Cultural Adaptation of a Cardiovascular Health Education Program among Hypertensive Primary Care Patients from Rural Nigeria

*Aina Olufemi Odusola and Ayoade Adedokun*

## **Abstract**

Culturally adapted behavioral treatments can optimize care. Following standard guidelines we adapted and tested a hypertension education program among primary care patients with hypertension from rural Nigeria. We reviewed literature and collected qualitative information from hypertensive patients to implement the first three of five cultural adaptation stages: *Information gathering, Adaptation design, and Preliminary adaptation testing*. Information obtained was used to adapt a *Cardiovascular Health Education Program* (CHEP) from a similar program *Culturally Appropriate Hypertension Education* (CAHE). CHEP was evaluated among 149 hypertensive patients using pre, post design, and performance of behavioral goals. Data were analyzed using descriptive statistics and thematic contents. CHEP retained essential features of CAHE and added new culturally relevant information. Local context factors like substitutability of dietary *salt* and exercisability with cultural activities motivated healthy behavior and enhanced cultural fitness. Culturally permissive unhealthy practices were discouraged; intentional weight gain (*big is beautiful*), and non-smoking tobacco use (*sniffing, licking*). Performance of behavioral goals was outstanding; over 60% practiced self-set goals effectively. Standard cultural adaptation of behavioral education program demonstrated potential to limit cardiovascular diseases among hypertensive patients. Guidelinebased culturally adapted intervention increased hypertension self-management capabilities among hypertensive primary care patients from rural Nigeria.

**Keywords:** standardized cultural adaptation, behavioral health education, goal setting assessment, hypertension self-management, rural Nigeria

## **1. Introduction**

Hypertension is a major risk factor of cardiovascular diseases (CVD), and is highly prevalent in sub-Saharan Africa (SSA) [1, 2]. CVD including ischemic heart disease and stroke are the world's biggest killers, having killed 15.2 million people in 2016 alone [3], and being responsible for 17.9 million (31%) of global deaths annually [4]. To limit CVD, World health organization (WHO) advocated preventive

management of hypertension and other CVD risk factors [4]. In Nigeria where the age-standardized prevalence of Hypertension is 19.3%, only 8% of hypertensive patients are aware, 3% controlled and just 5% are covered by treatment [5]. Fortunately though, willingness to adopt recommended lifestyle measures is encouraging among hypertensive patients [6].

further suggests that the more frequently goals are set and pursued, the easier and

A mixed methods study in two phases: in *phase 1* we conducted qualitative study to adapt a *Cardiovascular Health Education Program* (CHEP) from a similar *Culturally Appropriate Hypertension Education* (CAHE) program; while in *phase 2* we used quantitative and observational designs to evaluate the adapted CHEP for effectiveness and cultural fitness. **Figure 1** shows relationships between various phases of the adaptation process. The cultural adaptation process involved *formative* and *construction arms*. In the *formative arm* we collected information from literature and from qualitative interviews with 40 hypertensive patients to develop the original form and content of CHEP [22, 23]. In the *construction arm* we used information from the *formative arm* to supplement protocol and materials originally developed for CAHE by Beune et al. [24], to increase cultural sensitivity of CHEP for specific needs of hypertensive patients from Nigeria. CAHE was previously developed in the

Netherlands to support treatment adherence and BP control among Afro-Surinamese and Ghanaian primary care patients with hypertension [24, 25]. Similarly, CHEP was the main outcome of a cardiovascular disease (CVD) prevention project, *Quality Improvement Cardiovascular Care Kwara* (QUICK-2) in rural Nigeria [26]. The goal of QUICK-2 was to develop and evaluate a patient-centered cardiovascular health education program to increase adherence to prescribed pharmacologic treatment and healthy behavior among hypertensive patients. QUICK-2 was implemented in two consecutive parts: *development of CHEP* over

*Cultural adaptation study in relation to QUICK-1 and QUICK-2 studies.*

In this study, following standard guidelines and procedures we culturally adapted an existing hypertension education program to produce a similar variant with enhanced cultural content and sensitivity using the first three out of five sequential steps. We proceeded further to evaluate the adapted program for *cultural-fitness* using patients' performance of set behavioral goals, and for

*Cultural Adaptation of a Cardiovascular Health Education Program among Hypertensive…*

faster patients learn and acquire targeted self-management skills [19].

*effectiveness* using hypertension treatment outcomes.

*DOI: http://dx.doi.org/10.5772/intechopen.94542*

**2. Methods**

**Figure 1.**

**59**

**2.1 Background to study design**

In African rural settings deep-routed cultural orientations can manifest in beliefs and perceptions about health that vary with modern medical perceptions. It is beneficial to re-orientate people in such deeply cultural settings to acquire well informed modern health perspectives. This can be achieved by introducing culturally appropriate behavioral health interventions that have undergone cultural adaptation based on the people's traditional health practices and cultural beliefs.

*Cultural adaptation* is the systematic process of increasing cultural content and cultural sensitivity of existing behavioral treatments to effectively address distinct sub-cultural group needs. *Cultural sensitivity* has been defined in two dimensions: 1) surface structure elements; and 2) deep structure elements. While *Surface Structure elements* refer to the matching of intervention materials to observable superficial cultural characteristics of a target population e.g. music, food, places, dressing, language etc., *Deep Structure elements* refer to the use of cultural, historical, environmental and social norms and practices to modify targeted health behavior among a target population [7, 8].

An ideal behavioral treatment intervention should be adapted culturally by following standard procedures. Studies have shown that guideline-based cultural adaptation process has potential to increase acceptability, attractiveness and effectiveness of treatment support programs among target populations [9–11]. Furthermore evidence abounds that systematic cultural adaptation of behavioral treatments offer intrinsic self-efficacy benefits for patients [12–14]. Reports further suggests that cultural adaptation of health interventions can enhance service delivery when implemented as a living process with dynamism for continuous feedback, replicability and improvement [11]. Conversely other interventions that are not culturally adapted can unwittingly discourage uptake of recommended lifestyles by patients at risk of CVD [15]. Systematic review evidence from global perspective have also highlighted usefulness of culturally adapted interventions in control of CVD risk factors [16]. Currently however, there is a dearth of regional studies investigating usefulness and exploitability of cultural adaptation of treatment interventions in SSA settings.

To implement standard cultural adaptation, Barrera et al. identified five guideline-based sequential stages involved from a Consensus on Updates of Models for Effective Cultural Adaptation as follows: *Information Gathering (stage one), Preliminary Adaptation Design (stage two), Preliminary Adaptation Testing (stage three), Adaptation Refinement (stage four),* and *Cultural Adaptation Trial (stage five)* [10]. There is however a need for continuous improvement in the adaptation development process as issues and challenges were recently reported on emerging multistep frameworks design of cultural adaptation process, suggesting need for further research to conclude on effectiveness of interventions adapted based on such designs [17].

The effectiveness of culturally adapted interventions can be evaluated using standard testing procedures. Studies suggest that goal setting and pursuance among patients can be effective in promoting acculturation and adoption of adapted interventions among populations at risk of CVD. Similar evidence abounds that goal setting is useful in evaluating effectiveness of culturally adapted interventions including acquisition of behavioral self-management skills [18–21]. Indeed the setting and pursuing of culturally adapted goals to stimulate healthy behavior have enhanced chronic disease self-management skills [18, 20]. Available evidence

#### *Cultural Adaptation of a Cardiovascular Health Education Program among Hypertensive… DOI: http://dx.doi.org/10.5772/intechopen.94542*

further suggests that the more frequently goals are set and pursued, the easier and faster patients learn and acquire targeted self-management skills [19].

In this study, following standard guidelines and procedures we culturally adapted an existing hypertension education program to produce a similar variant with enhanced cultural content and sensitivity using the first three out of five sequential steps. We proceeded further to evaluate the adapted program for *cultural-fitness* using patients' performance of set behavioral goals, and for *effectiveness* using hypertension treatment outcomes.

## **2. Methods**

management of hypertension and other CVD risk factors [4]. In Nigeria where the age-standardized prevalence of Hypertension is 19.3%, only 8% of hypertensive patients are aware, 3% controlled and just 5% are covered by treatment [5]. Fortunately though, willingness to adopt recommended lifestyle measures is encouraging

In African rural settings deep-routed cultural orientations can manifest in beliefs

*Cultural adaptation* is the systematic process of increasing cultural content and cultural sensitivity of existing behavioral treatments to effectively address distinct sub-cultural group needs. *Cultural sensitivity* has been defined in two dimensions: 1) surface structure elements; and 2) deep structure elements. While *Surface Structure elements* refer to the matching of intervention materials to observable superficial cultural characteristics of a target population e.g. music, food, places, dressing, language etc., *Deep Structure elements* refer to the use of cultural, historical, environmental and social norms and practices to modify targeted health behavior

An ideal behavioral treatment intervention should be adapted culturally by following standard procedures. Studies have shown that guideline-based cultural adaptation process has potential to increase acceptability, attractiveness and effectiveness of treatment support programs among target populations [9–11]. Furthermore evidence abounds that systematic cultural adaptation of behavioral treatments offer intrinsic self-efficacy benefits for patients [12–14]. Reports further suggests that cultural adaptation of health interventions can enhance service delivery when implemented as a living process with dynamism for continuous feedback, replicability and improvement [11]. Conversely other interventions that are not culturally adapted can unwittingly discourage uptake of recommended lifestyles by patients at risk of CVD [15]. Systematic review evidence from global perspective have also highlighted usefulness of culturally adapted interventions in control of CVD risk factors [16]. Currently however, there is a dearth of regional studies investigating usefulness and exploitability of cultural adaptation of treatment interventions in

To implement standard cultural adaptation, Barrera et al. identified five guideline-based sequential stages involved from a Consensus on Updates of Models for Effective Cultural Adaptation as follows: *Information Gathering (stage one), Preliminary Adaptation Design (stage two), Preliminary Adaptation Testing (stage three), Adaptation Refinement (stage four),* and *Cultural Adaptation Trial (stage five)* [10]. There is however a need for continuous improvement in the adaptation development process as issues and challenges were recently reported on emerging multistep frameworks design of cultural adaptation process, suggesting need for further research to conclude on effectiveness of interventions adapted based on such

The effectiveness of culturally adapted interventions can be evaluated using standard testing procedures. Studies suggest that goal setting and pursuance among patients can be effective in promoting acculturation and adoption of adapted interventions among populations at risk of CVD. Similar evidence abounds that goal setting is useful in evaluating effectiveness of culturally adapted interventions including acquisition of behavioral self-management skills [18–21]. Indeed the setting and pursuing of culturally adapted goals to stimulate healthy behavior have enhanced chronic disease self-management skills [18, 20]. Available evidence

and perceptions about health that vary with modern medical perceptions. It is beneficial to re-orientate people in such deeply cultural settings to acquire well informed modern health perspectives. This can be achieved by introducing culturally appropriate behavioral health interventions that have undergone cultural adap-

tation based on the people's traditional health practices and cultural beliefs.

among hypertensive patients [6].

*Topics in Primary Care Medicine*

among a target population [7, 8].

SSA settings.

designs [17].

**58**

### **2.1 Background to study design**

A mixed methods study in two phases: in *phase 1* we conducted qualitative study to adapt a *Cardiovascular Health Education Program* (CHEP) from a similar *Culturally Appropriate Hypertension Education* (CAHE) program; while in *phase 2* we used quantitative and observational designs to evaluate the adapted CHEP for effectiveness and cultural fitness. **Figure 1** shows relationships between various phases of the adaptation process. The cultural adaptation process involved *formative* and *construction arms*. In the *formative arm* we collected information from literature and from qualitative interviews with 40 hypertensive patients to develop the original form and content of CHEP [22, 23]. In the *construction arm* we used information from the *formative arm* to supplement protocol and materials originally developed for CAHE by Beune et al. [24], to increase cultural sensitivity of CHEP for specific needs of hypertensive patients from Nigeria. CAHE was previously developed in the Netherlands to support treatment adherence and BP control among Afro-Surinamese and Ghanaian primary care patients with hypertension [24, 25]. Similarly, CHEP was the main outcome of a cardiovascular disease (CVD) prevention project, *Quality Improvement Cardiovascular Care Kwara* (QUICK-2) in rural Nigeria [26]. The goal of QUICK-2 was to develop and evaluate a patient-centered cardiovascular health education program to increase adherence to prescribed pharmacologic treatment and healthy behavior among hypertensive patients. QUICK-2 was implemented in two consecutive parts: *development of CHEP* over

#### **Figure 1.**

*Cultural adaptation study in relation to QUICK-1 and QUICK-2 studies.*

3 months (*part 1*), and *evaluation of CHEP* over the subsequent 6 months (*part 2*). Prior to this, QUICK-2 was preceded by a related QUICK-1 study over 12 months, to assess feasibility of providing quality CVD prevention care to 349 hypertensive patients enrolled in a community-based health insurance program in Kwara state, Nigeria [27]. At the end of QUICK-1, 149 of the 349 participants did not meet hypertension control targets despite accessing standard, quality CVD prevention care of QUICK-1. The 149 uncontrolled patients consequently met criteria for inclusion in QUICK-2. We had hypothesized that 'consulting room' health education made available to the patients during 'usual hypertension care' in QUICK-1 was inadequate to support adherence and improve treatment outcome. We therefore developed CHEP to improve adherence and outcome among the uncontrolled patients during QUICK-2 [13].

*2.2.1.2 Measures*

*DOI: http://dx.doi.org/10.5772/intechopen.94542*

*2.2.1.3 Procedures*

*2.2.1.4 Analysis*

Nigeria?

**61**

Beyond what was already known from CAHE, CHEP specifically sought to know the local, cultural and contextual factors the Nigerian hypertensive patients per-

*Cultural Adaptation of a Cardiovascular Health Education Program among Hypertensive…*

In addition to the qualitative interviews, at a later stage we conducted FGD with participants to get their views about usefulness, acceptability, sustainability and effectiveness or otherwise of CHEP. As was done in CAHE, the CHEP development interviews began with the interviewer familiarizing with respondents to determine preferred language of communication. Thereafter we introduced participants to the research objectives: to elicit patients' explanatory model of hypertension regarding cause, presentation, course, duration, consequence, treatment, self-management and contextual factors relating to hypertension including social, cultural, religious,

We used MAXQDA data management software [29], and Grounded Theory [30] to analyze our data. The analytic process was at first carried out by two researchers independently, thereafter the interview transcripts were exchanged and coding and analytic steps repeated all over by individual researcher. Following this, areas of disagreement were jointly resolved by discussing the data further. In analyzing, we repeatedly examined, compared, verified and reordered the data in line with identified themes and concepts. This produced a matrix of concepts, sub-categories and categories from multi-level coding along thematic lines as follows: a) first we identified clusters of similar concepts in each interview transcript by assigning series of open codes to similar text fragments and emerging themes that reflected same ideas. To produce a code list we inductively coded sections of each transcript that provided information on respondents' ideas about hypertension and hypertension self-management; b) next we reviewed the code list to eliminate duplicates and streamline similar concepts to produce a smaller set of mutually exclusive concepts; and c) we scrutinized the data further and grouped streamlined concepts and related text fragments under four major themes to address our core research question: what social, cultural or native factors affect compliance with prescribed pills, diet and healthy behavior among hypertensive primary care patients from rural

and financial factors. Furthermore, while CAHE sought to know the effect migration had on hypertension self-management efforts of its immigrant participants, CHEP explored how peculiar local features of Nigeria's rural, social and cultural environments can be exploited to optimize hypertension self-care.

ceive as inhibitors or enablers of prescribed hypertension care and selfmanagement: what hypertension is and how it presents; what situations make hypertension easy or difficult for patients to manage as advised; how patients' finances affect their treatment goals; and how patients' native customs and social environment affect their use of medications, food selection, exercise or weight management. During a follow-up focused group discussion (FGD) after CHEP counseling sessions, participants were further asked: how they view CHEP counseling on pills use, healthy diet, salt reduction/substitution and exercise; what was particularly helpful, or frustrating about CHEP counseling; how much they have been able to meet their hypertension self-management goals; and ways in which the

education program can be improved upon in future.

In the current study, our focus is to describe the *processes and stages* involved in cultural adaptation of CHEP from CAHE and the testing of adapted CHEP for cultural fitness, namely *Information Gathering (stage 1), Preliminary Adaptation Design (stage 2), and Preliminary Adaptation Testing (stage 3*). A CHEP effectiveness control trial would be implemented in future using two final stages: *Adaptation Refinement (stage 4),* and *Cultural Adaptation Trial (stage 5*).

#### *2.1.1 Study setting*

Our study was implemented at a primary healthcare center, *Ogo Oluwa Hospital* (OOH) in the sleepy agrarian rural town, Bacita in Edu local government area of Kwara state, north central Nigeria. At that time OOH was a provider in the Dutch government funded Kwara State Health Insurance (KSHI) program [28], http://hif und.org/. Bacita was inhabited by mainly Nupe and Yoruba ethnic groups in addition to pockets of few other Nigerian tribes. The predominant occupations in the region were artisanship, farming, petty trading and fishing.

In the following section we describe the steps taken in adapting CHEP from CAHE and in evaluating the former, based on designs, measures, procedures and analysis adopted.

#### **2.2 Study phase 1**

#### *2.2.1 Information gathering (stage one)*

#### *2.2.1.1 Design and participants*

In the *formative phase* (July to September 2010) we collected data for development of CHEP by interviewing 40 purposively selected hypertensive patients using a modified version of the *interview guide* previously used for CAHE patients in the Netherlands [12, 24]. The interview guide was however tailored to the Nigerian context to make it culturally relevant for the priority patients of this study. We additionally searched available literature for relevant information on hypertension care and self-management in rural contexts. Using grounded theory we transcribed and analyzed the interviews each lasting about 90 minutes, for thematic contents simultaneously as they were conducted. The CAHE participants are mostly literate African immigrants in the Netherlands while most participants in CHEP are relatively illiterate native Africans from rural Nigeria. Furthermore, to increase cultural content of CHEP relative to CAHE, while CAHE used non-native Dutch nurse practitioners to collect data in English language, CHEP used native nurse and medical practitioners from the study region to collect data in familiar local languages (Yoruba and Nupe).

*Cultural Adaptation of a Cardiovascular Health Education Program among Hypertensive… DOI: http://dx.doi.org/10.5772/intechopen.94542*

#### *2.2.1.2 Measures*

3 months (*part 1*), and *evaluation of CHEP* over the subsequent 6 months (*part 2*). Prior to this, QUICK-2 was preceded by a related QUICK-1 study over 12 months, to assess feasibility of providing quality CVD prevention care to 349 hypertensive patients enrolled in a community-based health insurance program in Kwara state, Nigeria [27]. At the end of QUICK-1, 149 of the 349 participants did not meet hypertension control targets despite accessing standard, quality CVD prevention care of QUICK-1. The 149 uncontrolled patients consequently met criteria for inclusion in QUICK-2. We had hypothesized that 'consulting room' health education made available to the patients during 'usual hypertension care' in QUICK-1 was inadequate to support adherence and improve treatment outcome. We therefore developed CHEP to improve adherence

In the current study, our focus is to describe the *processes and stages* involved in

Our study was implemented at a primary healthcare center, *Ogo Oluwa Hospital* (OOH) in the sleepy agrarian rural town, Bacita in Edu local government area of Kwara state, north central Nigeria. At that time OOH was a provider in the Dutch government funded Kwara State Health Insurance (KSHI) program [28], http://hif und.org/. Bacita was inhabited by mainly Nupe and Yoruba ethnic groups in addition to pockets of few other Nigerian tribes. The predominant occupations in the

In the following section we describe the steps taken in adapting CHEP from CAHE and in evaluating the former, based on designs, measures, procedures and

In the *formative phase* (July to September 2010) we collected data for development of CHEP by interviewing 40 purposively selected hypertensive patients using a modified version of the *interview guide* previously used for CAHE patients in the Netherlands [12, 24]. The interview guide was however tailored to the Nigerian context to make it culturally relevant for the priority patients of this study. We additionally searched available literature for relevant information on hypertension care and self-management in rural contexts. Using grounded theory we transcribed and analyzed the interviews each lasting about 90 minutes, for thematic contents simultaneously as they were conducted. The CAHE participants are mostly literate African immigrants in the Netherlands while most participants in CHEP are relatively illiterate native Africans from rural Nigeria. Furthermore, to increase cultural content of CHEP relative to CAHE, while CAHE used non-native Dutch nurse practitioners to collect data in English language, CHEP used native nurse and medical practitioners from the study region to collect data in familiar local

cultural adaptation of CHEP from CAHE and the testing of adapted CHEP for cultural fitness, namely *Information Gathering (stage 1), Preliminary Adaptation Design (stage 2), and Preliminary Adaptation Testing (stage 3*). A CHEP effectiveness control trial would be implemented in future using two final stages: *Adaptation*

and outcome among the uncontrolled patients during QUICK-2 [13].

*Refinement (stage 4),* and *Cultural Adaptation Trial (stage 5*).

region were artisanship, farming, petty trading and fishing.

*2.1.1 Study setting*

*Topics in Primary Care Medicine*

analysis adopted.

**2.2 Study phase 1**

*2.2.1 Information gathering (stage one)*

*2.2.1.1 Design and participants*

languages (Yoruba and Nupe).

**60**

Beyond what was already known from CAHE, CHEP specifically sought to know the local, cultural and contextual factors the Nigerian hypertensive patients perceive as inhibitors or enablers of prescribed hypertension care and selfmanagement: what hypertension is and how it presents; what situations make hypertension easy or difficult for patients to manage as advised; how patients' finances affect their treatment goals; and how patients' native customs and social environment affect their use of medications, food selection, exercise or weight management. During a follow-up focused group discussion (FGD) after CHEP counseling sessions, participants were further asked: how they view CHEP counseling on pills use, healthy diet, salt reduction/substitution and exercise; what was particularly helpful, or frustrating about CHEP counseling; how much they have been able to meet their hypertension self-management goals; and ways in which the education program can be improved upon in future.

#### *2.2.1.3 Procedures*

In addition to the qualitative interviews, at a later stage we conducted FGD with participants to get their views about usefulness, acceptability, sustainability and effectiveness or otherwise of CHEP. As was done in CAHE, the CHEP development interviews began with the interviewer familiarizing with respondents to determine preferred language of communication. Thereafter we introduced participants to the research objectives: to elicit patients' explanatory model of hypertension regarding cause, presentation, course, duration, consequence, treatment, self-management and contextual factors relating to hypertension including social, cultural, religious, and financial factors. Furthermore, while CAHE sought to know the effect migration had on hypertension self-management efforts of its immigrant participants, CHEP explored how peculiar local features of Nigeria's rural, social and cultural environments can be exploited to optimize hypertension self-care.

#### *2.2.1.4 Analysis*

We used MAXQDA data management software [29], and Grounded Theory [30] to analyze our data. The analytic process was at first carried out by two researchers independently, thereafter the interview transcripts were exchanged and coding and analytic steps repeated all over by individual researcher. Following this, areas of disagreement were jointly resolved by discussing the data further. In analyzing, we repeatedly examined, compared, verified and reordered the data in line with identified themes and concepts. This produced a matrix of concepts, sub-categories and categories from multi-level coding along thematic lines as follows: a) first we identified clusters of similar concepts in each interview transcript by assigning series of open codes to similar text fragments and emerging themes that reflected same ideas. To produce a code list we inductively coded sections of each transcript that provided information on respondents' ideas about hypertension and hypertension self-management; b) next we reviewed the code list to eliminate duplicates and streamline similar concepts to produce a smaller set of mutually exclusive concepts; and c) we scrutinized the data further and grouped streamlined concepts and related text fragments under four major themes to address our core research question: what social, cultural or native factors affect compliance with prescribed pills, diet and healthy behavior among hypertensive primary care patients from rural Nigeria?

#### *2.2.2 Preliminary adaptation design (stage two)*

In the preliminary adaptation stage, we tailored CHEP culturally using information collected in the *Information Gathering Stage*. Our underlying objective was to increase cultural content of CHEP. We made both *surface structure* and *deep structure* changes to the original contents of CHEP and CAHE to achieve a culturally adapted CHEP. *Surface Structure changes* refer to matching of educational intervention materials and messages to observable superficial characteristics of our target population e.g. use of familiar people, places, language, food, locations, and cultural activities preferred by the Nigerian patients, while *Deep Structure changes* involved incorporating social, cultural, environmental and historical components to influence the targeted hypertension self-management behavior among the Nigerian patients [7].

deployed a specially prepared take-home hypertension handbook to teach her relatively more literate participants about healthy food choices, food preparation methods, pills use and healthy lifestyle. Both CAHE and CHEP counseling trainings were structured into 3 modules and delivered on 3 occasions few weeks apart, over six months in between a baseline and a final assessment visit. In both programs, every participant had physiological, anthropometric and self-report measurements at baseline and final visits. However, CHEP additionally had these measures taken during each of the 3 intervening educational visits because it was observed during prebaseline information visits that the patients valued such interim measurements if the results are immediately communicated to motivate their self-management efforts.

*Cultural Adaptation of a Cardiovascular Health Education Program among Hypertensive…*

The *preliminary adaptation testing* took place in the second phase of the study (March to August 2012) during which we used quasi-experimental pretest-posttest design to assess cultural fitness and effectiveness of the newly adapted CHEP. We included, trained and evaluated a cohort of 149 patients over a period of 6 months. Participants were evaluated on performance of set behavioral goals to assess cultural fitness. At a later stage we conducted an FGD with a sub-set of the participants to assess their perceptions about usefulness and acceptability of the adapted intervention.

We measured and recorded participants'socio-demographic parameters (age, gender, ethnicity, marital status, income level, employment status, educational status, alcohol use and tobacco use) and assessed their hypertension treatment outcomes including blood pressure control, body mass index, medication adherence, behavioral adherence as well as social support, satisfaction with care, illness perception, beliefs about medicines, and medication adherence self efficacy. Furthermore we asked participants specific questions on physical activity and exercise, use of salt, alcohol and smoking and graded their responses on a Likert Scale. Finally we asked participants to set and practice preferred culturally adapted behavioral health goals and graded their performances of set goals as a measure of 'cultural fitness.

Each of the 149 participants individually had an initial baseline assessment, followed by 3 modules of CHEP training in groups of 12–15 at 6 weeks, 10 weeks and 14 weeks past baseline. They were later disaggregated to have final individual assessments at 6 months past baseline. In essence, each participant had five study visits including a baseline assessment visit, a final assessment visit and three intervening group educational and goals setting assessment visits. Following the baseline visit (1st study visit) each participant was guided to set 3 culturally adapted behavioral goals during the first training session (2nd study visit), and to practice the selected goals at home until he/she revisits for the second training session (3rd study visit). The same goals setting instructions were repeated at the end of second training towards the third and final training session (4th study visit). Participants were additionally guided to practice preferred physical exercises for 20 minutes during the 3rd training session only, and they were encouraged to continue the exercises at home until the final visits

**2.3** *Study phase 2*

*2.3.1.2 Measures*

*2.3.1.3 Procedures*

**63**

*2.3.1.1 Design and participants*

*2.3.1* Preliminary adaptation testing (stage three)

*DOI: http://dx.doi.org/10.5772/intechopen.94542*

#### *2.2.2.1 Design and participants*

Both CHEP and CAHE had notable similarities in forms and contents; each was implemented in three modules over 6 months among hypertensive patients in Europe (*CAHE*), and Africa (*CHEP*). But there were differences in their designs. CAHE used non-native nurse practitioners as educators in English language, while CHEP used native medical doctor and nurse to deliver the educational intervention in local languages. Furthermore, while CAHE recruited participants from four primary care clinics in urban Amsterdam, CHEP recruited participants from a single primary care clinic in rural Nigeria. Unlike CHEP, patients in CAHE benefited from modern lifestyle referral support e.g. gyms in Amsterdam city in addition to exposure to a hypertension handbook. In contrast, patients in CHEP had exposure to educational materials that were contextually tailored to Nigerian rural context e.g. audiovisuals and poster teachings on dietary salt replacement with suitable local substitute *Iru*, and use of household chores, farming, fishing, gardening, leisure activities (drumming, gaming, dancing, singing) etc., as forms of exercise. The audiovisuals were scripted and acted by familiar faces including some participants themselves.

#### *2.2.2.2 Measures*

Excluding goals setting and few self-report measures, many other measures were assessed in both CAHE and CHEP including patient demographics and physiological measures. Other measures include perceived stress, social support, and illness perception, beliefs about medicines, self efficacy, medication adherence, lifestyle adherence and satisfaction with care. Unlike CHEP however, a measure of 'discrimination' was deemed relevant and included in CAHE whose participants had migrated to Europe and could possibly experience social exclusion.

#### *2.2.2.3 Procedure*

A CHEP counseling visit usually began with participants familiarizing with others and the trainers. This is followed by: group interactive counseling on hypertension and hypertension self-management; poster teaching on culturally relevant exercises; a visit to the local market to familiarize with healthy foods; an audiovisual viewing session on pills use, healthy diet and lifestyle; a field practical exercise session; and a goal setting and assessment session. CAHE on the other hand was delivered in one-on-one teaching sessions, featured no audiovisual session, and did not involve teaching visits to local market or grocery store but nevertheless

*Cultural Adaptation of a Cardiovascular Health Education Program among Hypertensive… DOI: http://dx.doi.org/10.5772/intechopen.94542*

deployed a specially prepared take-home hypertension handbook to teach her relatively more literate participants about healthy food choices, food preparation methods, pills use and healthy lifestyle. Both CAHE and CHEP counseling trainings were structured into 3 modules and delivered on 3 occasions few weeks apart, over six months in between a baseline and a final assessment visit. In both programs, every participant had physiological, anthropometric and self-report measurements at baseline and final visits. However, CHEP additionally had these measures taken during each of the 3 intervening educational visits because it was observed during prebaseline information visits that the patients valued such interim measurements if the results are immediately communicated to motivate their self-management efforts.

### **2.3** *Study phase 2*

*2.2.2 Preliminary adaptation design (stage two)*

patients [7].

themselves.

*2.2.2.2 Measures*

*2.2.2.3 Procedure*

**62**

*2.2.2.1 Design and participants*

*Topics in Primary Care Medicine*

In the preliminary adaptation stage, we tailored CHEP culturally using information collected in the *Information Gathering Stage*. Our underlying objective was to increase cultural content of CHEP. We made both *surface structure* and *deep structure* changes to the original contents of CHEP and CAHE to achieve a culturally adapted CHEP. *Surface Structure changes* refer to matching of educational intervention materials and messages to observable superficial characteristics of our target population e.g. use of familiar people, places, language, food, locations, and cultural activities preferred by the Nigerian patients, while *Deep Structure changes* involved incorporating social, cultural, environmental and historical components to influence the targeted hypertension self-management behavior among the Nigerian

Both CHEP and CAHE had notable similarities in forms and contents; each was

implemented in three modules over 6 months among hypertensive patients in Europe (*CAHE*), and Africa (*CHEP*). But there were differences in their designs. CAHE used non-native nurse practitioners as educators in English language, while CHEP used native medical doctor and nurse to deliver the educational intervention in local languages. Furthermore, while CAHE recruited participants from four primary care clinics in urban Amsterdam, CHEP recruited participants from a single primary care clinic in rural Nigeria. Unlike CHEP, patients in CAHE benefited from modern lifestyle referral support e.g. gyms in Amsterdam city in addition to exposure to a hypertension handbook. In contrast, patients in CHEP had exposure to educational materials that were contextually tailored to Nigerian rural context e.g. audiovisuals and poster teachings on dietary salt replacement with suitable local substitute *Iru*, and use of household chores, farming, fishing, gardening, leisure activities (drumming, gaming, dancing, singing) etc., as forms of exercise. The audiovisuals were scripted and acted by familiar faces including some participants

Excluding goals setting and few self-report measures, many other measures were assessed in both CAHE and CHEP including patient demographics and physiological measures. Other measures include perceived stress, social support, and illness perception, beliefs about medicines, self efficacy, medication adherence, lifestyle adherence and satisfaction with care. Unlike CHEP however, a measure of 'discrimination' was deemed relevant and included in CAHE whose participants

A CHEP counseling visit usually began with participants familiarizing with others and the trainers. This is followed by: group interactive counseling on hypertension and hypertension self-management; poster teaching on culturally relevant exercises; a visit to the local market to familiarize with healthy foods; an audiovisual viewing session on pills use, healthy diet and lifestyle; a field practical exercise session; and a goal setting and assessment session. CAHE on the other hand was delivered in one-on-one teaching sessions, featured no audiovisual session, and did

not involve teaching visits to local market or grocery store but nevertheless

had migrated to Europe and could possibly experience social exclusion.

#### *2.3.1* Preliminary adaptation testing (stage three)

#### *2.3.1.1 Design and participants*

The *preliminary adaptation testing* took place in the second phase of the study (March to August 2012) during which we used quasi-experimental pretest-posttest design to assess cultural fitness and effectiveness of the newly adapted CHEP. We included, trained and evaluated a cohort of 149 patients over a period of 6 months. Participants were evaluated on performance of set behavioral goals to assess cultural fitness. At a later stage we conducted an FGD with a sub-set of the participants to assess their perceptions about usefulness and acceptability of the adapted intervention.

#### *2.3.1.2 Measures*

We measured and recorded participants'socio-demographic parameters (age, gender, ethnicity, marital status, income level, employment status, educational status, alcohol use and tobacco use) and assessed their hypertension treatment outcomes including blood pressure control, body mass index, medication adherence, behavioral adherence as well as social support, satisfaction with care, illness perception, beliefs about medicines, and medication adherence self efficacy. Furthermore we asked participants specific questions on physical activity and exercise, use of salt, alcohol and smoking and graded their responses on a Likert Scale. Finally we asked participants to set and practice preferred culturally adapted behavioral health goals and graded their performances of set goals as a measure of 'cultural fitness.

#### *2.3.1.3 Procedures*

Each of the 149 participants individually had an initial baseline assessment, followed by 3 modules of CHEP training in groups of 12–15 at 6 weeks, 10 weeks and 14 weeks past baseline. They were later disaggregated to have final individual assessments at 6 months past baseline. In essence, each participant had five study visits including a baseline assessment visit, a final assessment visit and three intervening group educational and goals setting assessment visits. Following the baseline visit (1st study visit) each participant was guided to set 3 culturally adapted behavioral goals during the first training session (2nd study visit), and to practice the selected goals at home until he/she revisits for the second training session (3rd study visit). The same goals setting instructions were repeated at the end of second training towards the third and final training session (4th study visit). Participants were additionally guided to practice preferred physical exercises for 20 minutes during the 3rd training session only, and they were encouraged to continue the exercises at home until the final visits

at 6 months (5th study visit). In the section on assessment of set goals, participants' goals related performances were rated on a Likert scale and compared over 6 months before and after the intervention. Full details of the effectiveness of CHEP evaluation study are available in a related study [13].

## *2.3.1.4 Analysis*

Data were analyzed based on: 1) qualitative self-report from each of the 149 participants on performance of set goals as instructed; and 2) quantitative 'before-, and after' comparison of changes in treatment outcomes of participants following intervention.

Hereunder we describe our results based on the first three out of five

**Characteristics N (%)** • Secondary education 9 (22.5%) • Tertiary education 3 (7.5%)

*Cultural Adaptation of a Cardiovascular Health Education Program among Hypertensive…*

• Nupe 6 (15%) • Yoruba 31 (77.5%) • Others 3 (7.5%)

A.**Cultural Inhibitors of Uptake and Practice of Healthy Behavior**

discourage uptake and practice of healthy behavior (**Table 2**).

The results are in two streams: a) *the cultural factors inhibiting uptake and practice of healthy behavior*; and b) *the cultural factors enabling uptake and practice of healthy*

Our data showed that a people's culture, customs and beliefs have capacity to

1.**Increasing use of dietary salt**: certain cultural practices increase use of salt by the local population. During food preservation practices, salt is used to preserve fish and meat against microbial decomposition. For example, when asked about the cultural practices influencing salt use, a 56 year old hypertensive female [ID37] replied "*we normally preserve our meat from getting rotten by salting and drying them in the sun daily*". Food preparation practices also encourage increased use of salt. Some people

have the habit of preparing meals with salt and salt-containing condiments e.g. maggi (salt *plus* hydrogenated oil *plus* monosodium glutamate). Others are accustomed to salty meals and would habitually add extra table salt to meals already prepared with salt. Some use the salty supernatant obtained from boiled meat to prepare soups believing this enhances its flavor. Furthermore, medicinal use of salt is common in the study region as it is common local practice to manage stomach upsets and abdominal discomforts by drinking salted water (salt solution).

2.**Increasing body weight and size**: some cultural practices encourage weight gain. A large body size is a desirable appearance to some as societal sign of affluence, comfort or wealth. And so, people may embark on intentional weight gain merely to show off perceived wealth or affluence. Furthermore, it is often perceived that a large body size enhances a woman's beauty or sexual attractiveness. There is societal perception that the fatter a lady is the more beautiful and fresh she is. On weight gain, a 50 year old female, [ID3] responded: *"people often see being fat as synonymous with affluence, comfort and peace of mind, and they sometimes associate robustness with beauty in women. Moreover, some of us women prefer to get fat believing that by so doing we are more attractive to our husbands and to men generally.* Our data further shows that people can

guideline-based cultural adaptation stages.

*Socio-demographic characteristics of participants.*

*DOI: http://dx.doi.org/10.5772/intechopen.94542*

**3.1** *Information gathering (stage 1)*

*behavior*.

**65**

Ethnicity

**Table 1.**

In assessing performance of set goals, we recorded the number and types of goals set by each participant during a current visit following practice of such goals at home as instructed during previous visit. Using a Likert scale we inquired and got qualitative responses from each participant on the extent to which they practiced selected goals at home. For the CHEP effectiveness study we employed descriptive statistics and regression analysis to evaluate changes in BP control, Body Mass Index, behavioral adherence and medication adherence and got promising improvements as reported in Odusola, et al. [13].

*Adaptation Refinement (Stage 4) and Cultural Adaptation Trial (Stage 5).*

By design we have reserved the last two stages of the cultural adaptation process, '*Adaptation Refinement'* and '*Cultural Adaptation Trial'* for the near future to implement CHEP Efficacy Trial. This is similar to procedures adopted in a previous US study on cultural adaptation of an evidence based treatment, the MLP for Latinas sub-cultural group [11].

## *2.3.1.5 Ethics*

Approval for Ethical conduct of the main study was obtained from the Ethics Committee of University of Ilorin Teaching Hospital on 30th March 2010. The current study is one of the sub-studies of the main study.

## **3. Results**

We collected qualitative information from 40 hypertensive patients (systolic BP ≥ 140 mmHg and/or diastolic BP ≥ 90 mmHg). Most of them were 50 years or older, two third were Christians, almost all (80%) earn less than 5USD per day while 70% had only primary school education, and most were artisans engaged in farming, fishing, or petty trading (**Table 1**).


*Cultural Adaptation of a Cardiovascular Health Education Program among Hypertensive… DOI: http://dx.doi.org/10.5772/intechopen.94542*


**Table 1.**

at 6 months (5th study visit). In the section on assessment of set goals, participants' goals related performances were rated on a Likert scale and compared over 6 months before and after the intervention. Full details of the effectiveness of CHEP evaluation

Data were analyzed based on: 1) qualitative self-report from each of the 149 participants on performance of set goals as instructed; and 2) quantitative 'before-, and after' comparison of changes in treatment outcomes of participants following

In assessing performance of set goals, we recorded the number and types of goals set by each participant during a current visit following practice of such goals at home as instructed during previous visit. Using a Likert scale we inquired and got qualitative responses from each participant on the extent to which they practiced selected goals at home. For the CHEP effectiveness study we employed descriptive statistics and regression analysis to evaluate changes in BP control, Body Mass Index, behavioral adherence and medication adherence and got promising

*Adaptation Refinement (Stage 4) and Cultural Adaptation Trial (Stage 5).*

'*Adaptation Refinement'* and '*Cultural Adaptation Trial'* for the near future to implement CHEP Efficacy Trial. This is similar to procedures adopted in a previous US study on cultural adaptation of an evidence based treatment, the MLP for

By design we have reserved the last two stages of the cultural adaptation process,

Approval for Ethical conduct of the main study was obtained from the Ethics Committee of University of Ilorin Teaching Hospital on 30th March 2010. The

We collected qualitative information from 40 hypertensive patients (systolic BP ≥ 140 mmHg and/or diastolic BP ≥ 90 mmHg). Most of them were 50 years or older, two third were Christians, almost all (80%) earn less than 5USD per day while 70% had only primary school education, and most were artisans engaged in

**Characteristics N (%)**

• 30–50 9 (22.5%) • 50–70 26 (65%) • 70–90 5 (12.5%)

• Male 16 (40%) • Female 24 (60%)

• None or primary education 28 (70%)

study are available in a related study [13].

*Topics in Primary Care Medicine*

improvements as reported in Odusola, et al. [13].

current study is one of the sub-studies of the main study.

farming, fishing, or petty trading (**Table 1**).

Latinas sub-cultural group [11].

*2.3.1.4 Analysis*

intervention.

*2.3.1.5 Ethics*

**3. Results**

Age group (years)

Educational level

Gender

**64**

*Socio-demographic characteristics of participants.*

Hereunder we describe our results based on the first three out of five guideline-based cultural adaptation stages.

## **3.1** *Information gathering (stage 1)*

The results are in two streams: a) *the cultural factors inhibiting uptake and practice of healthy behavior*; and b) *the cultural factors enabling uptake and practice of healthy behavior*.

## A.**Cultural Inhibitors of Uptake and Practice of Healthy Behavior**

Our data showed that a people's culture, customs and beliefs have capacity to discourage uptake and practice of healthy behavior (**Table 2**).


sometimes get discouraged when exercising to lose weight For example, an elderly male respondent [ID30] clarified a question on weight reduction saying "*in this region, people often link slimming down to disease particularly if the weight loss is pronounced, suggesting such might be due to disease,* and that "*slim people are miserly and would rather not spend enough money to feed well and get big*"*.*

**Category Sub-category Concepts and Examples**

*Cultural Adaptation of a Cardiovascular Health Education Program among Hypertensive…*

**Factors inhibiting healthy behavior**

Increase in body size perceived as wealth, affluence, comfort

Decrease in body size perceived as illness,

Increase in body size (bigness) perceived as a woman's beauty

disease

or sexual attractiveness

Weight gain or Obesity perceived inherited or natural in some families

Some local delicacies have fattening tendency

Perception of exercise as related to elderly "fragile" health and wellbeing

Perception of exercise as related to perceived

necessity

Following health counseling, I found out that meals prepared with *Iru* in place of salt are tastier and more delicious [n = 2]

I now get enough vegetables in my regular diet from vegetable gardening at my backyard

The bigger one is the wealthier, affluent and more comfortable he/she is perceived [n = 12]

The fatter a woman is, the more beautiful and attractive she is

Heaviness or fatness runs in my family; we normally have big

Popular local meals are often heavily starch-based, e.g. Pounded yam, Garri-eba [n = 5] Red Palm-oil, Groundnut oil readily available in our environment [n = 11] Popular local goat-breeding practice makes red meat readily

People will say: look at him, 'big for nothing', he will not be able to enjoy breathing, worse still

Popular view: exercising is dangerous with increasing age, and to health the elderly [n = 7]

Popular view: walking long distances just to exercise could only mean one is unserious and greedy to avoid spending travel

Deliberate weight loss or slimming down perceived as being caused by serious internal

disease [n = 13]

viewed [n = 7]

sizes [n = 3]

available [n = 2]

[n = 3].

costs [n = 5]

[n = 5]

**Factors motivating healthy behavior**

Endowment of rural environments with healthpromoting possibilities and practices: arable land for vegetable and fruit farming

and poultry; and streams and rivers for

fishing

substitute *Iru*

*DOI: http://dx.doi.org/10.5772/intechopen.94542*

Availability of suitable salt

Food related practices: Salt use

Food related practices: Fruits and vegetables consumption

Societal sociocultural perceptions: weight gain

Socio-cultural perceptions: weight reduction

Socio-cultural perceptions: lack of exercise

**67**

Cultural perceptions and orientations: being fat is tantamount to ugliness, sluggishness and physical

unfitness


## B. **Cultural Facilitators of Uptake and Practice of Healthy Behavior**

Our data yielded a rich mix of information on factors encouraging healthy behavior among participants (**Table 2**). Many felt cultural adaptation of certain local practices made it easier, cheaper and more attractive to practice healthy behavior.



*Cultural Adaptation of a Cardiovascular Health Education Program among Hypertensive… DOI: http://dx.doi.org/10.5772/intechopen.94542*

sometimes get discouraged when exercising to lose weight For example, an elderly male respondent [ID30] clarified a question on weight reduction saying "*in this region, people often link slimming down to disease particularly if the weight loss is pronounced, suggesting such might be due to disease,* and that "*slim people are miserly and would rather not spend enough*

3.**Physical inactivity and lack of exercise**: excerpts from our data show there is a strong cultural correlation between societal perception and 'need or needlessness' to exercise. Many believe exercise is a needless waste of time. Some perceive exercise as dangerous to health especially with advancing age when the body is assumed fragile and weaker. Deliberate attempts to exercise by trekking to destinations are perceived negatively. Such persons are taunted as being miserly and reluctant to fund transport costs to their destinations. On challenges encountered in exercising, an elderly male [ID30] said "*when people see me walking 'to exercise' they often slight me and make derogatory comments that I'm greedy and would rather walk long distances than spend money on transportation*.

4.**Use of tobacco and other stimulants**: curiously, social habits like use of stimulants and tobacco products are sometimes perceived as promoting health. A popular local alcoholic brew '*Palm wine*' is believed to make vision clearer while others like the '*Ogogoro*' (local gin), *Snuff* (Nicotine powder) and *Taba (fine-ground tobacco leaves)* are variously perceived to relieve stress and bodily tension, and stimulate work*.* Now better

informed, a 65 year old male [ID23] regretted: *"our fore fathers used to say palm wine makes one see very well, but it is now glaring to me that such views were misplaced*. Another participant [ID29] responded: "*in this region we believe chewing kola nuts and using snuff stimulate performance of household*

*chores and work although I personally don't use them".*

healthy behavior.

Food related practices: Salt use

**66**

**Factors motivating healthy behavior**

B. **Cultural Facilitators of Uptake and Practice of Healthy Behavior**

**Category Sub-category Concepts and Examples**

Our data yielded a rich mix of information on factors encouraging healthy behavior among participants (**Table 2**). Many felt cultural adaptation of certain local practices made it easier, cheaper and more attractive to practice

> **Factors inhibiting healthy behavior**

Food conservation practices

Food preparation practices

Salt can preserve food stocks against microbial degradation

A salt-less diet is repulsive to the African mindset [n = 7] Salt and salt products (e.g. maggi) are substantially used in meals preparation [n = 14]

sure panacea for abdominal/ stomach discomfort [n = 3]

[n = 3]\*

Medicinal use of salt Salted water (salt solution) is a

*money to feed well and get big*"*.*

*Topics in Primary Care Medicine*


*large expanse of land at my backyard which before now had laid waste, and from this I get sufficient supply of vegetables to meet my family needs".*

cultural linkages between health and body size, health and wealth, and health and beauty. In the study region, there was a popular cultural perception that "the fatter a woman is the more affluent, comfortable or beautiful she is". This perception has health implications as it encourages undue weight gain among the women. However, this perception is changing nowadays, and being too fat is now viewed as ugliness, sluggishness or physical unfitness. When asked what relationship exists between beauty and large body sizes, a respondent [ID26] replied: "*beauty is a good thing that sometimes goes with bigness but some people are ugly looking when fat"*. These newer perceptions

4.**Increasing physical activity and exercise**: although some participants view exercise as dangerous to health because of advancing age, many others nonetheless understood that exercise is generally good for health and helps to control their hypertension. After the educational counseling many are now aware that some level of physical fitness can be achieved using usual everyday activities in rural communities, and that exercising do not necessarily require formal regimented sessions like street jogging, gyms and swimming pools sessions applicable to cities and urban towns. Our data showed that if given relevant encouragement and training, participants are able and willing to adopt culturally modified versions of local practices to achieve physical fitness: *walking briskly and regularly to farm and other destinations; faith-based and cultural dancing, drumming, clapping or singing; food preparation practices like pounding yam and grains in mortars; farming and gardening activities including shoveling and hoeing; traditional laundry (washing clothes), sweeping floors, and drawing or fetching water from wells; and where feasible canoe paddling on rivers and cycling to move around*. A participant [ID21] responded: "*in my community, women prepare the popular local delicacy pounded yam using mortar, this*

*being a form of exercise since they sweat a lot when they pound"*.

rural communities.

**69**

**3.2 Preliminary adaptation design (stage two)**

5.**Limiting use of alcohol, tobacco and stimulants**: some participants leverage on existing cultural and religious perceptions to acquire healthy behavior. Following behavioral counseling the few who use tobacco (smoking and non-smoking forms) were able to exploit existing *genderbased,* and *faith-based cultural perceptions* to discontinue such practices, including faith-based religious abhorrence of smoking and use of alcohol, and gender-based disapproval of female use of tobacco, alcohol, and snuff. It is culturally reprehensible to see a woman smoking cigarette in

Cultural adaptation of the Education Program was accomplished based on the conceptual framework of formative research using information obtained from qualitative interviews with patients. The other anticipated source of information, literature review, did not yield much useful information on the topic from the study region. Osuna et al. similarly relied substantially on information from a Focus Group Discussion with participants to achieve cultural adaptation design of a

3.**Decreasing body size and weight**: some female participants perceive

*Cultural Adaptation of a Cardiovascular Health Education Program among Hypertensive…*

*DOI: http://dx.doi.org/10.5772/intechopen.94542*

have helped many to adopt healthier behavior.

**Table 2.**

*Motivational and inhibitory factors of healthy behavior: Thematic matrix of categories, sub-categories and concepts.*


*Cultural Adaptation of a Cardiovascular Health Education Program among Hypertensive… DOI: http://dx.doi.org/10.5772/intechopen.94542*

> *large expanse of land at my backyard which before now had laid waste, and from this I get sufficient supply of vegetables to meet my family needs".*


#### **3.2 Preliminary adaptation design (stage two)**

Cultural adaptation of the Education Program was accomplished based on the conceptual framework of formative research using information obtained from qualitative interviews with patients. The other anticipated source of information, literature review, did not yield much useful information on the topic from the study region. Osuna et al. similarly relied substantially on information from a Focus Group Discussion with participants to achieve cultural adaptation design of a

1.**Limiting use of dietary salt**: following enlightenment through the adapted education program some participants realized that *Iru* (a local food condiment) is a suitable and effective alternative to dietary salt. *Iru,* the locally grown African Locust Bean seed is a relatively cheaper food condiment commonly available. It is devoid of salt or sodium derivatives and participants agreed it makes food tastier and more delicious. Many now use *Iru* in place of salt to prepare their meals although few confessed they nonetheless add little salt despite using Iru. A 50 year old female [ID11] said "*I have been enlightened and I have since been using Iru in place of salt to prepare my family meals; truly I found out the meals so prepared are*

*Motivational and inhibitory factors of healthy behavior: Thematic matrix of categories, sub-categories and concepts.*

**Category Sub-category Concepts and Examples**

**Factors inhibiting healthy behavior**

Smoking and nonsmoking tobacco and Snuff uses are wrongly perceived beneficial to health

There's a perception that local alcoholic beverage (Palm wine) and Kola nuts are beneficial to health

Brisk trekking to farm, other destinations; dancing and clapping in church; drumming during festivals; food grains grinding and yam pounding; farming and gardening activities; laundry (washing clothes), sweeping floors,; and where feasible canoe paddling on rivers

Cigarette smoking and Snuff sniffing relieve tension and aid

Palm wine makes vision clearer [n = 1], chewing kola nuts stimulate task performance and it's a social standard for elders to chew kola nuts [n = 2]

Faith-based and gender-based abhorrence of smoking, alcohol and tobacco by women; society frowns seriously at sight of a woman smoking cigarette

work [n = 1]

**Factors motivating healthy behavior**

Cultural practices and environmental possibilities to achieve physical fitness

Faith-based and genderbased considerations that discourages use of alcohol

*Notes: n refers to the number of respondents who expressed the implied view.*

and tobacco

Socio-cultural perceptions: exercise and physical fitness

*Topics in Primary Care Medicine*

Socio-cultural perceptions: social habits

Socio-cultural perceptions: social habits

**Table 2.**

**68**

2.**Increasing consumption of dietary fruits and vegetables**: our data shows that rural African communities are endowed with potential for promoting health using existing socio-cultural and environmental peculiarities such as arable lands, domesticated animals and flourishing streams and rivers. They provide opportunities for vegetable farming, fishing, poultry and animal husbandry. To some participants, earning a

living through these *health-related* economic activities motivate hypertension self-management efforts. When asked how often he consumes fruits and vegetables an elderly participant [ID32] responded: "*based on advice from my doctor, I now practice vegetable farming on the*

*tastier and more delicious*.

diabetes Intervention program among Latinas in the United States [11]. The adaptation in our study was achieved through cultural modification of existing behavioral health practices among the local population. This involved modifying the *'form'* (surface structure elements) and the '*specific content'* (deep structure elements) into culturally friendly and adoptable methods of exercising within rural contexts. However, because information from our interviews also revealed local practices and beliefs perceived inhibitory to healthy behavior, we highlighted and discarded the inhibitory perceptions in order to achieve a culturally attractive and acceptable final behavioral counseling program. **Table 3** displays a synopsis of key differences and similarities in contents and procedures between the culturally adapted program (CHEP) and the adaptable program (CAHE).


**3.3 Preliminary adaptation testing (stage 3)**

participants' hypertension treatment outcomes.

(p < 0.001).

**71**

goals as reported by participants themselves over six 6 months.

**Category Sub-category Cultural perspectives and**

Rural African food preservation and preparation practices

*DOI: http://dx.doi.org/10.5772/intechopen.94542*

Local perceptions about body image and size

Perceived danger of exercise to health

Perceptions that it is difficult, expensive and time wasting to achieve physical fitness

Societal perceptions of certain behaviors as 'unfaithful' and 'antisocial' e.g. smoking and use of alcohol

Cultural endowments towards healthy behavior – Diet

Cultural awareness towards healthy behavior – Weight

Cultural practices and environmental endowments towards healthy behavior – Physical activity

Faith-based and societal perspectives and norms

**Table 4.**

*thematic linkages.*

Cultural reorientation towards healthy behavior – Exercise

**linkages**

diet

health

sizes

activities

Medicinal use of salt Health-driven ignorant use

*Cultural Adaptation of a Cardiovascular Health Education Program among Hypertensive…*

Africans are naturally accustomed to high-salt

of salt further diminishes

Societal perception driven preference for big body

Health-driven concerns about older age-related dangers of exercise

Realizations that physical fitness is also achievable using usual everyday household chores, cultural and occupational activities, leisure and faith-based

Health-driven exploitation of faith-based abhorrence of certain norms to drive healthy behavior

**Cultural adaptation and**

Ability to replace salt with Iru, a suitable local substitute

Provide enlightenment information about avoidable use of salt

Provide useful information to situate body size within health perspectives

Re-orientate patients about the possibility and practicability of cheap, user-friendly, attractive and acceptable cultural and environmental activities as

Provide useful information to exploit faith-based and gender-based socio-cultural

Re-orientate about benefits/risks of agetailored exercising

exercise

practices

**tailoring**

Preliminary evaluation of the culturally adapted educational intervention was implemented in two arms: 1) cultural fitness assessment based on performance of set behavioral health goals; and 2) assessment of effectiveness based on changes in

*Culturally adapted components of existing behavioral practices: Categories, sub-categories, concepts and*

To assess cultural fitness, we examined and recorded serial performance of set

Simultaneously, the effectiveness assessment study took place over same period but this not being the focus of the current study, is reported fully elsewhere [13]. Briefly it involved before-, and after assessments of changes in blood pressure (BP) control, medication adherence, behavioral adherence, and body mass index (BMI). Out of an initial 149 included participants, 140 (94%) completed the study. More participants reported high adherence to prescribed medications and behavioral advice at 6 months compared to baseline: respectively, 101 (72%) at 6 months versus 70 (50%) at baseline, (p < 0.001) and 126 (90%) at 6 months versus 106 (76%) at baseline, (p < 0.001). Similarly, participants with controlled BP doubled from 34 (24%) at baseline to 65 (46%) at 6 months, (p = 0.001). The median SBP and DBP decreased from 129.0 to 122.0 mmHg, (p = 0.002) and from 80.0 to 73.5 mmHg, (p < 0.001), respectively. However, BMI did not change (p = 0.444). The improvement in medication adherence was associated with a decrease in medication concerns (p = 0.045) and improvement in medication self-efficacy

#### **Table 3.**

*Contents and procedural variances and similarities between culturally adapted CHEP and CAHE.*

Furthermore, in **Table 4** we highlight the thematic categories of the relationships existing between traditional local perspectives and cultural practices, and their adaptability following educational counseling drawing from newly available culturally relevant information.

*Cultural Adaptation of a Cardiovascular Health Education Program among Hypertensive… DOI: http://dx.doi.org/10.5772/intechopen.94542*


#### **Table 4.**

diabetes Intervention program among Latinas in the United States [11]. The adaptation in our study was achieved through cultural modification of existing behavioral health practices among the local population. This involved modifying the *'form'* (surface structure elements) and the '*specific content'* (deep structure elements) into culturally friendly and adoptable methods of exercising within rural contexts. However, because information from our interviews also revealed local practices and beliefs perceived inhibitory to healthy behavior, we highlighted and discarded the inhibitory perceptions in order to achieve a culturally attractive and acceptable final behavioral counseling program. **Table 3** displays a synopsis of key differences and similarities in contents and procedures between the culturally adapted program

**CAHE CHEP**

Focus of program Hypertension self-management Hypertension self-management

African immigrants (mostly

Language of communication English Native Yoruba and Nupe

Qualitative interviews with hypertensive participants

of European urban/city environment

Promoted use of lifestyle referral facilities like gyms, swimming pool, walking out

Counseled participants to reduce dietary salt consumption

cultural fitness

Did not assess participants for

Significant improvements in diastolic blood pressure and lifestyle adherence

*Contents and procedural variances and similarities between culturally adapted CHEP and CAHE.*

Hypertension education program

Hypertensive primary care native Africans (mostly illiterate)

FGD and Qualitative interviews with

More deeply exploratory from a perspective of rural African socio-

Promoted use of cultural and environmental possibilities like household chores, farm work, food preparation activities etc.

Supported dietary salt reduction counseling with possibility to replace salt with a suitable local substitute *Iru*

Assessed participants for cultural fitness using culturally tailored behavioral health goals

Significant improvements in blood pressure control, medication adherence and lifestyle adherence

Rural Kwara, Nigeria

nurse practitioners

hypertensive participants

cultural environment

Used Dutch nurse Practitioner Used native African medical and

Furthermore, in **Table 4** we highlight the thematic categories of the relationships existing between traditional local perspectives and cultural practices, and their adaptability following educational counseling drawing from newly available

*Notes: CAHE – Culturally appropriate hypertension education; CHEP – Cardiovascular health education program.*

culturally relevant information.

(CHEP) and the adaptable program (CAHE).

Type of program Hypertension education

Implementation setting Urban Amsterdam,

Study population Hypertensive Primary care

Cultural exploratory content Exploratory from a perspective

etc.

program

Netherlands

literate)

**Program Content & Procedure**

*Topics in Primary Care Medicine*

Cultural familiarity of education counselors or

Information gathering

Behavioral health facilities available to support physical fitness and exercise habits

Adapted component of dietary counseling

Assessment of cultural

Effect on hypertension treatment outcome

fitness

**Table 3.**

**70**

trainers

method

*Culturally adapted components of existing behavioral practices: Categories, sub-categories, concepts and thematic linkages.*

#### **3.3 Preliminary adaptation testing (stage 3)**

Preliminary evaluation of the culturally adapted educational intervention was implemented in two arms: 1) cultural fitness assessment based on performance of set behavioral health goals; and 2) assessment of effectiveness based on changes in participants' hypertension treatment outcomes.

To assess cultural fitness, we examined and recorded serial performance of set goals as reported by participants themselves over six 6 months.

Simultaneously, the effectiveness assessment study took place over same period but this not being the focus of the current study, is reported fully elsewhere [13]. Briefly it involved before-, and after assessments of changes in blood pressure (BP) control, medication adherence, behavioral adherence, and body mass index (BMI). Out of an initial 149 included participants, 140 (94%) completed the study. More participants reported high adherence to prescribed medications and behavioral advice at 6 months compared to baseline: respectively, 101 (72%) at 6 months versus 70 (50%) at baseline, (p < 0.001) and 126 (90%) at 6 months versus 106 (76%) at baseline, (p < 0.001). Similarly, participants with controlled BP doubled from 34 (24%) at baseline to 65 (46%) at 6 months, (p = 0.001). The median SBP and DBP decreased from 129.0 to 122.0 mmHg, (p = 0.002) and from 80.0 to 73.5 mmHg, (p < 0.001), respectively. However, BMI did not change (p = 0.444). The improvement in medication adherence was associated with a decrease in medication concerns (p = 0.045) and improvement in medication self-efficacy (p < 0.001).

## *3.3.1 Performance assessment of set goals*

As indicated in the methods each participant made 5 visits over 6 months: a baseline assessment visit, three intervening group education visits, and a final assessment visit. Hereunder we report the performance of set goals by participants based on self-reports. Using information from our interview data we structured existing local behavioral health practices of the region into 12 distinct culturally tailored goals (**Box 1**). We guided participants to select, set and practice three preferred goals during the three intervening group visits as well as at home in the weeks that followed their current visit. Their performances were assessed qualitatively during the subsequent visits.

1.For how many days in a week did you perform the selected goal?

*Cultural Adaptation of a Cardiovascular Health Education Program among Hypertensive…*

2.For how many minutes in a day did you perform the selected goal?

(very good)

**Performance scale**

**Table 5.**

**73**

> 30 mins (very good)

*DOI: http://dx.doi.org/10.5772/intechopen.94542*

encountered no challenges (very good)

performed (good); always performed (very good).

perceived effectiveness in performing selected goals.

**Participants' graded performance (Minutes/day)**

*3.3.2 Preferential practice of particular behavioral goals*

*Assessment of performance of set goals by participants.*

Response grading: 0-1 day (poor); 2–3 days (fair); 4–5 days (good); 6–7 days

Response grading: 0–10 mins (poor); 11–20 mins (fair); 21–30 mins (good);

3.How seriously did you perceive any challenges or difficulties encountered in performing the goals you selected and how well did you resolve the challenges?

4.On a scale of 1 to 4 (1 – poor, 2 – fair, 3 – good, 4 – very good), how would you

Response: not performed at all (poor); sometimes performed (fair); often

Following this we graded self-rated performances of participants on a Likert scale (**Table 5**), and found that an overwhelming majority of them performed the selected goals reasonably well. At least 49% and 28% of participants were graded 'good' and 'very good' respectively on the number of minutes they performed selected goals daily. Furthermore, regarding number of days per week they performed selected goals, about 61% and 11% were graded 'good' and 'very good' respectively. On their abilities to resolve potential challenges faced, 18% and 56% of participants were graded 'good' and 'very good' respectively. Finally 30% and 53% of participants were graded 'good' and 'very good' respectively regarding their

> **Participants' graded performance (Days/week)**

Poor 23 (16) 21 (15) 11 (8) 0 Fair 10 (7) 19 (14) 25 (18) 24 (17) Good 68 (49) 85 (61) 25 (18) 42 (30) Very good 39 (28) 15 (11) 79 (56) 74 (53) Total 140 (100) 140 (100) 140 (100) 140 (100)

**Participants' graded performance (Resolution of challenges)**

N (%) N (%) N (%) N (%)

**Participants' self-rated goals performance (Effectiveness)**

The particular types of culturally adapted goals participants preferred to set and pursue yielded interesting information from our data. Viewed against the background of attractiveness and acceptability, such information can be useful in guiding physicians and care givers on behavioral health practices likely to be accepted and complied

Response grading: serious challenges, not resolved (poor); moderate challenges, partly resolved (fair); minor challenges, fully resolved (good);

rate yourself on degree of performance (effectiveness), of set goals?

We inquired verbally from participants about how well they practiced selected goals during a subsequent visit and graded their responses on a Likert scale as follows:


#### **Box 1.** *Culturally tailored behavioral health goals set by participants*

*Cultural Adaptation of a Cardiovascular Health Education Program among Hypertensive… DOI: http://dx.doi.org/10.5772/intechopen.94542*

1.For how many days in a week did you perform the selected goal?

Response grading: 0-1 day (poor); 2–3 days (fair); 4–5 days (good); 6–7 days (very good)

2.For how many minutes in a day did you perform the selected goal?

Response grading: 0–10 mins (poor); 11–20 mins (fair); 21–30 mins (good); > 30 mins (very good)

3.How seriously did you perceive any challenges or difficulties encountered in performing the goals you selected and how well did you resolve the challenges?

Response grading: serious challenges, not resolved (poor); moderate challenges, partly resolved (fair); minor challenges, fully resolved (good); encountered no challenges (very good)

4.On a scale of 1 to 4 (1 – poor, 2 – fair, 3 – good, 4 – very good), how would you rate yourself on degree of performance (effectiveness), of set goals?

Response: not performed at all (poor); sometimes performed (fair); often performed (good); always performed (very good).

Following this we graded self-rated performances of participants on a Likert scale (**Table 5**), and found that an overwhelming majority of them performed the selected goals reasonably well. At least 49% and 28% of participants were graded 'good' and 'very good' respectively on the number of minutes they performed selected goals daily. Furthermore, regarding number of days per week they performed selected goals, about 61% and 11% were graded 'good' and 'very good' respectively. On their abilities to resolve potential challenges faced, 18% and 56% of participants were graded 'good' and 'very good' respectively. Finally 30% and 53% of participants were graded 'good' and 'very good' respectively regarding their perceived effectiveness in performing selected goals.


#### **Table 5.**

*3.3.1 Performance assessment of set goals*

*Topics in Primary Care Medicine*

qualitatively during the subsequent visits.

or preservation by half before my next visit

vegetables and fruits daily before my next visit

meat and other fatty food daily before my next visit

before my next visit

by half before my next visit

daily by half before my next visit

before my next visit

*Culturally tailored behavioral health goals set by participants*

**Box 1.**

**72**

follows:

As indicated in the methods each participant made 5 visits over 6 months: a baseline assessment visit, three intervening group education visits, and a final assessment visit. Hereunder we report the performance of set goals by participants based on self-reports. Using information from our interview data we structured existing local behavioral health practices of the region into 12 distinct culturally tailored goals (**Box 1**). We guided participants to select, set and practice three preferred goals during the three intervening group visits as well as at home in the

We inquired verbally from participants about how well they practiced selected

1. To reduce amount of salt and salt-containing condiments I currently use in food preparation and/

2. To completely replace salt with *Iru* in all my food preparation and food preservation processes

3. To increase my consumption of healthy foods by eating more fish and at least 3 servings of

4. To decrease my consumption of unhealthy foods by eating less of red palm oil, groundnut oil, goat

5. To stop smoking completely if I do, or at least reduce the number of cigarette sticks I smoke daily

6. To completely discontinue the use of all socially acceptable non-smoking forms of tobacco (Taba/Snuff), and Kola nuts, or reduce the quantity I use daily by half before my next visit

7. To completely discontinue consumption of Alcohol and other alcoholic beverages (Spirit, Palm wine, Gin, Ogogoro) perceived as culturally acceptable, or at least reduce the quantities I consume

8. To exercise more regularly using locally available methods like brisk walking, canoe paddling,

9. To exercise more regularly using food preparation processes such as yam/grain pounding in mortars whenever feasible over at least 30 minutes per session before my next visit

10. To exercise more regularly using usual household chores such as sweeping floors, laundry (washing clothes), pulling/fetching water from wells or others over at least 30 minutes daily

11. To exercise more regularly using usual farming activities such as ground hoeing, shoveling, bush clearing, manual harvesting, gardening etc. over at least 30 minutes daily before my next visit

12. To exercise more regularly using usual leisurely or faith-related activities such as clapping, dancing, singing, drumming, gaming or others for at least 30 minutes daily before my next visit

cycling or others, to and from my destinations for at least 30 minutes everyday

weeks that followed their current visit. Their performances were assessed

goals during a subsequent visit and graded their responses on a Likert scale as

*Assessment of performance of set goals by participants.*

#### *3.3.2 Preferential practice of particular behavioral goals*

The particular types of culturally adapted goals participants preferred to set and pursue yielded interesting information from our data. Viewed against the background of attractiveness and acceptability, such information can be useful in guiding physicians and care givers on behavioral health practices likely to be accepted and complied with by hypertensive patients. This type of information can predict areas in need of counseling reinforcement for patients in efforts to improve hypertension selfmanagement skills. Extracts from our data (**Table 6**) reveals that the three most preferred and set goals are dietary salt reduction, exercising and compliance with pills use. Similarly, the three least preferred and set goals are stopping tobacco use, limiting alcohol use and stopping kola nuts consumption. Finally, important considerations that guided participants in selecting particular goals include funding performance of the goals, ease/rigor of performance, and access to practicing the goals.

improved participants' hypertension treatment outcomes and enabled increased performance of culturally tailored behavioral health goals among the participants. *Cultural adaptation* is the systematic modification of an existing evidence-based treatment to conform with a distinct group's language, culture, customs and local cultural contexts in a way that it becomes compatible with the group's cultural orientations and values" [9]. The cultural modification process enhances attractiveness and adoptability of a new program among targeted populations. The promising results reported in the previous CHEP evaluation study [13], are plausible in the light of findings from other studies in support of views that standardized cultural adaptation of behavioral interventions can improve treatment outcomes [9, 14, 15, 21, 31]. To the best of our knowledge no previous study conducted in rural African context has shown such potentials from implementing culturally adapted interventions. Following debates on the most appropriate process for cultural adaptation, researchers arrived at a consensus aggregating various approaches to establish a standard guideline involving five sequential stages: 1) information gathering, stage one; 2) preliminary adaptation design, stage two; 3) preliminary adaptation testing, stage three; 4) adaptation refinement, stage four; and 5) adaptation trial, stage five [10, 17]. In the current study however, by design we opted to adapt CHEP from CAHE using the first three of five guideline-based stages, deferring the last two stages for a future CHEP efficacy trial. A diabetes lifestyle intervention program was similarly adapted for Latinas in the USA using stages one to three only [11]. The local and cultural environments of patients in our study are endowed with materials and possibilities that influenced their hypertension self-management capacities. We found that locally grown Locust Beans '*Iru*' is a healthier condiment suitable in replacing dietary salt. This finding is strikingly comparable to a Peruvian study which reported successful introduction of a similar *salt substitute* with less elemental sodium among a local hypertensive population [32]. Our results also showed that exercising can be attractive and easier when performed using tradi-

*Cultural Adaptation of a Cardiovascular Health Education Program among Hypertensive…*

*DOI: http://dx.doi.org/10.5772/intechopen.94542*

Cultural fitness is determined by the extent to which a people accept and use the language, values, beliefs and materials characteristics of newly introduced culturally tailored interventions targeting their self-management skills. We assessed the adapted intervention for cultural fitness by conducting a goals setting and performance exercise among participants and got promising results on performances by most participants. Similar findings have also been reported from other studies [19–21]. Moreover during a follow-up FGD participants spoke excitedly and expressed desires to continue to use the education program even after the study. Interestingly we observed that the three most common behavioral goals practiced by participants were *salt reduction, exercise and weight reduction* while the three least commonly practiced goals were *smoking cessation, alcohol reduction and cessation of kola nuts use*. We believe such observations reflect new perceptions of the health risks which participants now associate with the habits following enlightenment from behavioral counseling. Such information on preferred and disliked behavioral practices can help physicians make informed decisions on areas most in need of attention in planning behavioral health

1.Participants could have been biased in recalling events and they may have given socially desirable answers on some aspects of our results that are based

2.Without prejudice to results obtained, logistics and funding constraints limited our ability to implement all the five guideline-based cultural adaptation stages

tional household chores and cultural practices.

interventions for patients with cardiovascular risk factors. Limitations encountered in this study include:

on self-reports

**75**


#### **Table 6.**

*Frequency and types of behavioral goals set during educational sessions.*

## **4. Discussion**

We examined the proceedings and results of cultural adaptation of a behavioral treatment program following standard guidelines, among primary care patients with hypertension from rural Nigeria highlighting cultural fitness and effectiveness of the adapted program on their hypertension self-management. Based on theoretical and conceptual framework of formative research described by Resnicow et al. [7], we combined information from exploratory interviews with hypertensive patients with extracts from a review of literature on the topic to adapt a Cardiovascular Health Education Program (CHEP) from an existing Culturally Appropriate Hypertension Education (CAHE) previously deployed among hypertensive African immigrants in the Netherlands [12]. The literature review however did not yield enough relevant information. Our goal was to increase cultural sensitivity and contents of CHEP relative to CAHE and to make the adapted CHEP relevant to specific needs of hypertensive patients from rural Nigeria. Resnicow et al. had proposed combining: a) *surface structure elements* (matching of adaptable behavioral practices and materials to observable superficial characteristics of the target population); with b) *deep structure elements* (incorporation of target population's customs, culture, beliefs and values into their existing adaptable practices). Drawing inspirations from this, CHEP used materials from both *surface structures* and *deep structures* in its development and adaptation processes. We additionally followed the guidelines described by Barrera et al. in a consensus of cultural adaption processes [10] in adapting CHEP. Finally we evaluated the adapted program and found that CHEP

#### *Cultural Adaptation of a Cardiovascular Health Education Program among Hypertensive… DOI: http://dx.doi.org/10.5772/intechopen.94542*

improved participants' hypertension treatment outcomes and enabled increased performance of culturally tailored behavioral health goals among the participants.

*Cultural adaptation* is the systematic modification of an existing evidence-based treatment to conform with a distinct group's language, culture, customs and local cultural contexts in a way that it becomes compatible with the group's cultural orientations and values" [9]. The cultural modification process enhances attractiveness and adoptability of a new program among targeted populations. The promising results reported in the previous CHEP evaluation study [13], are plausible in the light of findings from other studies in support of views that standardized cultural adaptation of behavioral interventions can improve treatment outcomes [9, 14, 15, 21, 31]. To the best of our knowledge no previous study conducted in rural African context has shown such potentials from implementing culturally adapted interventions.

Following debates on the most appropriate process for cultural adaptation, researchers arrived at a consensus aggregating various approaches to establish a standard guideline involving five sequential stages: 1) information gathering, stage one; 2) preliminary adaptation design, stage two; 3) preliminary adaptation testing, stage three; 4) adaptation refinement, stage four; and 5) adaptation trial, stage five [10, 17]. In the current study however, by design we opted to adapt CHEP from CAHE using the first three of five guideline-based stages, deferring the last two stages for a future CHEP efficacy trial. A diabetes lifestyle intervention program was similarly adapted for Latinas in the USA using stages one to three only [11].

The local and cultural environments of patients in our study are endowed with materials and possibilities that influenced their hypertension self-management capacities. We found that locally grown Locust Beans '*Iru*' is a healthier condiment suitable in replacing dietary salt. This finding is strikingly comparable to a Peruvian study which reported successful introduction of a similar *salt substitute* with less elemental sodium among a local hypertensive population [32]. Our results also showed that exercising can be attractive and easier when performed using traditional household chores and cultural practices.

Cultural fitness is determined by the extent to which a people accept and use the language, values, beliefs and materials characteristics of newly introduced culturally tailored interventions targeting their self-management skills. We assessed the adapted intervention for cultural fitness by conducting a goals setting and performance exercise among participants and got promising results on performances by most participants. Similar findings have also been reported from other studies [19–21]. Moreover during a follow-up FGD participants spoke excitedly and expressed desires to continue to use the education program even after the study. Interestingly we observed that the three most common behavioral goals practiced by participants were *salt reduction, exercise and weight reduction* while the three least commonly practiced goals were *smoking cessation, alcohol reduction and cessation of kola nuts use*. We believe such observations reflect new perceptions of the health risks which participants now associate with the habits following enlightenment from behavioral counseling. Such information on preferred and disliked behavioral practices can help physicians make informed decisions on areas most in need of attention in planning behavioral health interventions for patients with cardiovascular risk factors.

Limitations encountered in this study include:


with by hypertensive patients. This type of information can predict areas in need of counseling reinforcement for patients in efforts to improve hypertension selfmanagement skills. Extracts from our data (**Table 6**) reveals that the three most preferred and set goals are dietary salt reduction, exercising and compliance with pills use. Similarly, the three least preferred and set goals are stopping tobacco use, limiting alcohol use and stopping kola nuts consumption. Finally, important considerations that guided participants in selecting particular goals include funding performance of

**CHEP 1, N (%) CHEP 2, N (%) CHEP 3, N (%)**

We examined the proceedings and results of cultural adaptation of a behavioral treatment program following standard guidelines, among primary care patients with hypertension from rural Nigeria highlighting cultural fitness and effectiveness of the adapted program on their hypertension self-management. Based on theoretical and conceptual framework of formative research described by Resnicow et al. [7], we combined information from exploratory interviews with hypertensive patients with extracts from a review of literature on the topic to adapt a Cardiovascular Health Education Program (CHEP) from an existing Culturally Appropriate Hypertension Education (CAHE) previously deployed among hypertensive African immigrants in the Netherlands [12]. The literature review however did not yield enough relevant information. Our goal was to increase cultural sensitivity and contents of CHEP relative to CAHE and to make the adapted CHEP relevant to specific needs of hypertensive patients from rural Nigeria. Resnicow et al. had proposed combining: a) *surface structure elements* (matching of adaptable behavioral practices and materials to observable superficial characteristics of the target population); with b) *deep structure elements* (incorporation of target population's customs, culture, beliefs and values into their existing adaptable practices). Drawing inspirations from this, CHEP used materials from both *surface structures* and *deep structures* in its development and adaptation processes. We additionally followed the guidelines described by Barrera et al. in a consensus of cultural adaption processes [10] in adapting CHEP. Finally we evaluated the adapted program and found that CHEP

the goals, ease/rigor of performance, and access to practicing the goals.

**Types of Goals Educational Sessions**

*Frequency and types of behavioral goals set during educational sessions.*

Diet (salt restriction) 124 (89) 97 (69) 66 (47) Diet (fat restriction) 23 (16) 12 (9) 27 (19) Diet (vegetables & fruits consumption) 16 (11) 9 (6) 8 (6) Physical fitness & exercise 121 (86) 100 (71) 93 (66) Weight reduction 59 (42) 47 (34) 32 (23) Quit smoking 4 (3) 4 (3) 2 (1) Quit non-smoked tobacco 5 (4) 2 (1) 0 (0) Quit Kola nut 14 (10) 4 (3) 7 (5) Restrict alcohol 13 (9) 10 (7) 7 (5) Comply with pills use 92 (66) 78 (56) 59 (42) Comply with clinic appointments 13 (9) 19 (14) 15 (11)

**4. Discussion**

*Topics in Primary Care Medicine*

**Table 6.**

**74**

## **5. Conclusion**

We followed standard guidelines to culturally adapt an existing behavioral health intervention among hypertensive patients from rural Nigeria. Modeled after a similar intervention from Europe we systematically developed and adapted the new intervention using frameworks of formative research. We got quite promising results on evaluating the adapted intervention for cultural fitness and effectiveness. We submit that guide-line based culturally adapted behavioral treatments have potential to improve hypertension treatment outcomes and limit cardiovascular diseases.

## **5.1 Implication for practice**

The successful control of risk factors among patients at risk of cardiovascular diseases is a major goal of every attending physician. But a major obstacle to this goal is the difficulties faced by patients in adhering to prescribed pills and behavioral advices. Innovations like the current intervention which provides unique information on behavioral practices preferred and disliked by patients can guide physicians on acceptable and adoptable behaviors.

## **Acknowledgements**

Authors are grateful to the staff of Ogo Oluwa hospital and the health insurance company. We thank Health Insurance Fund, PharmAccess Foundation, and NUFFIC for supporting the study.

## **Conflict of interest**

The authors declare no conflict of interest.

## **Author contributions**

AO drafted the manuscript, designed and conducted the study. AA revised versions of the draft. Both authors approved the final draft.

**Author details**

Nigeria

**77**

Aina Olufemi Odusola<sup>1</sup>

University Teaching Hospital, Lagos, Nigeria

provided the original work is properly cited.

\*Address all correspondence to: f.odusola@gmail.com

\* and Ayoade Adedokun<sup>2</sup>

1 Department of Community Health and Primary Health Care, Lagos State

*Cultural Adaptation of a Cardiovascular Health Education Program among Hypertensive…*

*DOI: http://dx.doi.org/10.5772/intechopen.94542*

2 Department of Family Medicine, Lagos State University Teaching Hospital, Lagos,

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

*Cultural Adaptation of a Cardiovascular Health Education Program among Hypertensive… DOI: http://dx.doi.org/10.5772/intechopen.94542*

## **Author details**

**5. Conclusion**

*Topics in Primary Care Medicine*

diseases.

**5.1 Implication for practice**

**Acknowledgements**

**Conflict of interest**

**Author contributions**

**76**

NUFFIC for supporting the study.

physicians on acceptable and adoptable behaviors.

The authors declare no conflict of interest.

versions of the draft. Both authors approved the final draft.

We followed standard guidelines to culturally adapt an existing behavioral health intervention among hypertensive patients from rural Nigeria. Modeled after a similar intervention from Europe we systematically developed and adapted the new intervention using frameworks of formative research. We got quite promising results on evaluating the adapted intervention for cultural fitness and effectiveness. We submit that guide-line based culturally adapted behavioral treatments have potential to improve hypertension treatment outcomes and limit cardiovascular

The successful control of risk factors among patients at risk of cardiovascular diseases is a major goal of every attending physician. But a major obstacle to this goal is the difficulties faced by patients in adhering to prescribed pills and behavioral advices. Innovations like the current intervention which provides unique information on behavioral practices preferred and disliked by patients can guide

Authors are grateful to the staff of Ogo Oluwa hospital and the health insurance

company. We thank Health Insurance Fund, PharmAccess Foundation, and

AO drafted the manuscript, designed and conducted the study. AA revised

Aina Olufemi Odusola<sup>1</sup> \* and Ayoade Adedokun<sup>2</sup>

1 Department of Community Health and Primary Health Care, Lagos State University Teaching Hospital, Lagos, Nigeria

2 Department of Family Medicine, Lagos State University Teaching Hospital, Lagos, Nigeria

\*Address all correspondence to: f.odusola@gmail.com

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

## **References**

[1] Commodore-Mensah Y, Samuel LJ, Dennison-Himmelfarb CR, Agyemang C. Hypertension and overweight/obesity in Ghanaians and Nigerians living in West Africa and industrialized countries: a systematic review. J Hypertens. 2014 Mar;32(3): 464.

[2] Kengne AP, Awah PK, Fezeu L, Mbanya JC. The burden of high blood pressure and related risk factors in urban Sub-Saharan Africa: Evidences from Douala in Cameroon. Afr Health Sci [Internet]. 2007 Jan 1 [cited 2018 Mar 18];7(1). Available from: https:// www.ajol.info/index.php/ahs/article/ view/6989

[3] The top 10 causes of death [Internet]. [cited 2020 Feb 4]. Available from: https://www.who.int/news-room/ fact-sheets/detail/the-top-10-causesof-death

[4] Cardiovascular diseases [Internet]. [cited 2020 Feb 4]. Available from: https://www.who.int/westernpacific/ health-topics/cardiovascular-diseases

[5] Hendriks ME, Wit FWNM, Roos MTL, Brewster LM, Akande TM, Beer IH de, et al. Hypertension in Sub-Saharan Africa: Cross-Sectional Surveys in Four Rural and Urban Communities. PLOS ONE. 2012 Mar 12;7(3):e32638.

[6] Ike SO, Aniebue PN, Aniebue UU. Knowledge, perceptions and practices of lifestyle-modification measures among adult hypertensives in Nigeria. Trans R Soc Trop Med Hyg. 2010 Jan 1;104(1): 55–60.

[7] Resnicow K, Baranowski T, Ahluwalia JS, Braithwaite RL. Cultural sensitivity in public health: defined and demystified. Ethn Dis. 1999;9(1):10–21.

[8] Netto G, Bhopal R, Lederle N, Khatoon J, Jackson-Morris A. How Can Health Promotion Interventions Be Adapted for Minority Ethnic Communities? Five Principles for Guiding the Development of Behavioural Interventions. Health Promot Int. 2010 Mar 1;25:248–57.

Self-Efficacy in Community-Dwelling Older Persons. Curr Gerontol Geriatr Res [Internet]. 2013 [cited 2018 Mar 10];2013. Available from: https://www.

*DOI: http://dx.doi.org/10.5772/intechopen.94542*

[22] Odusola AO, Hendriks M,

*Cultural Adaptation of a Cardiovascular Health Education Program among Hypertensive…*

2014 Dec 10;14(1):624.

Schultsz C, Bolarinwa OA, Akande T, Osibogun A, et al. Perceptions of inhibitors and facilitators for adhering to hypertension treatment among insured patients in rural Nigeria: a qualitative study. BMC Health Serv Res.

[23] Olufemi Odusola A, Stronks K, Schultsz C, Hendriks M, Akeem Bolarinwa O, Akande T, et al.

Development of cardiovascular health education program for primary care patients with hypertension in rural Nigeria: a qualitative study. Health Educ Care [Internet]. 2017 [cited 2020 Jul 30];2(1). Available from: http://oatext. com/Development-of-cardiovascularhealth-education-program-for-primarycare-patients-with-hypertension-inrural-Nigeria-a-qualitative-study.php

[24] Beune E. Culturally appropriate hypertension care: from patients' perspectives towards practical tools.

Agyemang C, Schuster JS, Willems DL. How Ghanaian, African-Surinamese and Dutch patients perceive and manage antihypertensive drug treatment: a qualitative study: J Hypertens. 2008

[25] Beune EJ, Haafkens JA,

[26] Odusola AO, Hendriks M, Schultsz C, Stronks K, Lange J, Osibogun A, et al. Development and evaluation of a patient centered cardiovascular health education program for insured patients in rural Nigeria (QUICK - II). BMC Public Health. 2011 Mar 21;11(1):171.

[27] Hendriks ME, Bolarinwa OA, Wit FWNW, Brewster LM,

Odusola AO, Rosendaal NTA, et al.

cardiovascular disease prevention within a community-based health insurance program in rural Nigeria. J

Feasibility and quality of

Hypertens. 33(2):366–75.

Apr;26(4):648–56.

2010 Jan 1;

[15] Serour M, Alqhenaei H, Al-Saqabi S, Mustafa A-R, Ben-Nakhi A. Cultural factors and patients' adherence to lifestyle measures. Br J Gen Pr. 2007 Apr

Nicolaou M, Vissenberg C, Beune EJAJ, Hosper K, et al. Effectiveness of cultural adaptations of interventions aimed at smoking cessation, diet, and/or physical

ncbi.nlm.nih.gov/pmc/articles/

[16] Nierkens V, Hartman MA,

activity in ethnic minorities. a systematic review. PloS One. 2013;8

Psychol. 2010;6(1):213–39.

Nov 1;77(2):218–23.

(4):532–8.

**79**

[17] Castro FG, Barrera M, Holleran Steiker LK. Issues and Challenges in the Design of Culturally Adapted Evidence-Based Interventions. Annu Rev Clin

[18] DeWalt DA, Davis TC, Wallace AS, Seligman HK, Bryant-Shilliday B, Arnold CL, et al. Goal setting in diabetes self-management: Taking the baby steps to success. Patient Educ Couns. 2009

[19] Nothwehr F, Yang J. Goal setting frequency and the use of behavioral strategies related to diet and physical activity. Health Educ Res. 2007 Aug 1;22

[20] Pearson ES. Goal setting as a health behavior change strategy in overweight and obese adults: A systematic literature

components. Patient Educ Couns. 2012

[21] Strecher VJ, Seijts GH, Kok GJ, Latham GP, Glasgow R, DeVellis B, et al. Goal Setting as a Strategy for Health Behavior Change. Health Educ Q. 1995 Jul;22(2):190–200.

review examining intervention

Apr 1;87(1):32–42.

PMC3893800/

1;57(537):291–5.

(10):e73373.

[9] Domenech Rodríguez MM, Baumann AA, Schwartz AL. Cultural Adaptation of an Evidence Based Intervention: From Theory to Practice in a Latino/a Community Context. Am J Community Psychol. 2011 Mar 1;47(1– 2):170–86.

[10] Barrera M, Castro FG, Strycker LA, Toobert DJ. Cultural Adaptations of Behavioral Health Interventions: A Progress Report. J Consult Clin Psychol. 2013 Apr;81(2):196–205.

[11] Osuna D, Barrera M, Strycker LA, Toobert DJ, Glasgow RE, Geno CR, et al. Methods for the Cultural Adaptation of a Diabetes Lifestyle Intervention for Latinas: An Illustrative Project. Health Promot Pract. 2011 May 1;12(3):341–8.

[12] Beune EJAJ, Charante EPM van, Beem L, Mohrs J, Agyemang CO, Ogedegbe G, et al. Culturally Adapted Hypertension Education (CAHE) to Improve Blood Pressure Control and Treatment Adherence in Patients of African Origin with Uncontrolled Hypertension: Cluster-Randomized Trial. PLOS ONE. 2014 Mar 5;9(3): e90103.

[13] Odusola A, Nelissen H, Hendriks M, Schultsz C, Wit F, Bolarinwa O, et al. How Group-Based Cardiovascular Health Education Affects Treatment Adherence and Blood Pressure Control among Insured Hypertensive Nigerians: A Pre-Test, Post-Test Study. World J Cardiovasc Dis. 2015 Aug 1;5:181–98.

[14] Azizan A, Justine M, Kuan CS. Effects of a Behavioral Program on Exercise Adherence and Exercise

*Cultural Adaptation of a Cardiovascular Health Education Program among Hypertensive… DOI: http://dx.doi.org/10.5772/intechopen.94542*

Self-Efficacy in Community-Dwelling Older Persons. Curr Gerontol Geriatr Res [Internet]. 2013 [cited 2018 Mar 10];2013. Available from: https://www. ncbi.nlm.nih.gov/pmc/articles/ PMC3893800/

**References**

464.

view/6989

of-death

55–60.

**78**

[1] Commodore-Mensah Y, Samuel LJ,

Health Promotion Interventions Be Adapted for Minority Ethnic Communities? Five Principles for Guiding the Development of Behavioural Interventions. Health Promot Int. 2010 Mar 1;25:248–57.

[9] Domenech Rodríguez MM, Baumann AA, Schwartz AL. Cultural Adaptation of an Evidence Based Intervention: From Theory to Practice in a Latino/a Community Context. Am J Community Psychol. 2011 Mar 1;47(1–

2013 Apr;81(2):196–205.

[10] Barrera M, Castro FG, Strycker LA, Toobert DJ. Cultural Adaptations of Behavioral Health Interventions: A Progress Report. J Consult Clin Psychol.

[11] Osuna D, Barrera M, Strycker LA, Toobert DJ, Glasgow RE, Geno CR, et al. Methods for the Cultural Adaptation of a Diabetes Lifestyle Intervention for Latinas: An Illustrative Project. Health Promot Pract. 2011 May 1;12(3):341–8.

[12] Beune EJAJ, Charante EPM van, Beem L, Mohrs J, Agyemang CO, Ogedegbe G, et al. Culturally Adapted Hypertension Education (CAHE) to Improve Blood Pressure Control and Treatment Adherence in Patients of African Origin with Uncontrolled Hypertension: Cluster-Randomized Trial. PLOS ONE. 2014 Mar 5;9(3):

[13] Odusola A, Nelissen H, Hendriks M, Schultsz C, Wit F, Bolarinwa O, et al. How Group-Based Cardiovascular Health Education Affects Treatment Adherence and Blood Pressure Control among Insured Hypertensive Nigerians: A Pre-Test, Post-Test Study. World J Cardiovasc Dis. 2015 Aug 1;5:181–98.

[14] Azizan A, Justine M, Kuan CS. Effects of a Behavioral Program on Exercise Adherence and Exercise

2):170–86.

e90103.

[2] Kengne AP, Awah PK, Fezeu L, Mbanya JC. The burden of high blood pressure and related risk factors in urban Sub-Saharan Africa: Evidences from Douala in Cameroon. Afr Health Sci [Internet]. 2007 Jan 1 [cited 2018 Mar 18];7(1). Available from: https:// www.ajol.info/index.php/ahs/article/

[3] The top 10 causes of death [Internet]. [cited 2020 Feb 4]. Available from: https://www.who.int/news-room/ fact-sheets/detail/the-top-10-causes-

[4] Cardiovascular diseases [Internet]. [cited 2020 Feb 4]. Available from: https://www.who.int/westernpacific/ health-topics/cardiovascular-diseases

Roos MTL, Brewster LM, Akande TM, Beer IH de, et al. Hypertension in Sub-Saharan Africa: Cross-Sectional Surveys in Four Rural and Urban Communities. PLOS ONE. 2012 Mar 12;7(3):e32638.

[6] Ike SO, Aniebue PN, Aniebue UU. Knowledge, perceptions and practices of lifestyle-modification measures among adult hypertensives in Nigeria. Trans R Soc Trop Med Hyg. 2010 Jan 1;104(1):

[7] Resnicow K, Baranowski T,

[8] Netto G, Bhopal R, Lederle N, Khatoon J, Jackson-Morris A. How Can

Ahluwalia JS, Braithwaite RL. Cultural sensitivity in public health: defined and demystified. Ethn Dis. 1999;9(1):10–21.

[5] Hendriks ME, Wit FWNM,

Dennison-Himmelfarb CR, Agyemang C. Hypertension and overweight/obesity in Ghanaians and Nigerians living in West Africa and industrialized countries: a systematic review. J Hypertens. 2014 Mar;32(3):

*Topics in Primary Care Medicine*

[15] Serour M, Alqhenaei H, Al-Saqabi S, Mustafa A-R, Ben-Nakhi A. Cultural factors and patients' adherence to lifestyle measures. Br J Gen Pr. 2007 Apr 1;57(537):291–5.

[16] Nierkens V, Hartman MA, Nicolaou M, Vissenberg C, Beune EJAJ, Hosper K, et al. Effectiveness of cultural adaptations of interventions aimed at smoking cessation, diet, and/or physical activity in ethnic minorities. a systematic review. PloS One. 2013;8 (10):e73373.

[17] Castro FG, Barrera M, Holleran Steiker LK. Issues and Challenges in the Design of Culturally Adapted Evidence-Based Interventions. Annu Rev Clin Psychol. 2010;6(1):213–39.

[18] DeWalt DA, Davis TC, Wallace AS, Seligman HK, Bryant-Shilliday B, Arnold CL, et al. Goal setting in diabetes self-management: Taking the baby steps to success. Patient Educ Couns. 2009 Nov 1;77(2):218–23.

[19] Nothwehr F, Yang J. Goal setting frequency and the use of behavioral strategies related to diet and physical activity. Health Educ Res. 2007 Aug 1;22 (4):532–8.

[20] Pearson ES. Goal setting as a health behavior change strategy in overweight and obese adults: A systematic literature review examining intervention components. Patient Educ Couns. 2012 Apr 1;87(1):32–42.

[21] Strecher VJ, Seijts GH, Kok GJ, Latham GP, Glasgow R, DeVellis B, et al. Goal Setting as a Strategy for Health Behavior Change. Health Educ Q. 1995 Jul;22(2):190–200.

[22] Odusola AO, Hendriks M, Schultsz C, Bolarinwa OA, Akande T, Osibogun A, et al. Perceptions of inhibitors and facilitators for adhering to hypertension treatment among insured patients in rural Nigeria: a qualitative study. BMC Health Serv Res. 2014 Dec 10;14(1):624.

[23] Olufemi Odusola A, Stronks K, Schultsz C, Hendriks M, Akeem Bolarinwa O, Akande T, et al. Development of cardiovascular health education program for primary care patients with hypertension in rural Nigeria: a qualitative study. Health Educ Care [Internet]. 2017 [cited 2020 Jul 30];2(1). Available from: http://oatext. com/Development-of-cardiovascularhealth-education-program-for-primarycare-patients-with-hypertension-inrural-Nigeria-a-qualitative-study.php

[24] Beune E. Culturally appropriate hypertension care: from patients' perspectives towards practical tools. 2010 Jan 1;

[25] Beune EJ, Haafkens JA, Agyemang C, Schuster JS, Willems DL. How Ghanaian, African-Surinamese and Dutch patients perceive and manage antihypertensive drug treatment: a qualitative study: J Hypertens. 2008 Apr;26(4):648–56.

[26] Odusola AO, Hendriks M, Schultsz C, Stronks K, Lange J, Osibogun A, et al. Development and evaluation of a patient centered cardiovascular health education program for insured patients in rural Nigeria (QUICK - II). BMC Public Health. 2011 Mar 21;11(1):171.

[27] Hendriks ME, Bolarinwa OA, Wit FWNW, Brewster LM, Odusola AO, Rosendaal NTA, et al. Feasibility and quality of cardiovascular disease prevention within a community-based health insurance program in rural Nigeria. J Hypertens. 33(2):366–75.

[28] Hygeia Community Health Plan (HCHP) | The Center for Health Market Innovations [Internet]. [cited 2020 Jul 28]. Available from: https://healthmarke tinnovations.org/program/hygeiacommunity-health-plan-hchp

[29] Kuckartz DU. Udo Kuckartz Realizing Mixed-Methods Approaches with MAXQDA. :22.

[30] Corbin JM, Strauss A. Grounded theory research: Procedures, canons, and evaluative criteria. Qual Sociol. 1990 Mar 1;13(1):3–21.

[31] Heurtin-Roberts S, Reisin E. The Relation of Culturally Influenced Lay Models of Hypertension to Compliance With Treatment. Am J Hypertens. 1992 Nov 1;5(11):787–92.

[32] Pesantes MA, Diez-Canseco F, Bernabé-Ortiz A, Ponce-Lucero V, Miranda JJ. Taste, Salt Consumption, and Local Explanations around Hypertension in a Rural Population in Northern Peru. Nutrients [Internet]. 2017 Jul 5 [cited 2018 Mar 9];9(7). Available from: https://www.ncbi.nlm. nih.gov/pmc/articles/PMC5537813/

**81**

**Chapter 5**

**Abstract**

**1. Introduction**

**2. Classification**

dence and early retirement from life [7].

Visual Disability and Causes of

The World Health Organization (WHO) estimates, worldwide, approximately 1300 million people with a form of visual impairment. More than 314 million have a severe visual impairment. Of these, 37 million are blind and 124 million suffer from low vision. Eighty percent of all these cases are considered avoidable. The main causes of blindness from one country to another, in order of frequency, are cataract (39%), uncorrected refractive errors (18%), and glaucoma (10%). In Latin America and the Caribbean, the loss of vision in adults continues to be a public health problem. Blindness and visual impairment tombs have a remarkable impact on the socioeconomic development of individuals and societies and the prevention of avoidable visual disabilities in the long term in terms of attention to health care and social expenditures. Of all the organs of the body, the eye is more accessible to direct examination. The visual function can be evaluated by means of simple subjective tests. The same can be taken care of from an adequate primary care service.

**Keywords:** blindness, cataract, refractive errors, glaucoma, visual acuity

productivity in society, and negatively affect their quality of life [1–5].

significant economic burden for the individual, the family, and society [6].

The universal aging of the population is a global concern because of its association with degenerative diseases, which can cause disabilities in humans, limit their

In all societies, blindness has profound human and socioeconomic consequences. The costs of loss of productivity, rehabilitation, and education for the blind constitute a

Thus, it is interesting to know that total or partial opacification of the lens is the main cause of bilateral blindness and severe visual impairment represents about 48% of cases of visual impairment in the world and is known to have a multifactorial cause. In addition, it incapacitates the individual and increases their depen-

According to the WHO, visual function is subdivided into four levels: normal vision, moderate visual impairment, severe visual impairment, and blindness. Visual disability includes moderate and severe visual impairment and blindness [8, 9], see **Table 1**.

Preventable Blindness

*Mercedes Libeth Ramos Amador* 

*and Javier Eduardo Escober Torres*

## **Chapter 5**

[28] Hygeia Community Health Plan (HCHP) | The Center for Health Market Innovations [Internet]. [cited 2020 Jul 28]. Available from: https://healthmarke tinnovations.org/program/hygeiacommunity-health-plan-hchp

*Topics in Primary Care Medicine*

[29] Kuckartz DU. Udo Kuckartz Realizing Mixed-Methods Approaches

[30] Corbin JM, Strauss A. Grounded theory research: Procedures, canons, and evaluative criteria. Qual Sociol.

[31] Heurtin-Roberts S, Reisin E. The Relation of Culturally Influenced Lay Models of Hypertension to Compliance With Treatment. Am J Hypertens. 1992

[32] Pesantes MA, Diez-Canseco F, Bernabé-Ortiz A, Ponce-Lucero V, Miranda JJ. Taste, Salt Consumption, and Local Explanations around Hypertension in a Rural Population in Northern Peru. Nutrients [Internet]. 2017 Jul 5 [cited 2018 Mar 9];9(7). Available from: https://www.ncbi.nlm. nih.gov/pmc/articles/PMC5537813/

with MAXQDA. :22.

1990 Mar 1;13(1):3–21.

Nov 1;5(11):787–92.

**80**
