title: Barriers Influencing Linkage to Hypertension Care in Kenya: Qualitative Analysis from the LARK Hypertension Study.
abstract: BACKGROUND
  Hypertension, the leading global risk factor for mortality, is characterized by low treatment and control rates in low- and middle-income countries. Poor linkage to hypertension care contributes to poor outcomes for patients. However, specific factors influencing linkage to hypertension care are not well known.
  
  
  OBJECTIVE
  To evaluate factors influencing linkage to hypertension care in rural western Kenya.
  
  
  METHODS
  Qualitative research study using a modified Health Belief Model that incorporates the impact of emotional and environmental factors on behavior.
  
  
  METHODS
  Mabaraza (traditional community assembly) participants (n = 242) responded to an open invitation to residents in their respective communities. Focus groups, formed by purposive sampling, consisted of hypertensive individuals, at-large community members, and community health workers (n = 169).
  
  
  METHODS
  We performed content analysis of the transcripts with NVivo 10 software, using both deductive and inductive codes. We used a two-round Delphi method to rank the barriers identified in the content analysis. We selected factors using triangulation of frequency of codes and themes from the transcripts, in addition to the results of the Delphi exercise. Sociodemographic characteristics of participants were summarized using descriptive statistics.
  
  
  RESULTS
  We identified 27 barriers to linkage to hypertension care, grouped into individual (cognitive and emotional) and environmental factors. Cognitive factors included the asymptomatic nature of hypertension and limited information. Emotional factors included fear of being a burden to the family and fear of being screened for stigmatized diseases such as HIV. Environmental factors were divided into physical (e.g. distance), socioeconomic (e.g. poverty), and health system factors (e.g. popularity of alternative therapies). The Delphi results were generally consistent with the findings from the content analysis.
  
  
  CONCLUSIONS
  Individual and environmental factors are barriers to linkage to hypertension care in rural western Kenya. Our analysis provides new insights and methodological approaches that may be relevant to other low-resource settings worldwide.
authors.affiliation: Moi University College of Health Sciences, Eldoret, Kenya.|Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.|Kenya Medical Research Institute/Centers for Disease Control Research and Public Health Collaboration, Center for Global Health Research, Kisumu, Kenya.
authors.forename: Violet
authors.initials: V
authors.lastname: Naanyu
authors.affiliation: Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY, USA. rajesh.vedanthan@mssm.edu.|Kenya Medical Research Institute/Centers for Disease Control Research and Public Health Collaboration, Center for Global Health Research, Kisumu, Kenya. rajesh.vedanthan@mssm.edu.
authors.forename: Rajesh
authors.initials: R
authors.lastname: Vedanthan
authors.affiliation: Moi University College of Health Sciences, Eldoret, Kenya.|Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.|Kenya Medical Research Institute/Centers for Disease Control Research and Public Health Collaboration, Center for Global Health Research, Kisumu, Kenya.
authors.forename: Jemima H
authors.initials: JH
authors.lastname: Kamano
authors.affiliation: Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.|Kenya Medical Research Institute/Centers for Disease Control Research and Public Health Collaboration, Center for Global Health Research, Kisumu, Kenya.
authors.forename: Jackson K
authors.initials: JK
authors.lastname: Rotich
authors.affiliation: Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.|Kenya Medical Research Institute/Centers for Disease Control Research and Public Health Collaboration, Center for Global Health Research, Kisumu, Kenya.
authors.forename: Kennedy K
authors.initials: KK
authors.lastname: Lagat
authors.affiliation: Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.|Kenya Medical Research Institute/Centers for Disease Control Research and Public Health Collaboration, Center for Global Health Research, Kisumu, Kenya.
authors.forename: Peninah
authors.initials: P
authors.lastname: Kiptoo
authors.affiliation: Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY, USA.|Kenya Medical Research Institute/Centers for Disease Control Research and Public Health Collaboration, Center for Global Health Research, Kisumu, Kenya.
authors.forename: Claire
authors.initials: C
authors.lastname: Kofler
authors.affiliation: Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.|Kenya Medical Research Institute/Centers for Disease Control Research and Public Health Collaboration, Center for Global Health Research, Kisumu, Kenya.
authors.forename: Kennedy K
authors.initials: KK
authors.lastname: Mutai
authors.affiliation: Kenya Medical Research Institute/Centers for Disease Control Research and Public Health Collaboration, Center for Global Health Research, Kisumu, Kenya.|Duke University Medical Center, Durham, NC, USA.
authors.forename: Gerald S
authors.initials: GS
authors.lastname: Bloomfield
authors.affiliation: Moi University College of Health Sciences, Eldoret, Kenya.|Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.|Kenya Medical Research Institute/Centers for Disease Control Research and Public Health Collaboration, Center for Global Health Research, Kisumu, Kenya.
authors.forename: Diana
authors.initials: D
authors.lastname: Menya
authors.affiliation: Moi University College of Health Sciences, Eldoret, Kenya.|Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.|Kenya Medical Research Institute/Centers for Disease Control Research and Public Health Collaboration, Center for Global Health Research, Kisumu, Kenya.
authors.forename: Sylvester
authors.initials: S
authors.lastname: Kimaiyo
authors.affiliation: Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY, USA.|Kenya Medical Research Institute/Centers for Disease Control Research and Public Health Collaboration, Center for Global Health Research, Kisumu, Kenya.|Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain.
authors.forename: Valentin
authors.initials: V
authors.lastname: Fuster
authors.affiliation: Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY, USA.|Kenya Medical Research Institute/Centers for Disease Control Research and Public Health Collaboration, Center for Global Health Research, Kisumu, Kenya.
authors.forename: Carol R
authors.initials: CR
authors.lastname: Horowitz
authors.affiliation: Moi University College of Health Sciences, Eldoret, Kenya.|Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.|Kenya Medical Research Institute/Centers for Disease Control Research and Public Health Collaboration, Center for Global Health Research, Kisumu, Kenya.|Indiana University School of Medicine, Indianapolis, IN, USA.|Regenstrief Institute, Inc., Indianapolis, IN, USA.
authors.forename: Thomas S
authors.initials: TS
authors.lastname: Inui
mesh_terms: D000328:Adult; D005260:Female; D054625:Healthcare Disparities / Q000592:standards*; D006801:Humans; D006973:Hypertension / Q000175:diagnosis / Q000208:ethnology* / Q000628:therapy*; D007630:Kenya / Q000208:ethnology; D008297:Male; D008875:Middle Aged; D005791:Patient Care / Q000592:standards; D010865:Pilot Projects; D011787:Quality of Health Care / Q000592:standards*; D012424:Rural Population
keywords: cardiovascular disease; global health; hypertension; qualitative research; socioeconomic factors