title: Perceptions of inhibitors and facilitators for adhering to hypertension treatment among insured patients in rural Nigeria: a qualitative study.
abstract: BACKGROUND
  Universal health care coverage has been identified as a promising strategy for improving hypertension treatment and control rates in sub Saharan Africa (SSA). Yet, even when quality care is accessible, poor adherence can compromise treatment outcomes. To provide information for adherence support interventions, this study explored what low income patients who received hypertension care in the context of a community based health insurance program in Nigeria perceive as inhibitors and facilitators for adhering to pharmacotherapy and healthy behaviors.
  
  
  METHODS
  We conducted a qualitative interview study with 40 insured hypertensive patients who had received hypertension care for > 1 year in a rural primary care hospital in Kwara state, Nigeria. Supported by MAXQDA software, interview transcripts were inductively coded. Codes were then grouped into concepts and thematic categories, leading to matrices for inhibitors and facilitators of treatment adherence.
  
  
  RESULTS
  Important patient-identified facilitators of medication adherence included: affordability of care (through health insurance); trust in orthodox "western" medicines; trust in Doctor; dreaded dangers of hypertension; and use of prayer to support efficacy of pills. Inhibitors of medication adherence included: inconvenient clinic operating hours; long waiting times; under-dispensing of prescriptions; side-effects of pills; faith motivated changes of medication regimen; herbal supplementation/substitution of pills; and ignorance that regular use is needed. Local practices and norms were identified as important inhibitors to the uptake of healthier behaviors (e.g. use of salt for food preservation; negative cultural images associated with decreased body size and physical activity). Important factors facilitating such behaviors were the awareness that salt substitutes and products for composing healthier meals were cheaply available at local markets and that exercise could be integrated in people's daily activities (e.g. farming, yam pounding, and household chores).
  
  
  CONCLUSIONS
  With a better understanding of patient perceived inhibitors and facilitators of adherence to hypertension treatment, this study provides information for patient education and health system level interventions that can be designed to improve compliance.
  
  
  BACKGROUND
  ISRCTN47894401 .
authors.affiliation: Department of Global Health, Academic Medical Center, University of Amsterdam, Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands. A.O.Odusola@amc.uva.nl.
authors.forename: Aina O
authors.initials: AO
authors.lastname: Odusola
authors.affiliation: Department of Global Health, Academic Medical Center, University of Amsterdam, Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands. m.hendriks@aighd.org.
authors.forename: Marleen
authors.initials: M
authors.lastname: Hendriks
authors.affiliation: Department of Global Health, Academic Medical Center, University of Amsterdam, Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands. schultsz@gmail.com.
authors.forename: Constance
authors.initials: C
authors.lastname: Schultsz
authors.affiliation: Department of Epidemiology and Community Health, University of Ilorin Teaching Hospital, P.M.B. 1459, postal code 240001, Ilorin, Nigeria. drdeji@yahoo.com.
authors.forename: Oladimeji A
authors.initials: OA
authors.lastname: Bolarinwa
authors.affiliation: Department of Epidemiology and Community Health, University of Ilorin Teaching Hospital, P.M.B. 1459, postal code 240001, Ilorin, Nigeria. akandetm@yahoo.com.
authors.forename: Tanimola
authors.initials: T
authors.lastname: Akande
authors.affiliation: Department of Community Health, Lagos University Teaching Hospital, P.M.B.12003, Surulere, Lagos, Nigeria. akinosibogun@yahoo.co.uk.
authors.forename: Akin
authors.initials: A
authors.lastname: Osibogun
authors.affiliation: Department of Public Health, Academic Medical Center, University of Amsterdam, Meibergdreef 9, Amsterdam, 1105 AZ, The Netherlands. c.o.agyemang@amc.uva.nl.
authors.forename: Charles
authors.initials: C
authors.lastname: Agyemang
authors.affiliation: Division of Health and Behavior, Center for Healthful Behavior Change, Department of Population Health, NYU School of Medicine, New York, NY, 10016, USA. Olugbenga.ogedegbe@nyumc.org.
authors.forename: Gbenga
authors.initials: G
authors.lastname: Ogedegbe
authors.affiliation: Ogo Oluwa Hospital, 64/65 Ahmadu Bello Way, Bacita, Kwara State, Nigeria. agbedejk@yahoo.com.
authors.forename: Kayode
authors.initials: K
authors.lastname: Agbede
authors.affiliation: Hygeia Community Health Care, Hygeia HMO, 13B Idejo Street, Lagos, Nigeria. dradenusi@hygeiahmo.com.
authors.forename: Peju
authors.initials: P
authors.lastname: Adenusi
authors.affiliation: Department of Global Health, Academic Medical Center, University of Amsterdam, Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands. j.lange@aighd.org.
authors.forename: Joep
authors.initials: J
authors.lastname: Lange
authors.affiliation: Department of General Practice, Academic Medical Center, University of Amsterdam, Meibergdreef 9, Amsterdam, 1105, AZ, The Netherlands. h.c.vanweert@amc.uva.nl.
authors.forename: Henk
authors.initials: H
authors.lastname: van Weert
authors.affiliation: Department of Public Health, Academic Medical Center, University of Amsterdam, Meibergdreef 9, Amsterdam, 1105 AZ, The Netherlands. k.stronks@amc.uva.nl.
authors.forename: Karien
authors.initials: K
authors.lastname: Stronks
authors.affiliation: Department of General Practice, Academic Medical Center, University of Amsterdam, Meibergdreef 9, Amsterdam, 1105, AZ, The Netherlands. j.a.haafkens@amc.uva.nl.
authors.forename: Joke A
authors.initials: JA
authors.lastname: Haafkens
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D015438:Health Behavior; D006801:Humans; D006973:Hypertension / Q000188:drug therapy; D019458:Insurance Coverage; D007348:Insurance, Health; D008297:Male; D055118:Medication Adherence; D008875:Middle Aged; D009549:Nigeria; D010465:Perception; D011203:Poverty; D036301:Qualitative Research; D012424:Rural Population