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Patient Education and Counseling xxx (2019) xxx–xxxContents lists available at ScienceDirect
Patient Education and Counseling
journal homepage: www.else vie r .com/ locate /pateducou
Illness representations and coping practices for self-managing
hypertension among sub-Saharan Africans: A comparative study
among Ghanaian migrants and non-migrant Ghanaians
Gertrude Nsorma Nyaabaa,b,*, Charles Agyemanga, Lina Masanab,c, Ama de-Graft Aikinsd,
Erik a Beune , Cristina Larrea-Killingere, Karien Stronksa
aDepartment of Public Health, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam University Medical Centres, Amsterdam,
The Netherlands
bBarcelona Institute for Global Health (IS Global), University of Barcelona, Barcelona, Spain
cMedical Anthropology Research Centre-URV Tarragona, Spain
dRegional Institute for Population Studies, University of Ghana, Legon, Ghana
eDepartment of Social Anthropology, University of Barcelona, Barcelona, Spain
A R T I C L E I N F O A B S T R A C T
Article history: Objective: Hypertension (HTN) control is a major obstacle among sub-Saharan African populations partly
Received 13 November 2018 due to poor self-management. We explored and compared how persons’ social and physical context
Received in revised form 2 April 2019 shapes their illness representations regarding HTN and the coping strategies they develop and adapt to
Accepted 5 April 2019 mitigate challenges in self-managing HTN.
Methods: A cross sectional multisite qualitative study using semi-structured interviews among 55
Keywords: Ghanaians with HTN living in The Netherlands and urban and rural Ghana. A thematic approach was used
Hypertension in data analysis.
Self-management
Coping strategies Results: Family HTN history, personal experiences with HTN and outcomes of using biomedical and 
Context traditional treatments shaped participants’ illness representations and coping strategies. Migrants and
Africans urban non-migrants modified medication schedules and integrated taking medication into daily routine
Migrants activities to cope with experienced side effects of taking antihypertensive medication while rural non-
Urban and rural Africans migrants used traditional remedies and medicines to mitigate experienced medication side effects and/
Patient views or in search for a cure for HTN.
Social support Conclusion: Contextual factors within participants’ social and physical environments shape their illness
Traditional medicine for hypertension representations and coping strategies for HTN though interactive phrases.
Medication adherence
Practice implications: Health professionals should harness the relationships within peoples’ social and
Dietary recommendations
Alcohol recommendations physical environments, encourage implementation of family-wide behavioural changes and involve 
Smoking recommendations family and communities in HTN treatment to enhance patients’ self-management of HTN. 
Physical activity recommendations © 2019 Elsevier B.V. All rights reserved.
Social and cultural norms and practices1. Introduction
Adequate hypertension (HTN) control considerably reduces the
risk of cardiovascular events [1–3]. Yet, HTN control remains a
major problem particularly among people of sub-Saharan African
(SSA) descent [4,5], partly because it requires a great degree of self-
management.* Corresponding author at: Gertrude Nsorma Nyaaba, Department of Public
Health, Amsterdam Public Health (APH) research institute, Amsterdam University
Medical Centres, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam,
The Netherlands.
E-mail address: g.n.nyaaba@amc.uva.nl (G.N. Nyaaba).
https://doi.org/10.1016/j.pec.2019.04.008
0738-3991/© 2019 Elsevier B.V. All rights reserved.
Please cite this article in press as: G.N. Nyaaba, et al., Illness representatio
Saharan Africans: A comparative study among Ghanaian migrants and n
10.1016/j.pec.2019.04.008Self-management is gaining global health attention as a major
component of chronic disease care, which involves placing the
patient in a central position [6] to undertake daily activities
surrounding alcohol intake, smoking, diet, weight control and
physical activity [6,7] to manage and control their condition,
improve their health status and reduce complications [7,8].
Context, as a component of self-management [9], potentially
influences peoples’ HTN illness representations and self-manage-
ment practices for HTN. While studies suggest that contextual
factors such as environmental and socioeconomic factors, may
contribute to the increasing prevalence of HTN among SSA
populations living in different contexts [10,11], their influence
on self-management practices towards HTN control remains
under-researched.ns and coping practices for self-managing hypertension among sub-
on-migrant Ghanaians, Patient Educ Couns (2019), https://doi.org/
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2 G.N. Nyaaba et al. / Patient Education and Counseling xxx (2019) xxx–xxxFurthermore, health systems and healthcare access differ for
rural and urban SSA populations living in SSA and SSA populations
living in high-income countries (HICs). Many people living in SSA
experience geographical and financial barriers in accessing high
quality health care while SSA migrants in HICs have better access to
high quality health care [12]. Structural barriers, which hinder HTN
management in SSA [12–15] are compounded by lay perceptions
and cultural practices, which influence peoples’ health behaviour.
SSA migrants in HICs deal with double socio-cultural influences
from SSA and their countries of residence, which may influence
their illness representations and self-management practices. A
review categorised living with a chronic disease as a component of
the self-management process that includes coping or making
modifications to enable persons live with chronic conditions [16].
Evidence shows that chronically ill persons’ coping strategies can
be positive and/or negative, are multifaceted, and used to navigate
challenges presented by perceived problems [17]. Hale and
colleagues suggest that peoples’ construct of illness are influenced
by their knowledge and experiences, which are continuously
tested and adapted via coping strategies [18]. Studies have
explored how patients develop strategies to cope with how they
conceptualise their chronic conditions, their practical experiences
and their health outcomes [19–21] but not in HTN. Understanding
the coping strategies that SSA populations develop to mitigate
challenges in self-management may provide entry points for
improving HTN control among SSA populations.
This study aimed to explore and compare how context shapes;
a) hypertensive migrant and non-migrant Ghanaians’ illness
representations and b) the coping strategies that they develop
and adapt to mitigate challenges with self-managing HTN.
2. Methods
A cross sectional multisite qualitative study using a semi-
structured topic guide to collect data from a total of 55 purposively
sampled hypertensive Ghanaian migrants living in TheFig. 1. Study me
Please cite this article in press as: G.N. Nyaaba, et al., Illness representatio
Saharan Africans: A comparative study among Ghanaian migrants and 
10.1016/j.pec.2019.04.008Netherlands and non-migrant hypertensive Ghanaians living in
rural and urban Ghana. Verbal and written or thumb-printed
informed consent was sought from participants prior to conduct-
ing digitally recorded audio interviews. Interview time ranged
from 30 to 77 min. Fig. 1 presents a detailed description of the
study methodology.
2.1. Data analysis
The first author reviewed all interview transcripts and using a
thematic approach, analysed the transcripts in constant compari-
son to generate initial codes in QRS Nvivo 11 Pro guided by pre-
identified and emerging themes. The first, third and last authors
reviewed the initial codes prior to active data coding of transcripts.
We paid emphasis to how persons with HTN developed strategies
to cope with challenges with self-managing HTN and how context
influenced such coping strategies. Quotations were grouped under
codes and sub-codes and reviewed with all co-authors. Patterns
and linkages were explored in-depth to identify areas of
convergence and divergence between the three subcultural
groups.
3. Results
Table 1 shows the background characteristics of participants.
3.1. The context of diagnosis and treatment
This theme explores background factors that influence partic-
ipants’ illness representations. Sub-themes 1a and 1b in Box 1
presents supporting quotations.
3.1.1. Discovering hypertension
All participants reported being diagnosed with HTN at health
facilities while seeking healthcare for physical symptoms such as
dizziness and headaches. Only migrants additionally reportedthodology.
ns and coping practices for self-managing hypertension among sub-
non-migrant Ghanaians, Patient Educ Couns (2019), https://doi.org/
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G.N. Nyaaba et al. / Patient Education and Counseling xxx (2019) xxx–xxx 3
Table 1
Characteristics of participants selected for analysis (N = 55).
Migrants Urban Ghana Rural Ghana
(n = 20) (n = 15) (n = 20)
Socio-demographics
Sex (Male) 11 8 12
Age range 46-73 40-62 30-71
Educational completed
Elementary or less 7 7 16
Lower vocation or lower 4 2 2
secondary
Intermediate vocational or higher 6 3 2
secondary
Higher vocation or university 3 3
Employment Status
Employed manual 12 11 11
Employed formal 4 4
Retired 2 3
Unemployed 2
On social benefits 6
Relationship status
Married/registered partnership/ 14 9 17
cohabiting
Unmarried 1
Divorced or separated 5 4
Widow/widower 1 2 2
Religion (Christian) 18 14 9
Ethnicity
Akan/Fante/Ga/Ewe 20 15 1
Dagbani/Gonja 10
Gurune / Nankani 9
Comorbidity (Diabetes, asthma, 15 5 7
high cholesterol
Health insurance status (yes) 20 15 20
HTN Characteristics (self-reported)
Family history of HTN (Yes) 18 10 10
No of years living with HTN (3-36) (4-17) (2-15)
(range)
HTN controlled (Yes) 8 4 7
Smoking (yes/ quit smoking) 4 1 0
Physical activity (Yes) 9 7 15
Alcohol consumption
Never 6 2 7
Occasional (social events) 5
Frequent (weekends) 5 8 8
Regularly (daily) 4 5 5finding out about their HTN status during routine health checks.
Economic difficulties and experience of traumatic events such as
death of a relative resulting in feelings of anxiety were commonly
reported by non-migrant rural participants as causes of their HTN,
locally called Zhiduli [blood gone high] in Dagbani or Zeemzore ba-
a [blood is plenty] in Gurune (Box 1a). Non-migrant urban
participants additionally reported family history as a cause of their
HTN. Migrants commonly reported stress resulting from working
multiple jobs, paying taxes, and perceived discrimination as causes
of their HTN (Box 1a). While only migrant females reported
developing HTN during pregnancy, only migrant men mentioned
smoking and/or alcohol consumption as causes of their HTN.
3.1.2. Reactions to diagnosis and consequences
Most participants reported being frightened, anxious or
worried about disability or premature death after initial HTN
diagnosis (Box 1b.). While migrants’ fears were alleviated by co-
workers and by their own long-term experiences living with HTN,
non-migrant urban participants reported that, health personnel
and other persons living with HTN helped relieve their initial fears.
Non-migrant rural participants commonly reported disbelief in
diagnosis and non-adherence to HTN treatment, resulting in some
participants experiencing stiffness of their limbs and dizziness.
Both migrant and non-migrant participants who reported lessPlease cite this article in press as: G.N. Nyaaba, et al., Illness representatio
Saharan Africans: A comparative study among Ghanaian migrants and n
10.1016/j.pec.2019.04.008anxiety during initial HTN diagnosis had lived with a relative or
friend with HTN. Migrants who were diagnosed during routine
health checks did not consider HTN as “serious” and reported being
non-adherent to HTN treatment causing some of them to develop
stroke (Box 1b). Both migrant and non-migrant participants
indicated that health professionals informed them that these
experiences resulted from their non-adherence to HTN treatment.
3.2. Self-managing hypertension
This theme explores participants’ self-management challenges,
coping strategies developed and adapted to mitigate specific
challenges and facilitators for self-management. Boxes 2 and 3
present quotations based on the sub themes below.
3.2.1. Medication adherence
Participants reported challenges to medication adherence,
which they addressed by modifying prescribed medication dosage,
integrating taking HTN medication into routine activities and long
periods of medication non-adherence. Among non-migrant rural
participants, a key barrier to medication adherence was the fear of
developing other diseases because of long-term use of antihyper-
tensive medications. They added that the perception that HTN was
controlled, young people should not have HTN and taking
antihypertensive medication hinders the curative aspects of
traditional medicine were common reasons for medication non-
adherence (Box 2a). They reported at least, a month of medication
non-adherence and only taking medication when they experienced
perceived HTN symptoms. To avoid forgetting to take antihyper-
tensive medicines, migrants and non-migrant urban participants
commonly reported integrating taking their medication into daily
routine activities such as during morning ablutions, prior to
sleeping and during meals. Long distance journeys also reportedly
made it difficult for migrant and non-migrant urban men to self-
manage their medication because of medication shortages. They
coped by placing medicines in their travel bags and/ or used
traditional remedies such as chewing bitter kolanuts (a caffeine-
containing nut) or a clove of garlic daily, which they believed
helped to manage HTN. Among migrant and non-migrant rural
men, the experience of sexual weakness was commonly reported
to negatively affect their relationships/ marriages (Box 2a) and
they coped by altering medication dosage and/or schedule,
including not taking the medicines that they perceived caused
such side effects. While migrant men added that they took
antihypertensive medicines only in the mornings instead of twice
daily, non-migrant rural men used traditional medicines and/or
remedies such as chewing bitter kolanuts or dawadawa (fermented
African locust beans) to manage HTN. Among non-migrant urban
women, medication side effects such as tremors in the hand and
frequent urination were reported as hindering their ability to
engage in their daily activities. They coped by taking only
medicines perceived not to provide such side effects or only
taking medication at night instead of twice daily (Box 2a).
Frequent stock outs of antihypertension medications under the
National Health Insurance (NHIS) was mentioned by non-migrant
urban and rural participants as a challenge to medication
adherence, but not by migrants. While non-migrant urban
participants mitigated this barrier by out-of-pocket payments
for medicines, non-migrant rural participants reported periods of
between two to 12 weeks of medication non-adherence during
which periods, they used remedies like chewing bitter kola and
dawadawa (Box 2a).
Among all participants, coping strategies evolved from personal
experiences living with HTN. Both migrant and non-migrant rural
participants indicated that experiences using antihypertensive
medication and/or trying traditional medicines/remedies enabledns and coping practices for self-managing hypertension among sub-
on-migrant Ghanaians, Patient Educ Couns (2019), https://doi.org/
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Box 1. Diagnosis and treatment – Participant quotes.
Sub-groups a. Discovering HTN b. Reactions to initial diagnosis and consequences
Migrants “I was asked to go for a general check-up, “Hum, that day I was really nervous . . . afraid . . . maybe
and they said that I was diabetic, and I also one of my children will get it . . . For 6 months, I will sit
have it (HTN) " IDI-Male-11 down quietly at work and my chef . . . he said he too has it
and diabetes . . . he told me about his sickness, and it
made me better.” IDI-Male-05
"We think a lot since we came into this “I was not surprised because I had seen it, because of my
country. The way they treat me at the work mother and father, I had seen it before, and I wasn’t
place, someone will say nonsense to me, scared.” IDI-Female -04 " I thought it was not a serious
and I cannot reply . . . We came to work for sickness but when my hand died, I saw that it can kill" ID-
money . . . I close from my 1 st work, I do Male-19 “I was still smoking at the check-up . . . I was
cleaning for 2.5 hours . . . you need to pay getting up and I fell . . . this hand got dead so . . . my wife
your taxes and bill.” IDI-Female-20 came and helped me. My child called the ambulance and it
came and picked me to the hospital. From that time till
today I have not missed the medicine . . . so after I had the
stroke” IDI-Male-11
Non-migrant “I didn’t have pressure . . . It was when my "It didn’t worry me . . . because my father was
urban mother died . . . I was shocked how my hypertensive; he used to say it’s because of thinking all the
mother died and I am first born so I had to time . . . You cannot work like before because of tiredness
take care of my younger brothers and so money for the house is small . . . that’s why it kills a lot
sisters’, so I was always thinking . . . I was of people” IDI-Female-11 "I was afraid. I didn’t agree . . .
feeling dizzy and my head too, so I went to the doctor told me that many people have lived with it for
the hospital and they told me.” IDI- Female- many years . . . I meet some of people here[hospital] . . .
01 “I had a severe headache and I really felt one told me that he had it for about 25 years, and I thought
dizzy . . . so I came [health centre] and they oh it’s not a killer disease.” ID-Male-03 “When they first told
said I had pressure.” IDI-Female-07 me, I didn’t believe so I did not mind but one day, the
dizziness made me fall . . . I almost died so when the
doctor said it because of the blood, I try to do everything to
control it since then.” IDI-Male – 05
Non-migrant “When I was told about it [accident], I “They say it is dangerous . . . It can make your body die
rural became frightened and I fell . . . I was sent [stroke] and you cannot do anything so I was afraid . . . I
to the hospital . . . the doctor said that I pray that they [children] don’t get it . . . I used to trade, but
have Zhiduli [blood gone high] . . . he now I don’t because of my sickness . . . they [children] give
gave me those medicine and told me I will me to eat [upkeep].” IDI- Female-12 “The doctors said I am
be taking it till I die. “IDI-Female-06 having it, but I said no, I was not having it because I was
active . . . now, it’s as normal sickness that attacks
anybody . . . I don’t think it can attack them [children]” IDI-
Male -07
“ . . . sometimes I go for malaria treatment, "It about 12 to 14 years, I developed some stiffness in one of
but the headaches were still there . . . I my hands. It was very stiff such that I couldn`t rest it on
came here and they told me Zhiduli [blood anything I went back to hospital again. It was after that, that
gone high] sickness . . . . children come for I started not missing my medicine and stop the salt and
money to pay for something in school and sugar and meat.” IDI-Male-06 “When I first came and they
we cannot give them then my blood goes told me, I said I don’t have Zeemzore ba-a [blood is plenty]
up . . . .10 children . . . thinking caused the . . . I was feeling fit within me, so I took it for only one
blood to go high like that.” IDI-Female-05 month and I stopped it . . . then the dizziness came again
so I had to accept it.” IDI-Female-02them to develop and adapt their coping strategies for HTN. Both
migrant and non-migrant participants reported family and
community support though reminders to take medication as key
enablers to medication adherence. While among migrants and
non-migrant urban participants, adult children reminded them to
take medication via phone calls, among non-migrant rural
participants, adult children facilitated access to medication by
accompanying them on their routine visits or acquiring their
medicines for them.
3.2.2. Adherence to dietary recommendations
Adherence to dietary changes such as salt reduction was
reportedly a challenge as participants did not enjoy meals because
meals were tasteless. To mitigate this, male migrants reported that,
aware of their family’s disapproval, they surreptitiously used saltPlease cite this article in press as: G.N. Nyaaba, et al., Illness representatio
Saharan Africans: A comparative study among Ghanaian migrants and 
10.1016/j.pec.2019.04.008while non-migrant urban and rural men reported that their
partners/spouses used alternatives such as Maggi cubes/sauce to
prepare their meals (Box 2b). Non-migrant urban participants also
reported that due to their economic activities, they ate in public
places where meals were not prepared considering dietary
modifications. While migrant females reported that they coped
with this by separating their meals from family-wide meals, non-
migrant rural females reported that they often forgot to do this.
Non-migrant rural females added that because family members
could not eat tasteless meals and did not understand HTN,
preparing meals with little or no salt caused disagreements with
their family relations (Box 2b). Some participants' experiences
living with family relations with HTN reportedly enabled them to
cope with changes in diet, as they were already familiar with such
dietary modifications (Box 2b).ns and coping practices for self-managing hypertension among sub-
non-migrant Ghanaians, Patient Educ Couns (2019), https://doi.org/
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Box 2. Self-managing hypertension– Participant quotes.
Sub-groups a. Medication Adherence b. Adherence to dietary recommendations
Migrants “I take it in the evening after I eat my food . . . I do “My wife will not cook this rich food for
not pay anything. You can even call them (health you . . . I add some magi sauce because I
professionals) by phone . . . they give you some cannot eat . . . sometimes, I hide and add
instructions and they will tell you to go to the small salt because all die be die . . . she
pharmacist and collect them” IDI- Female – 01 always hides the salt (laughing) . . . she has it
[HTN] too so now the children are not here, she
cooks the way the doctor says.” IDI-Male-08
“It’s [medication] always in my bathroom . . . so I “Before, she cooked separately, or I cook for
take it after I have brushed my teeth . . . it makes myself but later you know cooking is hard, so I
me weak so I take it only in the morning so that my let them cook . . . I hide and eat their food
body can be strong in the evening (laughing)” IDI- sometimes . . . You know her children, they
Male-09 will be talking, and you cannot tell them to shut
up here (laughing).” IDI-Male- 19
“Here is different . . . even my daughter doesn’t “We don’t use salt . . . My husband and
ask . . . in Africa when you’re sick, your relatives mother have it many years before my own, so I
will attend to you.” IDI- Female -08 am already used to cooking without salt, so we
always eat without salt.” IDI- Female -07
“Sometimes I travel to Ghana. I take the “It is hard, but my wife is also a patient . . .
medicines with me, but it can happen that I will She always cooks so if you look in this house,
stay longer, and the medicine is finished but that there is no salt . . . I have no choice but to eat
one is not a problem . . . just one week or the food like that.” IDI-Male-10
two . . . I just eat and drink because the stress is
less at home.” IDI-Male-11
Non-migrant “I heard that if you take the doctor’s drugs too “It’s hard, salt makes food nicer and the taste
urban much, it will destroy your kidney or womb or changes if there is no salt in the food so I add
because you to get a different disease so it is not salt to my meat when frying but I put in plenty
always I take the medicine . . . my hands get a of the jumbo magi so that the soup will be
little bit stiff and the urine is too much . . . where tasty.” IDI- Female -08 “This one is always
will I be urinating like that in town? hard. You know we work in the market, so you
(Laughing) . . . If I take some today, I won’t take it always come home late . . . we eat in town
on the next day for like a week." IDI- Female -09 and they don’t cook food for people like us.”
“sometimes too, you cannot get all the medicine IDI-Male-02
so how will you take it? This disease is for the
rich . . . the government pays some and you
have to pay some . . . the expensive drugs that
they write for you to buy outside.” IDI- Female -10
“I can’t take all of them . . . I take the small ones “Hum, it was not easy. My wife cooks my food
when I don’t go anywhere because I can easily go separate because of what happened
and urinate . . . you know there is no place to [paralysed hand] but the food is not nice if
urinate like that in the market and I cannot leave there is no salt, so I just wait and when I get to
my things and be going to urinate like that in the the farm, I get my plantain and do something
market . . . they are by the bed so I will take when small to eat . . . she tries but the mouth
I am going to sleep” IDI- Female -01 doesn’t like (laughing).” IDI-Male-08
“Oh, I didn’t understand it will take me to this time “I cannot say I don’t eat salt all the time. when I
[chronic]. I thought it will go [cure] so I took cook, I don’t use salt because my father had it,
medicine for some time . . . I didn’t take it so I am used to it so my children to eat like that,
after . . . I used the herbal medicine in the but you know I trade so when I am hungry in
beginning but it [HTN] didn’t all go . . . it [BP] was town, I buy food and eat and that one has salt.”
always up, the nurse advised me so now, I don’t IDI- Female -06
joke with my medicine.” IDI-Male-11
Non-migrant “All the time . . . it brings sickness . . . so I stop for “When they remember, they fetch my soup
rural some time . . . maybe a moon [month] or when the before they put the salt . . . they add small
head is paining again, I take it again. They give me ‘Anapuna’ [magi] so I can also eat . . . ” IDI-
free with my paper [NHIS]. If it were not there, they Male-10 “It’s not easy at all (laughing). I fetch
would tell me to go to PK pharmacy for it with my my soup separate before I add the salt to the
paper. If he too doesn’t have, I go and come back rest . . . You don’t have appetite to eat
another time” IDI- Female -06 “The place [health because uh huh, no taste and the Amani and
facility] is far so the big ones [children] in school, even the other foods have small salt when we
when they come home . . . they take me to the dry them so it’s not easy.” IDI- Female -03
hospital.” IDI- Female -10
“It was affecting my strength [sexual weakness], “In the beginning, my wife tried it, but we
and my wives said I have girlfriends [laughing] couldn’t eat so she has been using magi so
and that is why I did not have strength again that we can eat . . . you know my work is in
so . . . I just stopped” IDI-Male- 06 town, so I eat in town so as for this one, it is
hard.” IDI-Male-02
“My mum said I was too young to be taking this “Cook without salt? Eh! You want them to sack
medicine for life so I stopped . . . the drugs also me from my husband’s house. In my house, I
causesexualweaknesssopeoplewillgoaroundand serve 14 bowls . . . I am not coming from a
Please cite this article in press as: G.N. Nyaaba, et al., Illness representations and coping practices for self-managing hypertension among sub-
Saharan Africans: A comparative study among Ghanaian migrants and non-migrant Ghanaians, Patient Educ Couns (2019), https://doi.org/
10.1016/j.pec.2019.04.008
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(Continued)
Sub-groups a. Medication Adherence b. Adherence to dietary recommendations
be saying you are a weak man. Meanwhile we are in small house [large family size] . . . we cook in
Africa.Ayoungmancannotbeweak.” IDI-Male-13“I turns; I cannot say because I do not eat salt,
get the drugs here with the card [NHIS] . . . they too should not eat salt . . . Where are the
sometimes if the drugs are not there . . . they write ingredients to cook like that? So, I fetch one
for me to go and buy . . . if I don’t have the money, I ladle down and sometimes, I forget and add
wait . . . maybe one moon [month]” IDI-Male-03 salt.” IDI- Female -123.2.3. Adherence to recommendations on physical activity, alcohol
consumption and smoking
Migrant and non-migrant participants indicated that cultural
norms around physical activity hinders adherence to its recom-
mendation. Among migrants, while riding bicycles in Netherlands
is common practice, it is perceived as a sign of poverty in their
cultural background (Box 3a). Routine use of a sports facility/gym
was not considered a cultural habit, which was reportedly
compounded by working multiple jobs because they are economic
migrants. Non-migrant urban and rural participants emphasised
that running (jogging) was uncommon in their communities with
such activities considered odd. They reportedly engaged in
physically intensive occupations such as farming and particularly,
non-migrant rural participants reported walking long distances as
a coping strategy (Box 3a).
Moreover, while social and cultural practices around alcohol
consumption reportedly hindered participants’ adherence to
alcohol recommendations, they enabled adherence to recommen-
dations for smoking. Participants explained that alcohol consump-
tion was useful for relieving stress and was considered as an
intrinsic part of their social events such as funerals, naming
ceremonies and weddings. Migrants coped by avoiding social
events in HICs where social events are less common compared
with the social events they are required to attend when they travel
to Ghana (Box 3a). When migrants travelled to Ghana, they
reportedly coped by consuming less alcohol during such events
although the frequency of alcohol consumption was reportedly
higher in Ghana because migrants felt less stressed when in Ghana.
While some non-migrant rural men did not regard traditional
alcoholic homemade brews such as "pito" as strongly alcoholic,
others reportedly coped by avoiding social events they perceived as
less important (Box 3a). Some non-migrant rural females reported
being able to cope with alcohol and smoking recommendations
because they were practicing Moslems.
Cultural and religious norms regarding smoking were strong
enablers for adherence to smoking recommendations among all
participants. The few male migrants, who had ever smoked,
reported an ease in smoking cessation. (Box 3a).
3.2.4. Adherence to HTN treatment
The fear of taking HTN medication lifelong was reported by
participants, particularly migrants and non-migrant rural
participants as a key reason for using traditional medicines
purported to manage and/or cure HTN. Migrants commonly
reported a belief that traditional remedies helped manage HTN
and indicated that they got information regarding remedies
from relatives, friends and the internet. Herbs, roots, spices
such as garlic, ginger and Prekese (Tetra pleuratetraptera), and
leaves such as dandelion and pear leaves were mentioned as the
main ingredients of traditional remedies. Migrants reported
concurrent use of herbal remedies and antihypertensive medi-
cations because they believe such remedies are harmless becausePlease cite this article in press as: G.N. Nyaaba, et al., Illness representatio
Saharan Africans: A comparative study among Ghanaian migrants and 
10.1016/j.pec.2019.04.008they are natural (Box 3b). Non-migrant rural participants stated
that traditional medicine could cure HTN completely particularly
when one had not received any injections from biomedical
treatments (Box 3b). They explained that traditional medicines
were made from dawadawa, plant leaves (neem leaves and\or
bitter leaves and\or moringa) and the roots and\or barks of trees.
Family, friends, community members and radio were the main
sources of information on traditional medicines and remedies
among non-migrant rural participants. Migrant and non-migrant
rural participants commonly reported the chewing of bitter
kolanuts and garlic to control HTN.
3.2.5. Accessing information for self-managing HTN
Both migrants and non-migrants reported the lack of HTN
information at health facilities as a challenge to self-managing
HTN. While migrants attributed this to time constraints and
language difficulties in the Netherlands, non-migrant urban and
rural participants attributed this to inadequate numbers of health
personnel and large crowds at health facilities resulting in shorter
patient-provider contact time (Box 3c). Non-migrant rural
participants further explained that because most of them were
not formally educated, they could not read print/electronic HTN
information. Both migrants and non-migrants got HTN informa-
tion from relatives who had experienced HTN, radio and\or
television with migrants accessing additional information from the
internet.
4. Discussion and conclusion
Our results provide in-depth insights into HTN self-manage-
ment practices among three cultural sub-groups of SSA migrants
and non-migrant persons via the influence of context and coping
strategies on their beliefs and practices. They show that patients
adopt and adapt their coping strategies based on the barriers that
they encounter, and the results of evolving treatment options
utilised. The findings show that SSA persons with HTN self-
management practices and coping strategies reflect key elements
of Leventhal’s Common Sense Model of self-regulation (CSM)
theoretical framework, which recognises changes in behaviour
that influence adherence and advocates that patients develop their
illness representations through dynamic, multi-level interactive
processes, which guides their self-management practices of
current and future health conditions [22–24].
4.1. Discussion
Our findings show that persons with HTN illness representa-
tions are influenced by family history of HTN and/or experiences
with HTN, the use of treatment options, and structural factors,
which shape the strategies they develop and adapt to cope with
HTN. While the results show commonalities in illness representa-
tions and coping strategies, the differences observed perhapsns and coping practices for self-managing hypertension among sub-
non-migrant Ghanaians, Patient Educ Couns (2019), https://doi.org/
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PEC 6244 No. of Pages 11
G.N. Nyaaba et al. / Patient Education and Counseling xxx (2019) xxx–xxx 7
Box 3. Self-managing hypertension– Participant quotes.
Sub-groups a. Adherence to b. Adherence to HTN treatment c. Accessing information for
recommendations on physical self-managing HTN
activity, alcohol consumption
and smoking
Migrants “They see you riding a bicycle “I take my medicines because I have “You know the doctors here;
and think, “Oh why is this big taken it for long . . . I am careful of 10 minutes . . . there is no
person riding bicycle?” . . . what I eat, and walk time to ask questions . . . I
you feel shy because we do not around . . . sometimes too I chew speak the Dutch small, so it is
do that in Ghana . . . If you the kola . . . that one is natural . . . small small . . . sometimes I
have the money, you can go Only when my pressure is coming don’t hear anything . . . oh,
and pay and exercise but we up, like the headaches, dizziness, if people talk, you know? People
came look for money, so the you chew the bitter kola, it comes who have had this sickness
work is too much no time.” IDI- down. I can feel it . . . I get it from the always talk about like the food,
Female -20 African shop, and it is natural . . . " drinking and thinking . . . ” IDI-
“The exercise? I walk . . . I IDI-Male-13 “I used to have severe Male-15
don’t even know how to ride headaches . . . So my uncle advised
[bicycle] . . . my me to try the bitter kola . . . it is not
grandchildren, I take them to expensive . . . 3 years now, my
park too to play so I can walk pressure does not go up and down.”
small . . . If my daughters are IDI-Male-16
around, they don’t want me to
drink so I drink like one or two
bottles and programs here are
not many like [in] Ghana so I
think I have reduced it. “IDI-
Male-08
“I was still smoking . . . it was “When they first told me, I was “You know we listen to radio
not difficult to stop . . . we worried . . . , some friends told my on the [inter] net . . . we hear
don’t smoke at home. It’s here, husband about some Ghana about the medicines from the
I started smoking . . . when I medicine that helped them . . . . I Ghana FMs . . . oh, you family
had this sickness, they said it bought some and my husband went member can buy and send to
was because of the smoking so to Ghana and brought some for me to you if you send the money.”
anytime I smoked, my friends drink like tea . . . . herbs and moringa IDI-Male-01
will be looking at me like I killed and they said I should add ginger and
myself (laughing) . . . I garlic . . . . I took it with the
stopped after the stroke. It was medicine . . . it was natural, so I
not easy, but my children are didn’t inform him [doctor] . . . ” IDI-
young, so I had to do it Female – 08
(alcohol).” IDI-Male-11
Non-migrant “Can you go to a wedding or “I don’t take the pressure drugs days “The doctor told me when I
urban even funeral and not drink? I take the herbal medicine . . . . I came that I should eat
You drink small.” IDI-Male-15 didn’t get any problem with the well . . . he didn’t tell me what
pressure when I was taking it.” IDI- foods I should not eat and you
Female -10 know I didn’t go to school like
“the Saturday programs are “I tried because they said it will cure you (laugh) . . . It’s the TV and
many and you have to attend it . . . . he said I can take both my friends who told me about
them so imagine that you drink because it is natural, but I should take the salt, and the drinking.” IDI-
one or two bottles and you the herbal one hour after taking the Male- 15 “Later the nurse
attend two or 3 hospital one . . . I didn’t see any explained about the
programs . . . you see? It is not difference, so I stopped . . . . like 3 sickness . . . . I heard the salt
easy . . . I cannot just get up years now” IDI-Male-09 " oh, I tried it and the alcohol from my
and be running around. People (traditional medicine) but my relative because she knows I
will think there is something daughter said if I take the hospital drink (laughing)"IDI-Male-12
wrong with me so that one, let medicine it will be fine because she
me say the walking to the farm does not trust these herbal
and the farm work is the medicines . . . since I have been
exercise” IDI-Male-05 “I have taking my medicine in the
never smoked . . . you know evening . . . I think I am fine." IDI-
we don’t Female -01
smoke . . . everybody knows
you, you cannot
smoke . . . People will say bad
things about you. “IDI-Male-05
Non-migrant “You know northern culture. “What kind of sickness cannot be “They did not tell me anything
rural You are poor that is why you cured? My relative told me if I chew about food or something. Only
take bicycle. If I get up and start the bitter kola and the dawadawa too, that I should not be thinking
running by the roadside, it would help so I have been doing too much . . . It is the wireless
people will talk. It is that and I do not have any [radio] that I heard that the
strange . . . the road is not problem . . . No! I heard that the sickness does not like alcohol.
Please cite this article in press as: G.N. Nyaaba, et al., Illness representations and coping practices for self-managing hypertension among sub-
Saharan Africans: A comparative study among Ghanaian migrants and non-migrant Ghanaians, Patient Educ Couns (2019), https://doi.org/
10.1016/j.pec.2019.04.008
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PEC 6244 No. of Pages 11
8 G.N. Nyaaba et al. / Patient Education and Counseling xxx (2019) xxx–xxx
(Continued)
Sub-groups a. Adherence to b. Adherence to HTN treatment c. Accessing information for
recommendations on physical self-managing HTN
activity, alcohol consumption
and smoking
good, so we walk to town and Dagbani medicine will not work well Some of us did not go to
the farm too is exercise or?” if I mix them, so I do not mix school so it’s the wireless we
IDI-Male- 06 them . . . hospital medicine was hear things. They speak
“It’s difficult to go out with made from herbs like our local Dagbani . . . ” IDI-Male-09
friends . . . weekends; it’s medicine.” IDI- Female -03 “I took the “They don’t tell us what to
always hard not to drink. The hospital medicine but no changes so eat . . . They said I should go
boys look at me funny so I one woman has it [HTN] . . . at a and see the food man
drink small . . . pito is just like funeral . . . she said I should try. It is [dietician] . . . he too is only
water . . . when people see called "miszingoro" [male/bitter one, so the place is always
you running around, they see kolanuts] . . . I took that for the crowded.” IDI- Female – 07
you as strange and me, some whole week . . . I went they took my "the hospital people are always
people told me I should get a BP and they say it is normal . . . I busy . . . My elder brother had
job instead of running around changed a hospital to check . . . the it and I took care of it, so I went
aimlessly . . . you know town BP is normal, so I stopped the and greeted the same
is far so I walk to town and hospital medicine till now . . . I chew medicine" IDI-Male-05
back.” IDI-Male-13 “It is not it.” IDI- Female -12 “oh, when they
hard because you know I pray told me, I didn’t believe . . . .roots,
[moslem] so people will talk if I neem leaves and dawadawa . . . add
drink alcohol or even smoke” garlic and boil . . . let it cool before I
IDI- Female -05 “I drink . . . 1 started drinking . . . if they haven’t
bottle of beer when I close injected you with their medicine
[work] . . . to remove the work [hospital] then it can be cured with
stress . . . pito, it is not that the Dagbani medicine . . . .It is one of
much alcoholic so that one is my relative . . . that I should stop the
nothing.” IDI-Male-06 “When I white man’s medicine and take the
forget they always make me "Dagbani medicine" . . . when I
remember . . . My wives stopped taking the white man’s
prepare my food separate . . . medicine my strength came back.”
my children always ask, “have IDI-Male-05 “I thought I was going to
you taken your drugs?" . . . the die . . . They said I will take it till I die
older children take me on so I took it and the dizziness
motor [motorbike] to get the stopped . . . I greeted Dagbani
hospital when I want to go medicine to cure it . . . you have to
there “IDI-Male-08 keep trying other ones and if God
blesses, you will get good health.”
IDI- Male-03suggests that contextual factors influence their illness represen-
tations and coping strategies.
Similar to other studies conducted among SSA populations,
HTN is perceived to be symptomatic [15,25,26] and biomedical
treatment used to diagnose and manage perceived HTN symptoms.
This provides an entry point for provider-patient interaction to
intensifying health literacy efforts on HTN and developing patient-
led strategies for coping with self-management challenges, which
could enhance patient practices to control HTN. Particularly in HICs
where SSA migrants have access to early diagnosis, this entry point
is critical to preventing HTN related complications.
Difficulties in accessing medications was only reported by non-
migrants, which suggests that contextual factors influence patient
practices towards medication adherence. Poor HTN medication
adherence among African Americans has been attributed to
contextual factors [27] with studies in southern Ghana reporting
frequent stock-outs of antihypertensive medicines under the NHIS
as key factor for the poor HTN medication adherence [14,28–31].
These factors potentially shape the coping strategies that non-
migrants develop. For instance, in an area with the highest poverty
and lowest literacy rates in Ghana [32–34], rural participants used
traditional remedies during medication stock outs because ofPlease cite this article in press as: G.N. Nyaaba, et al., Illness representatio
Saharan Africans: A comparative study among Ghanaian migrants and 
10.1016/j.pec.2019.04.008financial difficulties and a belief that HTN can be cured and/or
managed traditionally [15]. Urban participants, however, paid out
of pocket for antihypertensive medicines possibly because the
numerous HTN studies conducted in southern Ghana have
informed health delivery practices by providing contextual
evidence on HTN [35–40], empowered health personnel with
HTN information and training [35] and informed the institution-
alisation of specialised HTN clinics, which emphasis patient
education and consequently better understanding of HTN among
non-migrant urban participants. It is also plausible that the belief
in the curative abilities of traditional medicine for HTN is fading
because, although traditional medicine is used for primary health
care needs by over 70% of people in Ashanti Region [41], urban
participants did not report any traditional medicine use. It is also
likely that after initial diagnosis and traditional medicine use for
HTN cure, urban participants did not observe any improvements
and subsequently discontinued traditional medicine use.
While frequent urination was not a reported challenge to
migrant females HTN medication adherence, it was a key challenge
for females in Ghana because it is related to access to basic facilities
in people’s physical environments. Most non-migrant females are
traders in market places and on major commercial streets wherens and coping practices for self-managing hypertension among sub-
non-migrant Ghanaians, Patient Educ Couns (2019), https://doi.org/
G Model
PEC 6244 No. of Pages 11
G.N. Nyaaba et al. / Patient Education and Counseling xxx (2019) xxx–xxx 9access to public sanitary facilities are limited. This side effect
presents a nuisance they are keen to avoid by modifying their
medication and shows how the social and physical environments
influences people with HTN’s health practices in LMICs.
Consistent with findings among Nigerians [12], social and
cultural norms concerning behavioural practices influence
patients’ self-management practices. For instance, in this study,
social norms were found to discourage smoking and this influence
persisted even with migration to HICs. These cultural norms,
however, hinder adherence to recommendations for physical
activity and alcohol consumption. For instance, despite jogging/
running and riding of bicycles being social norms in HICs, some
migrants found it difficult to take up these activities because of
their cultural perceptions regarding these activities.
Using alternatives for salt as a coping strategy has serious
implications for HTN control, as alternatives such as magi cubes
and/or sauce are high in sodium content, having similar effects on
BP. Interestingly, migrant men reported surreptitious salt use in
order to avoid disapproval of family members living with them.
This highlights the influence of family on patient practices and
suggests potential changes in the kinship structure of African
migrants living in HICs where migrant men develop coping
strategies to navigate adherence to behavioural changes facilitated
by family members. In general, men with HTN appear to have more
partner and/or family support in coping with implementing
dietary changes compared with their female counterparts. Rural
women with HTN also face gender related barriers in adhering to
dietary recommendations possibly due to cultural roles where
women are caregivers during ill health and are responsible for
cooking and housekeeping. While, this presents an apt opportunity
to implement dietary changes that could contribute to HTN control
and reduce family members’ risk of developing HTN, this
opportunity is hindered because family members do not recognise
their own risk. This is more evident when women, particularly
rural women, live with their extended family where cooking and
housekeeping is communal, requiring women to take turns
cooking for large families. As an important aspect of family life,
introducing dietary changes requires negotiations with family,
with family disagreements potentially causing marital problems
and conflict. Involving people within the social and physical
environments of persons’ with HTN could enhance their self-
management practices. While studies have identified adherence to
dietary recommendations as a key barrier to HTN control among
SSA populations [12,38,42], our finding highlights gendered and
contextual differences that persons with HTN face in coping with
implementing dietary recommendations.
Similar to findings in studies in SSA [12,42–44], Europe [45,46]
and the Americas [47], the use of traditional medicines for
treatment and self-care contributes to poor medication adherence
among hypertensive patients. Persons with HTN perceived
traditional remedies as natural and continuously adapt their
medication coping strategies based on their experiences using
traditional medicines. Similarly, in some Asian countries, patients
had a preference for using traditional Chinese herbal remedies
because long term use of “western medication” was perceived as
potentially harmful [48,49]. It is possible that participants’ belief in
a cure for HTN results from an expectation that HTN illness
duration would be similar to the illness duration of the
traditionally prevalent communicable diseases in Ghana. The
use of traditional remedies and the belief in their effectiveness are
apparently steeped in treatment experiences of relatives and in
traditional and cultural health care practices [15]. For instance,
bitter kola, has traditionally been used for the treatment of several
illnesses [50], as a stimulant and an aphrodisiac [51] in African
societies. It is probable that, it presents an alternative for coping
with perceived or experienced sexual weakness associated withPlease cite this article in press as: G.N. Nyaaba, et al., Illness representatio
Saharan Africans: A comparative study among Ghanaian migrants and n
10.1016/j.pec.2019.04.008antihypertensive medications among men. Although majority of
migrant and non-migrant urban participants are Akan by ethnicity,
only migrant men reported bitter kola use. Migrant men might be
influenced by Nigerian migrants because kolanuts are perceived as
helpful for controlling HTN among Nigerians [12]. Other studies
suggest that SSA migrants associate HTN with changes in the
environment and diet as a result of migration [25]. It is plausible
that migrants’ concurrent use of antihypertensive medicines and
traditional remedies reflects an inclination towards a cure seeking
behaviour because HTN does not physically hinder their activities.
Perhaps it also reflects how migrants’ health seeking behaviour are
influenced by integrating two different health care cultures.
Lastly, the chewing of bitter kolanuts and use of dawadawa to
manage HTN in rural areas further resulted from the fear of
developing other sicknesses from long term use of antihyperten-
sive medication, the fear of being considered weak men and
experienced disruptions in family life resulting from experiences of
sexual weakness. The reported positive treatment outcomes of
traditional medicine use by family members and relatives further
facilitated their use by persons’ with HTN and contributed to the
poor medication adherence. It is plausible that participants’ low
formal education and documented structural factors such as health
worker shortages and high illiteracy rates reported in rural Ghana
[32–34] limit access to HTN information and contribute to shaping
their illness representations and coping strategies. It shows how
social relationships and lay perceptions influence individuals’
health behaviour towards HTN treatment and control.
4.2. Limitations of this study
This was a multi-site qualitative study among a homogenous
SSA population living in different contexts to explore and compare
how they self-mange HTN towards improving HTN control. Nearly
half of the study participants had comorbid chronic conditions so,
the findings potentially include coping strategies shaped by having
co-morbid chronic conditions. However, we do not anticipate that
co-morbidity influenced our results greatly as most chronic NCDs
have shared risk factors. Also, adherence to HTN treatment was
self-reported, which could account for the medication adherence
differences observed between the groups but we conducted a
rigorous data analysis and studies have reported similar findings
on HTN beliefs [25,52], medication adherence [45] and use of
traditional medicines and remedies for HTN [26,43].
4.3. Conclusion
Our findings show that hypertensive patients coping strategies
are developed and adapted though interactive stages from
diagnosis, various treatment experiences and experiences living
with HTN. Contextual factors in social and physical environments
contribute to shaping individuals’ HTN illness representations and
their coping strategies.
4.4. Practical implications
The findings highlight how context influences hypertensive
patients illness representations and the coping strategies they
develop and adapt to mitigate challenges with self-managing HTN in
different settings.They show that collaborating with communities to
harness the relationships and structures within patients’ social and
physical environments could strengthen hypertensive patients’ self-
management practices towards HTN control. They further empha-
sise the need for building the capacities of health professionals to
enable them to provide patient centred education in order to
enhance hypertensive patients’ self-management practices for HTN
control in Ghana and other low-resource settings.ns and coping practices for self-managing hypertension among sub-
on-migrant Ghanaians, Patient Educ Couns (2019), https://doi.org/
G Model
PEC 6244 No. of Pages 11
10 G.N. Nyaaba et al. / Patient Education and Counseling xxx (2019) xxx–xxxHealth personnel should explore individual’s understanding of
the chronicity of HTN, the risk implications of having HTN and their
intentions and use of alternative remedies in order to identify HTN
patients for whom personalized educational and motivational
interventions could improve medication acceptance and long-
term adherence. They should also emphasise the importance of
implementing family-wide behavioural changes and involve
family members in HTN treatment to enhance the self-manage-
ment practices of persons with HTN. The influence of cultural
norms and practices on patient behaviour should not be under-
estimated during sensitisation and together with patients,
strategies should be explored that enable them cope with HTN.
Data sharing statement
Data collected for this study is primary data collected at study
locations in Ghana with the consent of participants, which is stored
in a password-protected folder on the AMC/UvA digital platform.
The data analysed during the current study is not publicly available
due to potentially identifying information contained in interview
transcripts but data requests can be made through the Institutional
Review Board of the AMC, University of Amsterdam, The
Netherlands for researchers who meet the criteria for access to
confidential data.
Ethics approval
The study received ethical approval from the Ghana Health
Service Ethical Review Services (GHS\ ERC) numbered GHS-ERC 09/
01/201 and from the Committee for Human Research, Publications
and Ethics at Kwame Nkrumah University of Science and
Technology, Kumasi, Ghana. Administrative consent was also
received from the regional health directorates of the three regions
and facility administrators.
Competing interests
The authors declare that they have no competing interests.
Funding
This work is part of Ms. Nyaaba’s doctoral studies funded by the
Erasmus Mundus Joint Doctorate Program of the European Union,
Framework Partnership Agreement 2013-0039, Specific Grant
Agreement 2015-1595
Author contributions
GNN, CA, AdGA and KS conceived the study idea and designed
the study proposal. GNN collected the data, reviewed transcripts,
coded, analysed, interpreted the results and developed the
manuscript. CA and KS supervised GNN in coding, analysis,
interpretation and revising the manuscript. LM and AdGA
contributed to refining the study design, designing topic guides,
supervised GNN in data collection, interpreting results and
revising the manuscript. EB contributed to interpreting the results
and revising the manuscript. All authors read and approved the
final manuscript and are accountable for all aspects of the
manuscript.
Acknowledgements
The Erasmus Mundus Joint Doctorate Program of the European
Union supports this work though the Amsterdam Institute of
Global Health and Development (AIGHD) as part of Ms. Nyaaba’s
PhD candidacy at the Academic Medical Centre /University ofPlease cite this article in press as: G.N. Nyaaba, et al., Illness representatio
Saharan Africans: A comparative study among Ghanaian migrants and 
10.1016/j.pec.2019.04.008Amsterdam. The authors thank the leaders of the Ghanaian
Christian and Moslem communities in Amsterdam and the health
administrators and staff of the health facilities in all study sites
who assisted the research team to identify and contact study
participants. We also thank the directors and staff of the regional
health directors in the Ashanti, Northern and Upper East Regions
for all their support during fieldwork in Ghana. We acknowledge
the support received from Dr. Briamah Baba Abubakari (GHS, NR),
Dr Fredrick Boateng (GHS, Ashanti Region), Mr. Gideon Sarpong
(Ashanti Region) and Mr. Duncan Adogboba (GHS, UER) during
data collection in Ghana. Finally, we thank the study participants
for participating in this study.
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