CARDIOVASCULAR JOURNAL OF AFRICA • Volume 35, No 3, September – October 2024 182 AFRICA lifestyle modifications and prevent CVD. Early intervention and changes to sedentary lifestyles are the best approaches, and controlling modifiable risk factors is essential to preventing CVD.23 Community attitudes and knowledge influence identification of risk factors and prevention of CVD.18 Understanding the need for lifestyle modification Population-based studies illustrate that individuals residing in LMICs are predisposed to an increased CVD risk due to their poor socio-economic circumstances. There is some awareness of behavioural factors among South African respondents, and their knowledge was predominantly on salt intake, consumption of fatty foods as well as tobacco smoking.15,19 Almost three-quarters of Ga-Rankuwan participants enjoyed their food lightly salted and only one-third of participants knew the recommended daily salt allowance for cardiovascular health.22 Respondents in the Western Cape, South Africa, were aware that certain meal-preparation techniques made some meat products less unhealthy, such as trimming the fat off and grilling meat, as well as consuming smaller meal portions with decreased oil content.15 Only a minority of respondents in a Ga-Rankuwa study were aware that at least five fruit and vegetable portions per day should be consumed.22 In Limpopo, South Africa, the cognisance of the need for a healthy diet for prevention of hypertension was recognised and the common factor preventing a healthy diet was poverty.19 The need to consume more fresh fruit and vegetables and less fatty foods was not always possible in low-income communities due to cost factors and general poverty. Healthy living is not seen as affordable to the majority because larger volumes of less healthy products can be purchased for the same value as smaller quantities of the healthier substitutes.19 On the other end of the spectrum, a group of Limpopo participants believed that even with alleviation of poverty, people will still maintain unhealthy eating habits.19 Lower educational level was associated with less knowledge about a healthy diet. The most frequent lifestyle modification suggested in the Ga-Rankuwa study was doing exercise, reducing stress and smoking cessation, however, only 12% considered hypertension control as fundamental and only 14.3% considered weight reduction as a fundamental lifestyle modification.22 Stress- and anxiety-related factors in Limpopo were recognised as factors that promoted the development of hypertension. This revolved around family fueds, domestic problems and an inability to provide for their family due to unemployment.19 Variations in disease prevalence and obesity may be attributed to social inequalities between different ethnic groups. Studies have shown that certain cultural beliefs have led sub-Saharan Africans to believe that obesity is positively related to access to clean water and electricity as well as factors associated with good health and a more affluent lifestyle.24 Religious and cultural beliefs such as ‘dark spirits’ or ‘deity’ were considered by certain communities in the Western Cape, South Africa, as the cause of CVD.15 There is an urgent and pressing need to design and implement a culturally acceptable and appropriate community awareness, health educational and health promotional programme about CVD risk factors and CVD for the community, which can be modified and adapted for other rural populations.16 Men have been shown to be more physically active than women.25 This could be due to cultural barriers regarding the acceptibility of wearing tight-fitting clothing while exercising or perceptions that participating in physical activity results in less time to complete household chores.24 Physical activity was shown to be higher in South Africans residing in urban areas where crime was not perceived to be a problem. This was supported by a Nigerian study that also showed that safety, cleanliness and aesthetics were positively associated with physical activity.24 Barriers to physical activity included lack of time, lack of discipline, as well as depression.25 Behavioural changes may be influenced by the perception and knowledge that certain actions may be detrimental and cause harm to their health. Implementing health initiatives will potentially enhance CVD knowledge and awareness, and engaging with healthcare workers to participate in these campaigns is especially important for low-income groups in whom sub-optimal knowledge was identified, yet who carry the largest disease burden. Understanding medication, the need for compliance and reasons for non-adherence The consequences of poor adherence to cardiovascular medication have led to an increase in rates of morbidity and mortality, and the cost of healthcare.26 Although limited in the number of studies available, Kronish and Ye27 found that there was a lack of patient compliance with their prescribed medications, therefore only one out of every two patients achieved the blood pressure goals. This is limited to only a few studies; further studies on patient compliance are warranted. Effective management of hypertension with medication is achievable, yet a substantial number of individuals remain untreated or have uncontrolled blood pressure.8 Management of CVD is impacted on by multiple factors. These include decreased awareness of CVD, lack of motivation to attend clinic visits, lack of adequate screening and educational facilities, large patient numbers, and patients lost to follow up.28 The high proportion of individuals with CVD highlights the need for surveillance programmes to raise awareness, educational campaigns to encourage patients to comply with and adhere to medical therapy, together with lifestyle modification and regular follow-up visits. Many South Asian patients recognised the role of medication on a long-term basis and knew the importance of medication to treat CVD.29 Other factors that have been identified in a few patients include patients taking medication purely as prescribed with no awareness as to why, and some respondents noted that poor adherence to anti-hypertensive medication could lead to a stroke.15 Nigerian respondents only associated taking medication with when physical symptoms were present, and taking their medication only when they felt unwell.16 Patients’ concerns of becoming dependant on their medication if taken regularly, as well as perception barriers that convey the notion that a reduction in or absense of physical symptoms is an indication that medication is no longer mandatory, emphasises the need to communicate with patients to overcome the misunderstanding. Medication knowledge was low amongAustralian participants with known heart failure and chronic obstructive pulmonary disease (COPD), with only 47.6% of patients understanding
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