Q u a l i t a t i v e R e s e a r c h T h e H e a l t h B e h a v i o u r o f B l a c k H y p e r t e n s i v e Pa t i e n t s a t a C h r o n i c D i s e a s e s C l in ic i n a d e p r e s s e d S o c i o - E c o n o m i c A r e a o f J o h a n n e s b u r g , S o u t h A f r i c a . STEWART A V, EALES C J, SHEPARD K ABSTRACT: A sample o f hypertensive patients and the health care practition­ ers at an urban community health clinic were studied to identify their health sta­ tus and behaviours. Barriers to compliance with health advice were also inves­ tigated. A descriptive qualitative approach was used consisting o f semi-structured interviews, observations and the analysis o f patients’ records. Themes were generated fro m the coded data. The data revealed that the p a tients’ com ­ pliance was poor (66% attendance at the clinic), the mean blood pressure level was 157/99 and they were often sym p­ tomatic. Patients’ understanding o f hypertension was fragm ented and they did not see it as a silent, chronic disease. They were beset by financial and fam ily worries and stresses. The sta ff fo u n d that it was increasingly difficult to edu­ cate the patients as the numbers o f patients at the clinic were increasing. KEYWORDS: HEALTH BEHAVIOUR, COMPLIANCE, UNDERSTANDING, BARRIERS INTR O D U C TIO N Patients’ adherence to medical regimens and life-style modification is central to the management o f most chronic disease. These patients are the ones who, on a daily basis, have to modify their health behaviour in such a way that they can m anage their disease and cope with their daily lives. How well patients are able to manage their disease is dependent on how severe they see the disease is and w hether they see the benefits o f life - style modification as being worth the effort they will have to m ake to achieve these changes. M aking this effort is dependent on a variety o f psycho-social factors. (Janz and B ecker 1984) Two paradigm s o f patient education have been described. (Bartlett, 1982). The first is based on a teaching approach and the second on a behavioural diagnosis. M any questions are continually being raised about the effectiveness o f patient education. Studies have shown that raising know ledge levels does not necessarily m ean that there will be a behavioural change (H aynes, 1976; M orisky et al, 1982). This is particularly so in the m an­ agem ent o f a disease such as hypertension which, because o f it’s very nature, is fraught with difficulties (Caldwell et al, 1983; Sluijs, 1991). The second is based on a behavioural diagnosis w hich is the “assessm ent o f influences on the desired patient behaviour” ( B artlett, 1982). The behavioural diagnosis considers a variety o f factors w hich either prom ote or d is­ courage p atients’ adherence to health re­ gim ens (B artlett 1982). Various authors (G reen, 1978; Jenkins, 1979) described classifications o f behavi­ our which influence p atien ts’ adherence. G reen (1978) suggested a fram ew o rk which incorporates a wide range o f factors which may influence behaviour. H e de­ scrib es th ese as p red isp o sin g facto rs (know ledge, attitude, values, perceptions and norms); reinforcing factors (attitudes and behaviours o f health personnel, family, p e e rs, te a c h e rs an d e m p lo y e rs ) and enabling factors (availability o f resources, access, refe rral, d esig n ated skills and governm ent health policy). Bartlett (1982) argues that these classi­ fication system s although representing a m ajor step forw ards in patient education have a num ber o f shortcom ings namely, difficult term inology, difficulty in fo llo w ­ ing com plicated m edical regim ens and com bining social and environm ental fac­ tors into one category. He suggests a m uch sim pler classifica­ tion as follows: (see Figure 1) C O RRESPO N D EN CE: M rs A Stew art Senior L ecturer Physiotherapy D epartm ent 7 York R d PA RK TOW N 2193 S A Jo u r n a l o f Ph y s io t h e r a p y 1 9 9 9 V o l 5 5 N o 1 11 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) TABLE 1: EXAMPLES OF INTERVIEW QUESTIONS FOR PATIENTS • What do you think caused your illness? • Why do you think it started when it did? • What do you think this illness does to you? • How does it work? • How bad do you think your illness is? • Do you think it will last for a long time or be better soon? • What kind of treatment do you get at the clinic? • What kind of treatment would you like to have? • What do the staff at the clinic teach you about your illness? • Do you think that what you eat affects your illness? • Do you do any exercise? • Do you drink or smoke? • Do you get worried about things? • What do you do to look after yourself? • What are the problems your illness has caused you? • Does your family help you? • Can you get time off work to come to the clinic? • Do you have to wait for a long time at the clinic? • Is it difficult for you to get to the clinic? An example of a probe question is: What are the things that worry you? T his study was undertaken to identify the health behaviour o f patients attending a hypertension clinic at a prim ary health care centre in a depressed socio-econom ic area o f Johannesburg, South Africa. The aim o f this study was to evaluate the indi­ vidual, social and environm ental factors and the medical regim en w hich may in­ fluence patients’ health behaviour and thus their health status. M ET H O D Ethical clearance for this study was obtained from the human ethics com m ittee o f the U niversity o f the W itw atersrand. A descriptive qualitative approach was used in this study. SAM PLE 1. A “typical case” sam ple o f patients was drawn from the chronic diseases clinic at A lexandra H ealth Clinic, an urban pri­ mary health clinic in a depressed socio­ econom ic area in Johannesburg. South Africa. Typical case sam pling was used to illu stra te “a v e ra g e ” ex am p les (Patton, 1987). This was done by ex am ­ ining com pliance data established by the clinic and from a previous study done at the clinic. (Donahue, 1996; Eales and Stewart, 1996). Patients w ere included in the study if they had been identified as m oderate to severe hyper­ tensives, if they had been com ing to the clinic for at least 6 m onths and if they w ere betw een the ages o f 25-70 years. 2. A group o f 17 patients was interview ed 3. All health-care practitioners involved at the clinic w ere interview ed, 6 in all. 4. A fam ily m em ber o f the patients who lived with their fam ilies was sent a questionnaire via the patients, provided that the patients agreed to this. A total o f 6 questionnaires was sent out. All participants signed informed consent. D EM O G R A P H IC DATA O F PATIENTS The sam ple consisted o f 17 patients, 15 were fem ale and 2 w ere male. The mean age was 56 and the mean educational level was G rade 8. N ine w ere unem ployed, 3 w orked part-tim e and 2 w ere em ployed full-tim e and three w ere pensioners. F if­ teen lived with their fam ilies, 1 on her own and 1 in an old-age home. The m ean height was 161 cms and their m ean mass was 73 kgs. T heir BM I was 28.1. T heir m ean blood pressure level was 157/99. They had been at the clinic for a m ean o f 4.3 years. D E M O G R A P H IC DATA O F THE HEALTH-CARE PRACTITIONERS The 6 health care professionals included one m ale p h ysician w ho had been in charge o f the clinic since it’s inception 6 years ago, 2 fem ale prim ary health care nurses w ho had been at the clinic for 4 years and 3 fem ale lay health care workers who had been at the clinic for variable lengths o f time Data Collection All participants signed informed consent prior to participation in the study. In te rv ie w s Patients who could speak English and the health care practitioners w ere inter­ view ed by the first author. In the case of the Sotho and Zulu patients a second interview er nam ely a qualified physiothe­ rapist who was Sotho speaking and who had been trained by the researcher did the interview s. Sem i-structu red interview s using “open-ended” and “probe” questions covered the areas listed in Table 1 and Table 2. All interviews were tape-recorded. T he patients and the health care practi­ tioners w ere either given the opportunity to listen to the tape-recordings and make any changes if they w ished to, or w ere given copies o f the transcripts to check and m ake changes as they w ished. This was done in order to establish the cred i­ bility (internal validity) o f the data (M erri- man, 1988). T he “open-ended” questions w ere used in such a way as to get the m axim um depth o f answ er from the sub­ jects. T he form at o f the questions was changed to get greater clarity if required and “probe” questions w ere used to get m ore inform ation in certain areas o f the interview if needed. T he basic fram ew ork fo r the q u estio n s a sk e d co m es from K leinm an et al (1978) who proposed that such questions could be used to gain infor­ mation about the p atien t’s understanding o f their disease. Tables 1 and 2 give exam ­ ples o f questions asked. The patients w ere given a one page questionnaire to give to a fam ily m em ber 12 S A Jo u r n a l o f Ph y s io t h e r a p y 1 9 9 9 V o l 5 5 N o 1 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) TABLE 2: EXAMPLES OF QUESTIONS ASKED OF HEALTH-CARE PRACTITIONERS Disease Beliefs • What do patients believe is wrong with them? • Do they understand the causes of hypertension? • Do they understand that it is a chronic disease? • Do they understand the complications? Treatment Beliefs • How good is the patients' compliance? • What key information should the patients have? • What do they understand about reduction of risk factors? • How do you check up on them? • Do they know what medication they are on and what it does? Barriers • What sort of things affect patients' compliance? • What influence do their families have-are they supportive? • Are they motivated to comply with health advice? • Do they understand what they have to do? • Do they forget about taking their medication? • Do they deny that they are ill? to fill in and send back to the researcher. A stam ped return envelope was included. T he questionnaire was based on the ques­ tions ' used in the interv iew s fo r the patients and health care practitioners. Sufficient numbers o f the above subjects were interview ed to ensure saturation o f the data (Strauss and Corbin, 1990) that is the stage where no new data w ere being obtained. O b s e rv a tio n The interactions betw een patients and the health-care practitioners at the clinic was observed by the first author, and observational m em os written with parti­ cular reference to the therapeutic relation­ ship between patients and practitioners, and the method o f patient education. ANALYSIS O F ARTIFACTS The patients’ records w ere exam ined to estab lish therap eu tic regim en. P a tie n ts ’ records w ere also used to estab lish the com pliance o f patients to both the m edi­ cation regime and risk factor modification. T hese w ere exam ined over the six month period leading up to the study, how ever some o f the data in the p atie nts’ files were incom plete. (Table 3). AN A LYS IS O F THE DATA The tape recordings w ere transcribed “in extenso” . The Sotho and Zulu inter­ views w ere transcribed and then translated into English by a translator in the A frican languages departm ent at the U niversity o f the W itwatersrand. The second interviewer then ch eck ed the tran slatio n s fo r their c o n te xtu al sense. D etailed field notes w ere made both during and im m ediately after the observations at the clinic. The com pliance data was condensed by using means and ranges. All the data was then analysed in the follow ing way (M erriman, 1988; Strauss and Corbin, 1990). Step 1 O p e n C o d in g The transcripts w ere read through suffi­ cient times to establish comm on concepts. L ine by line analysis was done in order to estab lish these co n cep ts. T h e co n cep ts were then grouped into discreet categories. Sim ilar categories w ere then grouped into b roader categories and these categories appropriately coded in order to reduce the data in such a w ay that co m p ariso n s across interview s could be made. Step 2 A x ia l C o d in g A xial co d in g w as then u n d e rta k e n to make connections betw een the categories in the open coding so that the m ost im por­ tant them es from the data could be identi­ fied. From this the theory o r relationships betw een categories could be established by considering causal conditions, context, interactive effects and consequences. Step 3 R e lia b ility C heck The categories identified in the tran­ scribed data were checked fo r reliability. A researcher who was not involved in the data collection review ed subsets o f the data and independently coded the data. An interrater reliability o f 85% was achieved. This process ensured that the codes/cate­ gories w ere understandable, exhaustive, mutually exclusive and independent. Step 4 T ru s tw o rth in e s s o f th e D a ta The trustw orthiness o f the data, that is the “credibility, transferability and depen­ dability” o f the data, was determ ined in the follow ing m anner (Strauss and Corbin, 1990; P atton, 1987; L in co ln and G uba, 1985). 1.The exact language o f the interview s was analysed w ithin m eaningful seg­ ments o f speech. Use o f subjects’ exact language is known as “ thick low infe­ rence data” , that is the researcher keeps inferences m ade about the data close to the exact words used by the subjects. An ex am ple o f ex act lan g u ag e is, “A ctually you know som etim es w hen I wake up in the m orning then I think o f som ething like going to work you see then there is som ething that is exciting me. I feel very m uch excited then sud­ denly I get palpitations and the head­ aches then I realise oh no the blood pressure is high.” 2. T riangulation o f the data was achieved by looking for sim ilarities found in m ultiple data sources, fo r exam ple, from interview s o f patients, health-care S A J o u r n a l o f P h y s io th e r a p y 1 9 9 9 V o l 55 N o 1 13 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) practitioners and fam ily m em bers, from interactions between patients and health­ care workers and from patients’ records. Credibility o f the date is ensured when the sam e factors, for exam ple support or lack o f support by fam ily m em bers, are identified from a num ber o f different sources. 3. M em ber Check Subjects listened to the tape recordings o r read through the transcripts and m ade changes if they needed to. This ensured that the researcher accurately captured the interview ee’s perspective. 4. Reliability check o f data coding Subsets o f data w ere coded and an inter­ rater reliability o f 85% was obtained. 5. D ata saturation D ata w ere collected and analysed using multiple methods and sources until satu­ ration of data was obtained, that is until no new concepts or categories emerged. RESULTS A N D DISCUSSION T he them es generated in this study are discussed under the p atien ts’ health b e­ haviour, health status and the factors affe c tin g c o m p lian ce as d escrib ed by B artlett (1982). FACTORS AFFEC TING C O M PLIANCE Individual Factors K n o w le d g e Studies on com pliance state that in order for patients to be able to accept health advice and com ply with medical instructions they need to have a basic understanding o f the pathology and the na­ ture of the disease which they are trying to m anage (H eggenhougen and Shore, 1986; Stanton, 1987). They need to be able to m ake a connection betw een the health behaviours they are trying to adopt and the effect they will have on the disease process. This sample o f patients had a very lim ited idea o f the pathology o f hyperten­ sion. N one o f them described it as being a pressure problem , or increased resistance in their blood vessels. A few o f the p a­ tients felt that it had som ething to do with the heart or with the blood. T here is a p er­ ception am ong the staff that som e patients think that they have too m uch blood, w hich could explain w hy it is often referred to as “high blood” , leaving o ff the m ost im portant word w hich is pressure. H ow ever although the patients talk about hypertension as being “high blood” , this perception am ong the staff was not evident in the p atie nts’ descriptions. They said that they had “high blood” but, except for one patient, did not say that they had too m uch blood. The staff felt that the patients did not understand w hat high blood pres­ sure was. The doctor felt that patients needed to know that it was a pressure problem and that it was a silent disease. T he staff and in particular the lay health w orkers, when asked w hat they felt patients should know, concentrated on the com pliance to the m e­ dical regim en and diet and did not m en­ tion an understanding o f the pathology. W hen asked w hat their blood pressure was only a few patients said that it was “ 170 or som ething” or “ 150/90 o r som e­ thing.” Som e said “it is hig h ” and some could feel w hen their blood pressure was high because they experienced sy m p ­ toms. A few o f the o ld er patients seem ed to understand that hypertension was a chronic disease but in this understanding there alm ost seem ed to be an inevitability about it, som e saying that the next stage was a stroke. W ith the exception o f one patient, at no time did patients express any understanding o f the fact that hypertension could be con­ trolled. They did not realise that although it w ould be with them always, they could by their own actions lessen the im pact on their lives. W ith the exception o f the doc­ tor, w ho said that the disease was silent and that control was im portant, none of the staff identified blood pressure control and the understanding that hypertension is a chronic disease as being facts that patients should understand. A lthough the doctor said that patients knew that their blood pressure should be 120/80 and that was w hat they w ere aim ing at, this was not the case. All that cam e across in the patients’ interviews was the perception that their blood pressure “m ust be low er” . S y m p to m s W hen asked about their physical status patients com plained about being sym pto­ matic. They com plained that they often had headaches, freq u en tly w hen they w oke up but also at o ther tim es o f the day. They w ere also frequently dizzy. T hese sym ptom s interfered with their w ork and their ability to m anage household chores. They also had a variety o f ill defined aches and pains particularly the older ones. M any o f them spoke about the fact that they felt as though they “w ere fallin g ” . This is possibly due to the dizziness. TABLE 3: COMPLIANCE AND SYMPTOM DATA FROM PATIENTS' FILES The patient attendance over a 6 month period ranged from 33% to 100% with a mean of 66%. Pill count incomplete data Compliance with life-style changes Food - Salt 4 patients were using salt - Meat Average of 3x per week (range 2x-4x) Exercise None was exercising Alcohol One patient abused alcohol Smoking None was smoking Symptoms Nocturia Headaches Dizzy Palpitations 6 patients 3 patients 1 patient 1 patient 14 S A J o u r n a l o f P h y s io th e r a p y 1 9 9 9 V o l 55 N o 1 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) This picture is far from the “silent dis­ ease” often quoted in the literature and described by the doctor, who said that patients need to understand that hyperten­ sion is a silent chronic disease. H ow ever there is a perception that patients usually com e to the clinic w hen they are sym pto­ matic and d o n ’t attend w hen they are asymptomatic. They could describe how they felt when they w ere feeling well. They said that they felt strong and could get out o f bed and do their work. W hen they w ere not feeling well they felt w eak and did not want to get up. One patient described it as, “I feel in the m orning w hen I w ake up that I d o n ’t w ant to have anything to do with me” . Som e o f them said that they w ere aw are o f their hearts pum ping and they had a feeling o f heat at night such that they could not sleep under the blankets. They described a heaviness in their legs and that their legs were swollen like “the legs o f an old w om an” . The sym ptom s d e­ scribed by these patients were sim ilar to the descriptions o f a group o f African- Am erican patients in a study done in New O rleans (H eu rtin -R o b erts and R eisin, 1992). The staff did not feel or record that the patients w ere sym ptom atic and the only sym ptom s w hich appeared on the flow ­ sheet with any regularity w ere nocturia and som etim es headaches and dizziness. Som e o f the patients said that if they took their m edication they felt fine. It was dif­ ficult to ascertain the linkage betw een com pliance with m edication and decrease o f symptoms. Stress All the patients spoke about their w or­ ries and resultant stress, to the p oint that they w ere central to the p atie nts’ descrip­ tions o f their illness experiences. Worries and stress w ere m ostly linked to financial and fam ily problem s. M any o f them had had some sort o f event w hich they fell had increased their stress, and this event was often a fam ily problem . An exam ple o f a patient’s stress is contained in the fo l­ lowing description: “I think w hat disturbed me was my m other’s death. She was killed by a c ar and that w orried me. My boy was shot in 1991, he was selling beer. The other one is crazy and the last one is at hom e in M abopane” . They also w orried that if they did have a jo b that there w ould be problem s taking time off to come to the clinic. Poor co m ­ pliance is linked to disturbing life events such as general poor health, being unm ar­ ried, unem ployed and having a low er in­ com e (Caldw ell et al, 1983). T he staff did not see this as the biggest p ro b lem facing the p atie nts although som e o f them m entioned work related and financial concerns as worrying the patients. The problem s o f family, unem ploym ent and financial w orries seem ed to be the over-riding concerns o f these patients. Ed u ca tio n T he group o f patients who w ere inter­ view ed in English had a mean educational level o f G rade 11 (G rade 8-G rade 12) and the group interview ed in Sotho o r Zulu had a m ean level o f G rade 5 (G rade 0 to G rade 12). G enerally the patients were poorly educated and those who w ere em ployed had unskilled jobs. Com pliance with this level o f education is always problem atic (H aynes, 1976). M ost o f the patients felt that they were not being educated at the clinic. This observation was borne out by the staff. T he staff said that they did not have time to educate the patients because they had to deal with very long queues o f patients and they w ere short staffed. Patients who had been at the clinic for a num ber o f years seem ed to feel that they had had some education at som e stage and some said that they were given some exercises at the clinic. Staff used a “flow sheet” (which listed sym ptom s, signs and com pliance issues) as an educational tool and as they checked the p atient’s signs, sym ptom s and com pliance they explained and reinforced d iet and m edication com pliance. SOCIAL FACTORS Family Support The staff felt that the patients did not get very m uch fam ily support. This was because it was not obvious that there was anything w rong with the patient. Som e o f the patients said that their fam ilies were w orried about them but in many instances they them selves w ere in fact carrying the financial and other responsibilities fo r the fam ilies. For the m ost part they did not get very m uch help with household re ­ sponsibilities nor help with the m anage­ m ent o f their m edical regim en and dietary requirem ents. The addition o f som e sort o f fam ily support is an im portant factor in p atient com pliance (Bartlett, 1982; Stro- gartz and Earp, 1983; Hill, 1989; W h et­ stone and Reid, 1991). A total o f 6 questionnaires w ere sent hom e with the patients to be filled in by fam ily m em bers. O nly one reply was re ­ ceived. This may further illustrate the lack o f fam ily involvem ent. Patient Staff Interactions Patients said that they felt free to ask questions o f the staff and felt that the staff “w ere free” that is that they w ere friendly. H ow ever m ost o f them did not ask ques­ tions and som e did not appear to w ant to ask questions The staff, with the excep­ tion o f the doctor, cam e from sim ilar cul­ tural backgrounds and spoke the same languages. In this way transcultural interac­ tion difficulties w ere avoided (de Villiers, 1991). The observed interactions were very b rief but w ere friendly and non threaten­ ing. The point was m ade that patients are continually encouraged to com ply with treatm ent and the inform ation is con tin u ­ ally reinforced. Patients are not d ealt with in a judgm ental way but are praised and encouraged all the time. The relationship betw een patient and health care practi­ tioner is a very im portant one in the m an­ agem ent o f chronic disease. The relation­ ship should be one o f negotiation b e­ tween the patient and health care practi­ tioner. This negotiation process affects the doctor patient relationship and in turn the m edical care (Evans et al, 1987; Bothelo, 1992). Patient-Employer Relationship Patients w ho w ere em ployed expressed concerns about having to be at the clinic for such a long tim e on their “ch eck-up” days. They felt that their em ployers had difficulty in giving them the time o ff work needed for them to com e to the clinic. E N V IR O N M E N T A L FACTORS Transport M ost patients felt that to get to the clinic was not a problem because o f the very good taxi service. The main problem in this regard was the ability to pay for the taxi. Som e o f them w ere within w alking distance o f the clinic. A ccessibility of clinics and transport problem s can add to p a tie n ts ’ d ifficulties w ith co m p lian ce. K eeping appointm ents with health-care providers can involve five different acti­ vities. These are; m aking the appointm ent, arranging transport, arranging other o b li­ gations for example child care, getting time off w ork and m aking the next appoint­ ment (Hill, 1989). Financial Concerns M any patients expressed their concerns about financial difficulties. These concerns S A Jo u r n a l o f Ph y s io t h e r a p y 1 9 9 9 V o l 5 5 N o 1 15 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) affected their daily lives. Financial restric­ tions also affected their ability to m anage a p p ro p ria te d ietary reco m m en d atio n s. Patients lost m oney while they spent time at the clinic and often had difficulty pay­ ing fo r transport to the clinic. The staff identified financial problem s as one o f the difficulties the patients had to deal with. T h e treatm en t its e lf w as free if the patients w ere unem ployed. Financial con­ siderations will affect p atients’ ability to com ply with m edication (Flack, 1996). Queues The patients arrive at the clinic in the early hours o f the m orning some getting there as early as 0500 hrs. They then w ait in queues for attention. They can have up to a 5-6 hour wait to be seen and to col­ lect their medications. The interaction time with various health care practitioners is approxim ately 10-15 m inutes. The clinic has only one doctor and he is often away at m eetings and involved in other adm i­ nistrative obligations. If patients are sche­ duled to see the doctor they are inevitably further delayed. The patients spend the better part o f a w orking day at the clinic and m ost o f them get m edication to last a 4 week period, which m eans that patients spend a day at the clinic every month. This creates problem s for patients who are em ployed, as they feel that em ployers are not alw ays sym pathetic and if they are self em ployed mostly as haw kers they are losing tim e to make money. M EDIC AL R EG IM EN The patients all knew how m any drugs they w ere taking and m ostly identified them by colour. They seem ed to know when the drugs should be taken. In addi­ tion to the drugs for hypertension patients frequently took medication such as Panado and Brufen for “pains” . They knew that the drugs fo r hypertension w ere to bring their blood pressure dow n but they did not know the effects o f their individual drugs. Lim ited discussion o f the effects o f drugs took place. A pill count was done in the sense that patients were asked how m any tablets they had left over and w hen they last took them. This was recorded on the flow sheet. Patients said that they som etim es forgot to take their pills particularly w hen they w ere w orking and busy with other things. T he staff co n cu rred w ith this observation. Patients require a com bina­ tion o f ap proaches such as rem in d er strategies to help them adhere to their drug regim en (G reen et al, 1979). The staff w ere o f the opinion that patients fo r­ got their m edication w hen they felt well, this led to poor control o f hypertension resulting in the patients becom ing sym p­ tom atic. The data on pill counts was diffi­ cult to use because o f discrepancies in the way data w ere recorded (see Table 3). PATIENTS' HEALTH B EH AV IO U R Disease management Central to this clinic for chronic d is­ eases is the thought that patients should com ply in order for the m anagem ent of hypertension to be effective. The doctor stated that this was the m ost im portant consideration o f the clinic. The health workers all explained how they taught patients what to eat. They m ust not eat salt, they m ust eat vegetables, m ust cut dow n on red m eat and tinned foods and replace them with chicken. One m en­ tioned sugar as being unacceptable. The “flow sheet” used by the staff listed the foods that patients should and should not eat and this was used to check p atien ts’ co m p lian ce. P a tien ts knew that they should cut down on meat, tinned food and salt. This inform ation appeared to be well understood by patients. They said that they tried to eat the “rig h t th in g s” . D ifficulties w ere experienced w hen they did not do the cooking and they w ere dependent on others for the preparation o f their m eals. A nother problem was financial w hich m ade the acquisition of the right foods a problem . The staff also felt that the patients tried to comply. This education o f patients as to w hat they should eat seem ed to pervade everything. S taff w ere o f the opinion that this is p ri­ m arily w hat they taught and this was ex actly the k n o w led g e p a tie n ts had gained from them. The nature o f the flow sheet was such that w hat patients had been eating was checked on at each visit to the clinic. T here was only one m em ber o f the staff w ho m entioned the im portance o f w eight control. O nly one patient m entioned the need to control her weight. The link be­ tw een the correct diet and w eight loss had not been identified by the health care w orkers and therefore was not perceived by the patients. This was sim ilar to the N ew O rleans study (H eurtin-R oberts and Reisin, 1996). Patients spoke about what they should eat but did not say that they needed to keep their w eight w ithin certain lim its. This was despite all the patients being w eighed at each attendance at the clinic. Attendance at the Clinic O ver a period o f six m onths the atten­ dance o f a patient was on average 66%. It was not possible to ju d g e the m edication com pliance from the p a tie n ts’ records. M ost o f the patients said that they took their m edication regularly although some adm itted that they forgot at tim es. Studies at the clinic have show n blood pressure control to be poor (D onovan, 1996; Eales and Stew art, 1996). B lood pressure only starts to fall significantly w hen patients take 89% of their m edication. The adhe­ rence to the m edical regim en is the single m ost difficult problem in the m anagem ent o f essential hypertension (M orisky et al, 1986; Hill, 1989). Poor blood pressure control is associated with poor com pli­ ance (C aldw ell et al, 1983). Drinking and Smoking The sam ple did not sm oke and did not drink very m uch with the exception of one p a tie n t w ho ab u sed alcohol. The patients did not m ention either o f these two risk factors as needing to be co n ­ trolled. They also did not see either drink­ ing or sm oking as causes o f hypertension. O nly the doctor and one other m em ber of the staff, w hen asked w hat patients need­ ed to know, m e ntio ne d d rink in g and sm oking as risk factors w hich the patients needed to modify. HEALTH STATUS The m ean blood pressure level o f this sample of patients was 157/99 which does not reflect effective blood pressure control. In addition they w ere often sym ptom atic, com plaining o f frequent headaches and dizziness. CO NCLU S IO N The blood pressure control o f these patients is poor, as is the p atien ts’ co m p li­ ance. T h eir understanding o f the disease is fragm ented thus m aking it difficult for them to really know w hat it is that they are trying to achieve. The concept o f a silent chronic disease requiring control did not com e across at all. Patients felt sym ptom atic often. They w ere beset by w orries and stresses due to financial con­ cerns and fam ily problem s. The staff em phasized eating the correct food and patients w ere very aw are o f w hat they should be eating but not that w eight con­ trol was im portant. T herefore w hat the staff felt was im portant to teach patients, they had successfully taught. If the staff w ere m ore aw are of the essential k n ow ­ ledge required to control hypertension, it 16 S A Jo u r n a l o f Ph y s io t h e r a p y 1 9 9 9 V o l 5 5 N o 1 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) FIGURE 2: FACTORS RELATED TO POOR COMPLIANCE BY BLACK HYPERTENSIVE PATIENTS IN A DEPRESSED SOCIO-ECONOMIC AREA OF SOUTH AFRICA seem s reasonable that patients w ould suc­ cessfully com ply with the total regimen to control hypertension. T he staff felt that they had too many patients to deal with and as a result the education o f the patients had been com ­ prom ised. H ow ever it w ould seem that the ability to teach is not the problem but the content that m ust be taught is lacking. T he above conclusions can be presented in a new fram ew o rk as follow s: (see Figure 2) A C K N O W LED G E M EN T The authors would like to thank the p a­ tients and staff at the Alexandra H ealth C linic for their help in m aking this study possible. REFERENCES B a rtlett E E 1982 B ehavioural diagnosis: a practical approach to patient education. Patient C ounselling a n d H ealth E ducation 4: 29-35 B othelo R J 1992 A negotiation m odel for the doctor-patient relationship. Family Practitioner 9(2): 210-218 C aldw ell J R, Theisen V, K aunisto C A, R eddy P J, S m ythe P S, Sm ith D W 1983 Psychosocial factors influence control o f m ode­ rate and severe hypertension. Social Science a n d M edicine 17(12): 773-782 de Villiers S 1991 B eliefs and behaviours in transcultural health-care. 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