierdie artikel ondersoek die insig en houdings van gemeenskapgesondheidsw erkers ten opsigte van hipertensie. Hulle standaard van kennis van hipertensie, asook hulle persoonlike houding daarteenoor is deurslaggewend vir die styl en kwaliteit van hulle intervensies. Gemeenskapgesondheidswerkers se rol in die bevordering van gesondheid word al hoe meer erken, en kan help om die voorkoms van hipertensie onder beheer te hou of te verminder deur die gemeenskap te bei'nvloed om ’n gesonde lewenstyl te volg. Drie en veertig gem eenskapgesondheidsw erkers wat by Zanempilo in twee studiegebiede, Sektor B en C in Khayelitsha in die Kaapse Skiereiland, Suid-Afrika werksaam is, is by die studie betrek. Eerstens is fokusgroeponderhoude met 17 gemeenskapgesond­ heidswerkers wat doelbewus geselekteer is gevoer om hulle houdings, menings en insig omtrent hipertensie te ondersoek. Vervolgens is onderhoude gevoer om hulle basiese kennis omtrent die oorsake, voorkoming en hantering van hipertensie te bepaal. Die fokusgroep­ onderhoude het getoon dat gemeenskapgesondheids­ werkers onseker is omtrent die oorsake van hipertensie. Hulle het gesukkel om te begryp dat mense sonder risikofaktore soos oorgewig, of ’n familiegeskiedenis van hipertensie ook hipertensief kan wees. Baie van hierdie werkers glo in tradisionele medisyne en tuisgem aakte bier as die beste behandeling vir hipertensie. Hulle glo dat mense wat op mediese behandeling is, sieker word en dat hulle gesondheid ook vinniger agteruitgaan. Risiko faktore vir hipertensie wat gedurende die gestruktureerde onderhoude genoem is, sluit oorerflikheid, ’n gebrek aan oefening, en ’n verhoogde souten vetinname in. Die gevolgtrekkings van die bevindings van gemeenskapgesondheids­ werkers se antwoorde dui op hulle gebrekkige kennis van hipertensie as ’n chroniese lewenstylverwante siekte. Intussen word daar van hulle verwag om ’n rol te speel om die gemeenskap se belangstelling te prikkel aangaande die breë beginsel in die handhawing en voortsetting van voorkomende gesondheid. Data wat uit hierdie navorsing verkry is, kan gebruik word vir die beplanning van programme ter bevordering van gesondheid. Dit behoort die voorkoming van hipertensie in te sluit asook om die primêre hantering van indiwiduele lyers te verbeter. As gevolg van hulle werksverband en noue kontak met die gemeenskapgesondheidswerkers, behoort Gemeenskapsverpleegsters in die primêre gesondheidsorgdienste hierdie menings en houdings in ag te neem aangesien dit van hulle s’nkan verskil.


Introduction
Hypertension is an important public health problem, espe cially among the black urban South African population.Previous studies have reported age-adjusted prevalence of hypertension of 15-34% in all South African ethnic groups, but less prevalence in blacks residing in deep rural areas (Steyn, 1991).A national survey of 1998 (Steyn, Gaziano, Bradshaw, Laubscher & Fourie, 2001:1722), using a cut-off point of 140/90 mmHg, reported an overall ageadjusted prevalence of 21 % for hypertension.The preva lence was 23% and 25% in African men and women respec tively.
Studies show that hypertension is positively associated with increased risk of coronary heart disease, stroke, con gestive heart failure, end-stage renal disease and periph eral vascular disease (Rozanski, Blumenthal & Kaplan, 1999:2192;Lunt, Edwards, Steyn, Lombard & Fehrsen, 1998:544).Because of the high costs of curative and reha bilitative care toward hypertension, a population based approach preventive measure would be more cost effec tive, and community management would appear feasible in those already affected.The contributions of socio-cultural, psychological, behav ioural and health-care system factors are fundamental in achieving the magnitude of decrement in morbidity and mortality that can be attained through well-directed pre vention strategies (Hill & Becker, 1995:S123).
Most patients with hypertension are treated in primary care settings.Several studies have reported poor control of hypertension in patients attending health care facilities (Lunt etal., 1998:544;Steyn et al.. 2001Steyn et al.. :1717)).Possible reasons for poor control include poor attendance at clinics and lack of compliance with treatment and lifestyle modification, which is probably due to beliefs held by patients about health and illness.Community-based nurses and health workers who supplement physician office-based practice are known to be effective in promoting cardiovascular health (Hill et al. 1995: S I23).The CHW's positive role as key agents in improving health has been widely documented (World Health Organisation, 1989).Because of their under standing of the social environment, they are able to work closely with families to enhance active patient participa tion.
It was therefore necessary to explore the CHWs beliefs and attitudes about hypertension because non-governmental organizations are increasingly using them for their outreach programs (Felix-Aaron, Bone, Levine, & Rubin, 2002:88).CHWs are persons trained to assist professional health personnel in communicating with residents in the commu nity concerning needs and availability of health services.By influencing the community, including those at risk to adopt healthy lifestyle, the Community Health Workers (CHWs) can help reduce the prevalence of hypertension.Aside from these preventive measures and health educa tion, they can assist in the management of the disease since the workload in primary health care facilities are often cited as a reason for the poor control of the disease.
CHWs included in this study were employed by Zanempilo (formerly known as SACLA), a non-governmental organi zation, to render health care services in under-resourced areas in and around Khayelitsha, Western Cape Province.They were residents of Khayelitsha and shared the same socio-cultural and demographic profiles as ordinary mem bers of this community.In 2000, Zanempilo, at the request of the community agreed to add a component of health promotion in the activities of CHWs.While CHWs play a role in health promotion in general, there have so far been no programs for primary prevention of cardiovascular dis eases targeting CHWs in particular.Hence Zanempilo initi ated chronic diseases of lifestyle programme with the aim to develop an intervention programme for primary preven tion of cardiovascular diseases.The main aim of the study was to describe the knowledge, beliefs and attitudes of CHWs employed by Zanempilo about hypertension as this may have had an influence in their health promotion strat egies at community level.
Khayelitsha is a large predominantly informal settlement located some 30km from the centre of Cape Town Metropole Council.The size and population of the settlement is dis puted, with estimates ranging from 350 000 to 900 000.It is estimated that 43% of adults are unemployed.The majority of employed people fall into types of occupations that are typically unskilled and low-paid (The Social Economy of Khayelitsha, 2002:4).Public health problems such as HIV/ AIDS, under-nourishment, tuberculosis and inadequate health facilities in the area are matters of concern.

Methodology
Study design: An exploratory, qualitative and quantitative study aimed to describe the beliefs, attitudes and percep tions of CHWs, and to assess their basic knowledge of hypertension as a chronic disease of lifestyle.
Sampling procedure and data capture: All 43 CHWs who were employed by Zanempilo in two study areas, Site B, and C in Khayelitsha were included in the study.The study was structured in two data collection phases.In the first phase, two focus group discussions (FGDs) to explore the attitudes, beliefs and perception of hypertension based on socio-cultural backgrounds of CHWs were conducted with a purposive sample of 17 CHWs (8 and 9) in each group.Two researchers conducted the discussions and used the CHW's indigenous language to exclude misunderstand ings.A question 'We would like to find out what you, including the patients in the community know and be lieve about high blood pressure, that is, what is high blood pressure, what causes it, and how it is treated' was dis cussed in the two groups.A tape recorder was used and field notes were taken.Information obtained from group discussions was used to guide development of a question naire to validate the information collected through focus group discussions.The questionnaire was developed in English, then translated into isiXhosa and back translated on to English.In the second phase, CHWs were interviewed to assess basic knowledge about risk factors and control of hypertension.D ata analysis: Tape-recorded qualitative data from focus group discussions was transcribed ad verbatim by two researchers independently and then translated to English.Codes were developed after review of responses and two researchers independently grouped them according to the themes that emerged.Quantitative data from interviews was analysed using the Epilnfo 2000 computer program.Fre quencies and percentages were calculated.

Ethical Considerations
The study assured complete confidentiality, as the data set and analysis were not linked to the name of the partici pants.The protocol to conduct this research was presented to and approved by the ethical committees of the Medical Research Council in Parowvallei and the University of the Western Cape in Bellville.The purpose of the study was explained to the participants and informed consent was obtained.The findings were presented to the Western Cape Department of Health, Zanempilo managers and the partici pants, and other stakeholders.

Focus group discussions (FGDS)
Themes that arose from FGDs are discussed below.

General perceptions about causes, prevention and control of hypertension
Hypertension was defined according to their beliefs, which does not correspond to the medical definition.'High blood pressure commonly known as hi-hi is when a person has too much blood in the body and the heart cannot manage to pump it w ell'.CHWs had some understanding of the link between risk factors (perceived causes) such as high salt intake in diet; lack of exercises; stressful life and hypertension.They also related blood pressure to eating fatty foods.'Hypertension is caused by eating too much salt and fatty fo o d '. 'It is also caused by stress '. pertension.' We understand that Hypertension is a disease common in overweight people, but we also see thin people who ad here to healthy living (these people were considered not at risk) with no fam ily history o f hypertension, but told that they suffer from hypertension.Most o f the people think that hypertension is therefore caused by witchcraft'.

Hypertension is a society norm
The CHWs thought that it was normal for adults to be taking treatment for hypertension.
'Almost every adult in the community is on treatment fo r hi-hi (hypertension).People are surprised to meet some one above 50 years who is not on treatment fo r hyperten sion.It is just like overweight, almost all women in the community are overweight'.

Hypertension control versus poverty
The CHWs mentioned that community members are not concerned about hypertension as a chronic disease, but are more worried about poverty.
'People are not concerned about hi-hi, because o f pov erty.They worry about what they are going to e a t... peo ple are depressed about their poverty situation and some are very stressed... people are not working and this forces them to eat whatever is available.You may fin d that one person in the house has diabetes or hypertension but can not control her diet because the little fo o d available has to be shared with the whole fam ily'.'People usually ask-how can I take medicine in an empty stomach?'

Compliance to treatment
Much as they understood the incurable nature of hyper tension -to them this was another medical notion.They believed that traditional remedies like natural herbs and home brewed beer could control the disease.Medical treat ment was considered "toxic" and had short-term effects.Some people skip medication or take less than what is pre scribed to avoid unwanted effects.'You cannot take tablets fo r the rest o f your life ... i t ' s poison ... people get tired'.'The tablets make people more sicker.They become very sleepy.One man told me that his wife had accused him o f having an affair with another women because he was al ways sleepy.Even during the night he could not wake up at a ll'.
CHWs indicated that most people were aware that if they do not take treatment as prescribed they may get stroke, but because they have many other problems, taking treat ment is not a priority.

Difficulty in understanding the risk factors for hypertension
CHWs mentioned that most people from the community including themselves were uncertain about causes of hy-'One woman told me that the tablets make her pass a lot o f urine.To avoid going to the toilet during the night she is taking one tablet instead o f two that were prescribed'.Patients seem not to take prescribed treatment as expected.They only take treatment few days before they visit the clinic for check-up.They do not often tell the doctors that they are taking other home remedies.
'One patient told me that he never took his prescribed tablets but took half a cup o f home brewed beer every day.When he went fo r routine follow-up the doctor who checked his blood pressure said well done, your blood pressure is Ok, continue with the same treatment you are taking.The man went to tell other patient that the home brewed beer works '.

Cultural beliefs
CHWs indicated that they found it difficult to discourage some of the beliefs and attitudes held by the community about the treatment of hypertension.'It is difficult fo r us to advice people not to take tradi tional and home remedies because it is part o f our culture to take some herbal medicine routinely.We believe in pro tecting ourselves from evil spirits.I remember when we were growing up we used to drink herbal medicine everyday and we never got sick, maybe i f hypertension could be treated with medicine instead o f tablets patients may take the medicine as required'.

Problems with the staff and the health system
CHWs indicated that some patients rather re duce the treatment so that it last them longer in order to delay going back to the clinics for check-up.
' Patients tell us that visiting the clinics means getting up at 4am in order to be at the clinic door by 5am.Otherwise they would sit at the clinic fo r the whole day.They also complain about lack o f respect from the nurses who talk to them anyhow '.

Interviews Demographic Profile and History of Illness
A statistical profile of CHWs showed that 38 were females and 5 males, ranging in age from 29 to 59 years (mean 43 years).Education levels ranged from 4 to 12 years of school ing with 35% having attained grades 11 or 12. Thirty-six (80%) had worked as CHWs for more than 5 years.Twentytwo (51%) had basic training in hypertension, and 21 (49%) had a family member who suffered from hypertension.Ten of CHWs who participated in this study suffered from hy pertension.

Perceived risk factors for hypertension
A large percentage of CHWs mentioned that consuming lots of fat was a risk factor for hypertension.Only few of them mentioned overweight (Table 1).

Organs affected by hypertension
As Table 2 depicts, 88% of participants mentioned the heart as an organ most affected in hypertensive patients followed by blood vessels, liver and kidney.

Advice given to hypertensive patients
Seventy nine percent of CHWs indicated that they tell pa tient to eat less fatty foods, reduce salt intake (56%) in crease physical activity (9%) stop smoking (4%).Table 3.

Measures taken to control hypertension
Most CHWs (93%) mentioned that the important control measure for hypertension is taking treatment regularly.The least mentioned were weight control and reduction of alco hol intake (Table 4).

Discussion
This study has used a combination of qualitative and quan- Understanding the beliefs of this category of health work ers is necessary as they are a link between the community they serve and the health sector.Lack of appreciation of the beliefs of this category of health workers may contrib ute to persistently poor rates of hypertension control.
CHWs seemed to have insufficient knowledge and health information on the prevention and management of hyper tension.Accompanying lack of knowledge was the fact that they found it difficult to understand who is at risk of getting these diseases because their experience suggest that anybody irrespective of weight or eating habits has the chance of getting the disease.
Although overweight was mentioned as a risk factor for hypertension, it was least mentioned as a health measure to control hypertension.This may be due to positive per ceptions that this population is overweight.An earlier study (Puoane, Rosling, De Goede & Van der Meij, 2001:225) un dertaken among the participants of this study reported that overweight was associated with dignity, respect and dig nity, respect, confidence, and good feeling good about one self.Studies have indicated that exercises and weight loss can lower blood pressure in hypertensive patients as well as in norm otensive patients (Georgiades, Sherwood, Gullette, Babyak, Hinderliter, Waugh, Tweedy, Craighead, Bloomer & Blumenthal 2000:174).In a population where overweight is valued it is very difficult to encourage peo ple to lose weight but, if we encourage them to adopt healthy lifestyles by making healthy choices about the food they eat and increase physical activity we may help to re duce the prevalence of chronic diseases in this population.
A recurring theme is that of combining medical treatment with traditional remedies including herbal medicine.This is supported by the findings of Daniels, Biesma, Otten, Levitt, Steyn, Martell andDick (2000:1208), who found that pa tients discontinued prescribed medication in favour of tra ditional remedies.Wilson, Freeman, Kadza, Andrews, Berry, Vaeth, and Victor (2002:26) also found that middle-low in come urban African-American believed that high blood pressure was linked to eating pork and was considered treatable with other herbs.This behaviour, which seem to be common in other cultures may be due to lack of under standing of the benefits of taking the treatment even in the absences of pain.Does this population know the benefits of taking the treatment even if there is no pain?This is especially of concern because most of black South African population do not usually go for medical or physical check ups.It is when individuals experience pain that medical help is usually sought (Mbombo 1996:109).Another possi ble explanation is a difficulty in understanding the concept of a "chronic condition".People usually visit a doctor look ing for a cure of their disease.Some fail to understand why they should continue with the treatment for life.Therefore, they conclude that the western medicine is not very effec tive, and start looking around for the cure for the condition.
Because hypertension is not associated with pain, patients often think that they are well, and only take prescribed treatment when they feel sick or have a headache.
The manner in which health personnel communicate mes sages to patients may also influence adherence to treat ment.Patients may just listen to orders given to them with out negotiation but may inwardly say 'you may tell me what to do, I will make a decision about what to do because this is my life and my body'.Weiss and Hutchinson (2000:521), examined factors affecting adherence to health care directions in patients with diabetes and hypertension, and reported that patients felt the pressure to adhere to treatment but did not feel like having a partnership relation ship with their health providers.Patients therefore need to be informed about their rights to health care and health care providers should be encouraged to establish a thera peutic partnership with patients so as to improve control of hypertension.
Financial hardship is a barrier, which should not be ignored, as it is a contributory factor to non-compliance.If people are hungry nothing matters except food.People either take the treatment very late when they have had something to eat or forget about the treatment at all while trying to deal with other problems of poverty.Maybe health personnel need to think about how to assist poor patients with chronic conditions.People who reside in informal houses may not have access to toilets facilities; they may therefore reduce or omit their medication in order to avoid going out to look for a toilet during the night.The situation constitutes also a barrier to compliance to treatment.
The study implies that because they are lay people, CHWs need to be orientated and trained in the prevention and management of chronic diseases including hypertension before they execute their roles in communities.To address the growing problem of non-communicable diseases in South Africa, the health authorities need to initiate pro grammes for the cost-effective management of chronic dis eases through the use community health workers.Although information about CHWs and their role in the prevention of cardiovascular diseases has not been widely documented, some studies have shown that if integrated into the pri-mary health system, CHWs bridge the gap between poor communities and health care facilities.Because of their working relations and close link with community health workers, community nurses in primary health care facilities need to recognize these beliefs and attitudes as they may differ from theirs hence establish the pros and cons of health-care delivery in communities.However, the limita tions were that these findings could not be generalised as the study was conducted in one setting and therefore needs to be replicated in other settings in order to get a broader view on this subject.

Table 4 : Health care measures taken in the presence of hypertension
• A training program for the primary prevention of cardiovascular diseases should be initiated.Educa tion and information should include: Basic anatomy and physiology; the role of nutrition, physical inac tivity, body weight, smoking and alcohol in causa tion of hypertension.Patients suffering from hyper tension should be given culturally accurate dietary and lifestyle information about their diseases by CHWs who are an entry point to health system for residents.• Future research should look at the contents of home brewed beer to find out what it is that lowers the blood pressure or makes people who take it feel bet ter.• Community nurses need to consider the inclusion of a community health workers' programme in pri mary health care to enable them to recognize their role in health promotion and prevention of diseases.• Ongoing evaluation of CHWs is crucial as more health-care providers and non-governmental organi zations increase their use for outreach programmes.Urban African-American Community: An Opportunity for Improving Hypertension Control.The American Journal of Medicine, 112(1): 6-30.WORLD HEALTH ORGANIZATION 1989: Strengthen ing the performance of community health workers in pri mary health care.Report of a WHO Study Group.(WHO Technical Report Series, No 780) Geneva, World Health Organisation.