Skip to main content
Download PDF

Sociocultural perceptions of physical activity and dietary habits for hypertension control: voices from adults in a rural sub-district of South Africa

BMC Public Health volume 24, Article number: 2194 (2024) Cite this article

Abstract

Background

Over half of adults from rural South Africa are hypertensive. Apart from pharmaceutical treatment, lifestyle changes such as increasing physical activity and reducing dietary salt have been strongly advocated for the control of hypertension. However, the control rates of hypertension for adults in rural South Africa are low. In this paper we explore whether this is due to the recommended lifestyle intervention not aligning with the individual’s socio-cultural determinants of behaviour change.

Aim

To explore the social and cultural beliefs, perceptions and practices regarding physical activity and diet as a hypertension control intervention on hypertensive adults living in a rural sub-district in South Africa.

Methods

Nine focus group discussions were conducted with hypertensive adults aged 40 years and above from Bushbuckridge sub-district in Mpumalanga Province of South Africa using a semi-structured interview guide. Each session began with introductions of the discussion theme followed by a short discussion on what the participants know about hypertension and the normal blood pressure readings. Physical activity and dietary habits were then introduced as the main subject of discussion. Probing questions were used to get more insight on a specific topic. A thematic analysis approach was used to generate codes, categories, and themes. A manual approach to data analysis was chosen and data obtained through transcripts were analysed inductively.

Findings

Participants had a lack of knowledge about blood pressure normal values. Perceived causes of hypertension were alluded to psychosocial factors such as family and emotional-related issues. Physical activity practices were influenced by family and community members’ attitudes and gender roles. Factors which influenced dietary practices mainly involved affordability and availability of food. To control their hypertension, participants recommend eating certain foods, emotional control, taking medication, exercising, praying, correct food preparation, and performing house chores.

Conclusion

Lifestyle interventions to control hypertension for adults in a rural South African setting using physical activity promotion and dietary control must consider the beliefs related to hypertension control of this population.

Peer Review reports

Introduction

Hypertension is one of the world’s most prevalent and modifiable risk factors for cardiovascular and cerebrovascular diseases such as heart attacks and strokes [1,2,3]. Trends from 1975 to 2015 show that the number of people with hypertension worldwide has doubled from 594 million in 1975 to 1.13 billion in 2015 [2]. Reports suggest that 31.1% of adults worldwide had hypertension in 2010, with an estimated 9.4 million deaths (Mills et al., 2020;World Health Organization, 2013). Over the past decade, the prevalence of hypertension has increased worldwide, especially in low- and middle-income countries (LMICs). This reported prevalence was higher in LMICs (31.5%) than in high-income countries (28.5%) [4].

Hypertension or high blood pressure is defined as systolic blood pressure higher than 139 mmHg or diastolic blood pressure higher than 89 mmHg [2]. The most cited national prevalence of hypertension among older adults in South Africa is 77.3% in 2008 among a sample of adults aged 50 years or older [5]. In 2014, Lloyd-Sherlock and colleagues reported a South African hypertension prevalence of 77.9% amongst older adults aged 50 years and above [6]. These numbers can be attributed to factors such as ageing of the population, rapid urbanization, diet and lifestyle changes, and an increase in psychosocial issues [7]. The prevalence of hypertension in rural South Africa for individuals aged 15 years and above is reported to be 41% in Limpopo (mean age = 44.2 ± 20.9) (Dikgale Health and Demographic Surveillance Site) [8] and 40% (women), 30% (men) in Mpumalanga (mean age not reported) (Agincourt Health and Demographic Surveillance Site) [9]. Some of the reported risk factors for hypertension in LMICs are overweight/obesity, being married, older age group, low education, and alcohol consumption [7, 10,11,12].

People 40 years and older in rural Mpumalanga seem to be aware of their blood pressure status (awareness rate − 64.4%) and amongst those aware most are on medication for hypertension (89.3%) although the level of control remains low (45.8%). However, the number of people receiving treatment dropped to 49.7% when considering the overall hypertensive population and not only those who were aware of the condition [13].

A longitudinal observational study in rural Agincourt that followed individual adults on usual care for hypertension, found improved rates of hypertension over a four-year follow-up period [14]. Studies for hypertension control using physical activity in South Africa focused on monitoring and goal setting (increasing the number of steps taken a day) [15, 16]. Studies targeting dietary changes for hypertension control have focused on providing advice on diet that is usually not affordable or not accepted by the rural adults [17, 18]. There is one known study in rural Agincourt of South Africa aimed to reduce hypertension through provision of monthly supply of low sodium salt [19], where participants expressed a challenge with sustainability of this approach because the sodium salt product is not available in local stores. For effective implementation of this recommendation, one must first understand the contextual (personal and environmental) factors regarding salt and calorie intake in this population.

Providing a description of what individual factors contributed to the improved hypertension control rates [14], considering the influences of physical activity performance [16], and understanding the socioeconomic factors contributing to dietary consumption [17, 18] could yield better hypertension control rates. A recent systematic review concluded that future research in developing countries should consider individual risk perceptions, cultural barriers, and gender when designing interventions for hypertension control [20].

Various personal and/or environmental factors along with the person’s level of functioning can influence the uptake of an intervention [21]. For example, physical activity interventions to control hypertension in rural South Africa may be different from other populations more studied due to the daily physical activities in rural South Africa such as walking for wood collection, different aspects of farming, yard work, walking longer distances for daily chores, and housework [15, 22]. Activities are also likely constantly evolving because of urbanization, migration, and an ageing population [7, 23].

When developing interventions in South Africa to reduce hypertension, there is a need to consider the cultural and social beliefs and practices that influence behaviour of the rural adult population. Both a reduction in salt and caloric intake, and an increase in physical activity are the most extensively recommended lifestyle approaches to help meet national hypertension targets [24,25,26]. However, promoting change in behaviour of someone through an intervention needs an understanding of the contextual realities at play that influence that person’s behaviour. We aimed to explore the social and cultural beliefs, perceptions and practices regarding physical activity and diet from hypertensive adults living in rural South Africa and to explore how these perceptions may influence future behaviour change. This should inform novel interventions for the control of hypertension in this population.

Methods

Setting

This qualitative study was conducted at Bushbuckridge sub-district in Mpumalanga province South Africa where the Agincourt Health and Demographic Surveillance System (HDSS) has been running since 1992. The HDSS is run by the MRC/ Wits Rural Public Health and Health Transitions Research Unit from the University of the Witwatersrand. The Agincourt HDSS covers an area of 450km2 with 115 000 individuals (approximately 52 000 older than 18 years) living in approximately 20 000 households [27]. We used as a sampling frame the cohort of 5059 adults aged 40 years and above within the Agincourt HDSS, named the Health and Aging in Africa: A Longitudinal Study of an INDEPTH (International Network for the Demographic Evaluation of Populations and Their Health) community in South Africa (HAALSI) [28]. The prevalence of hypertension in this cohort is 57%, defined as systolic blood pressure ≥ 140 mmHg or diastolic blood pressure ≥ 90 mmHg or self-reported medication of hypertension.

Healthier food options in this setting are available in large supermarkets, but due to the high costs involved people often grow their own food [17]. Cheaper food items are available in smaller food stores, but availability of healthier food is limited. Physical activities are mainly centred around the performance of activities of daily living such as walking, livelihood activities, and household duties [22].

Population selection

Participants for the focus groups were randomly selected from the HAALSI cohort including men and women aged 40 years and above with a diagnosis of hypertension. We chose a random sample because we wanted to observe opinions from a mixed sample (age, gender, awareness of hypertension status). Participants must have been living in Agincourt for the past six months prior to the start of the focus group discussions to ensure that they have adapted to the daily routine of the community. We produced a random list of 150 potential participants, and they were contacted by phone and asked to participate in a focus group on high blood pressure. Participants were interviewed until data saturation required was reached. Participants were contacted by a locally trained research assistant who speaks the local language (Xitsonga), and they were compensated for their participation in the focus group discussion.

Focus group preparation

The focus group interview guide (Appendix A) was developed by the first author and reviewed and approved by all co-authors. The focus group guide included questions on physical activity and dietary practices and influences, barriers and enablers of physical activity and dietary approaches, for hypertension control.

Focus group discussions (FGD)

FGDs were facilitated by a female locally trained qualitative research assistant. Moreover, the first author and a second male locally trained qualitative research assistant were present to co-facilitate. Each FGD included 6 to 9 participants and lasted 45 to 90 min. Each session began with introduction of the discussion theme and then followed by a short discussion on what the participants knew about hypertension, the average normal blood pressure reading as well as their awareness of their blood pressure status. Physical activity and dietary habits were then introduced as the main subject of discussion using the focus group guide. Probing questions were introduced to get more insight on specific topics if needed. The FGDs were audio recorded and the co-facilitator documented the discussion during each session. Translation to English and transcription of the audio recorded interviews occurred after each session. The FGD were performed at a private venue in the Agincourt HDSS premises. All participants were fetched from their homes and dropped off after the session.

Trustworthiness of data

We ensured trustworthiness of our data by following the principles of credibility, transferability, dependability, confirmability, and reflexivity [29]. To ensure credibility of the data, locally trained qualitative research assistants were employed to conduct the FGDs and transcribe the data. The transcribed FGDs audio data was reviewed by the first author and all co-authors. The first author received feedback from all co-authors on the interview guide ahead of data collection and amendments made when indicated. Throughout the data analysis process, codes were generated and reviewed by three experienced peer qualitative researchers not involved in the research project as well as a senior co-author (HM). Transferability, though limited in qualitative research, was ensured by providing a thick description of the study setting and population selection in this paper to allow for repeatability. Dependability was achieved through inviting qualitative researchers not involved in the research study to view and give feedback on the field notes and initial codes created through a debriefing session. The authors have also kept an audit trail of interview recordings and transcripts. The first author kept a clear focus during the data analysis phase by examining his own judgments, practices, and belief systems regarding the topic of analysis through a reflexive journal which documented the study rationale and methodological decisions. To ensure confirmability, direct excerpts from the interviews are provided under the findings section.

Data analysis

A thematic analysis approach was used to generate codes, themes and categories. All transcripts were analysed using an inductive approach. We employed a manual analysis technique to generate codes, categories, and themes. This process included printing hard copy transcripts, photocopying, line-by-line coding, coding in margins, cutting, cut-and-paste, sorting, reorganising, hanging and arranging colour-coded sticky notes on a large display wall [30,31,32]. The five-step approach to qualitative data analysis outlined by [33] was followed.

Findings

The analysis of the data revealed eight main themes: (i) lack of knowledge of normal blood pressure values; (ii) perceived causes of hypertension; (iii) variety in daily physical activity practices; (iv) limited variety in daily diet; (v) ways in which the participants control their hypertension; (vi) alternative beliefs for hypertension control; (vii) factors that influence their dietary practices; and (viii) community influences on physical activity. The themes are presented with their categories and accompanying excerpts from the participants (Table 1). The daily dietary practices are presented on a separate table to indicate the frequency of consumption (Table 2).

Table 1 Findings from focus group discussions according to identified themes, categories, codes, and participants excerpts
Full size table

Limited variety in daily diet

The daily dietary practices were categorised into breakfast meals, lunch meals, and dinner meals. These meals are presented in Table 2 together with the frequency in which they are consumed. All meal items are consumed for breakfast, lunch meals consist of bread, porridge, soft porridge, vegetables, meat, and tea. For dinner the consumed food items are porridge, vegetables, meat, and tea.

Table 2 Daily meals consumed by hypertensive participants
Full size table

Discussion

This qualitative study identified eight major themes relating to hypertensive adults’ lack of knowledge of normal blood pressure values, perceived causes of hypertension, variety of PA practices, ways to control hypertension, alternative beliefs for HPT control, factors influencing dietary practices, the influence of community on PA, and limited variety in daily diet. These insights are key to guide interventions on sociocultural considerations when developing strategies to control hypertension from a rural, African lens. Few studies have reported on hypertensive adults’ knowledge of normal blood pressure values; however, some studies have investigated knowledge about hypertension as a health condition [34,35,36,37,38]. Our study found that hypertensive adults have little to no knowledge about high blood pressure normal values, the little knowledge which they have is obtained from ongoing research studies conducted in their community [27]. A study in Ghana by Agyei-Baffour [39] also reported that knowledge of hypertension was very low in their participants. They reported that those participants who had knowledge about hypertension obtained it from the media, followed by health staff. Our study showed that health staff have very little influence on hypertension education and sharing feedback on measured blood pressure results in this community. Suggestions for health promotion in rural communities from previous studies have included alternates to clinic-based education, such as door-to-door, peer education (teaching the youth who will teach the adult), working with local church leaders to provide church-based education, and providing education via pamphlet handout and billboards [37].

In almost all our focus group discussions, participants spoke about the influence of poor emotional wellbeing and stress-related factors as causes of elevated blood pressure. They referred strongly to stress induced by family members. This finding is not unique to our study and has been reported by participants in rural KwaZulu-Natal who described that unhappiness and stress were major contributing factors to elevated blood pressure [40]. Similarly, Jongen and colleagues [37] identified stress/anxiety as factors that prompt the development of hypertension. The participants in their study [37] reported that fighting with children or spouse or the inability to support the family financially due to unemployment were the major triggers of stress and/or anxiety. There appears to be an unmet need for psychosocial support in rural South Africa.

Regarding the influence of diet as a cause of hypertension, our study participants recognised that high sodium salt consumption, oily and fatty food items, and certain spices can cause hypertension. These risk factors have been reported and confirmed by other studies as contributors to the development of hypertension [37, 41, 42]. Participants in our study also identified being obese as a cause of hypertension. There is a reported positive relationship between obesity and overweight with hypertension [43, 44].

Our results highlight the variety of sociocultural and livelihood physical activities adults perform as part of their daily living in this setting. These activities include walking while herding cows, sweeping the yard, ploughing, and walking to fetch firewood which all have been previously reported by other studies as playing a major part of physical activity involvement for rural adults [45,46,47]. It is important to note that most of these reported activities, such as sewing mat while seated, household activities, walking activities, and unstructured activities are defined as sedentary or light/moderate intensity physical activity [46]. Public health interventions aiming at increasing physical activity for hypertensive adults in a rural population may therefore want to target increasing the intensity of already existing physical activity practices.

Family members of hypertensive adults appeared to often discourage physical activities of high intensities. The participants are told by their family members that doing chores every day is a form of punishment and suffering. However, the participants continue performing these activities due to lack of help. This suggests that most house chores in rural South Africa are left for the adults, an opportunity which can enhance physical activity participation for health benefits. Indeed, participants recognised that performing daily chores was beneficial to their health because it keeps their heart pumping more blood and this is good to control their blood pressure. It was interesting to note that females are often discouraged from performing chores linked to vigorous intensity physical activities instead of the males. This has been explained by Oyewumi [45] who highlighted the role of gender in household activities. The author explains that adult men are expected to perform more vigorous intensity physical activities at home such as heavy lifting, chopping wood, or digging in the garden and women are expected to perform activities of lower intensity. The influence of gender cannot be ignored when designing public health physical activity interventions for blood pressure control.

Dietary approaches to stop hypertension (DASH) is a globally recommended approach to dietary habits for hypertension control which has been in existence for over 25 years [48]. The DASH diet is considered the golden standard in high blood pressure control, and it emphasizes foods rich in potassium, protein, fiber, magnesium, and calcium [49]. Such foods may include fruits and vegetables, nuts, beans, whole grains, low-fat dairy, and limiting food high in saturated fat. However, the daily diet consumed by participants in our study indicates lack of variety of different food types. Participant’s diet appears mainly rich in starch which is high in carbohydrates as seen by the bread, porridge, soft porridge, and fermented porridge and milk consumed daily.

Our study revealed multiple factors which are linked to the reasons why hypertensive adults in our study setting may not follow the DASH diet recommendations. Lack of control in the type of food eaten because of attending social events like parties and funerals, where there is no choice of food, was a contributing factor. In rural African settings, when attending a social event, it is uncommon to have different meals prepared based on an attendee’s dietary recommendations. Although social and community gatherings happen occasionally in rural South African populations, the consumption of unhealthy diet such as high dietary sodium in the long-term can lead to dysregulation of the renin-angiotensin system, contributing to hypertension [50]. Religion was another influence in our study where certain religious groups prohibit eating certain types of food and may promote other types of food and beverages regardless of an individual’s health status [51]. In addition, participants reported that the taste of the food played a major role in food choice. They found that unhealthy food items taste better and reported that “hypertensive meals are not enjoyable”. Another important contributor to food choice mentioned by our participants and that has been reported in multiple studies was affordability and availability of different, healthier foods [17, 52, 53].

Due to the high poverty and unemployment rate in rural areas of South Africa, people often eat what is affordable and readily available [54]. Most families living in poverty purchase larger quantities of less healthy food products compared to smaller healthier substitutes [37]. This highlights the importance of considering the local financial context when designing dietary interventions for the control of elevated blood pressure. Charlton and colleagues [55] explain that sometimes the DASH diet is not realistic to people living in rural areas with high unemployment and poverty. They recommend that the best dietary approach to controlling hypertension may be making small adjustments to current daily salt intake instead of advising people to change what they eat. This recommendation is important to consider as it has proven effective in other similar settings [24, 56, 57]. In our study setting, it was recently reported that 65% of study participants aged 40–75 years had a mean salt intake of 6 g/day [58]. This is higher than the recommended daily salt intake of 5 g/day by World Health Organization [59].

Participants in our study were knowledgeable with regards to strategies for controlling hypertension. They mentioned the importance of psychosocial wellbeing, adhering to pharmaceutical treatment, dietary control, and involvement in daily household chores and exercise. These measures have been well documented in literature as effective strategies for hypertension control [60,61,62]. Regarding psychosocial wellbeing, our participants highlight the value of engaging with other people and sharing positive thoughts and having a spiritual connection with higher powers. They expressed that managing stress and anger is important in controlling hypertension. These findings have also been reported by adults in a study by Jongen [37] and in a church-based intervention by Tussing-Humphries [63].

Participants in our study believed that traditional medicine must not be mixed with pharmaceutical/western medicine. This may be attributed to the ongoing research and collaborations between traditional healers in the communities and the research team (WITS HDSS Research and Surveillance System). One important wild herb that adults in our study setting strongly emphasised as assisting in high blood pressure control is Nkaka (Momordica balsamina), also known as the African Pumpkin. Although it is not a cure for hypertension, this herb is reported to contain high potassium content which is good for hypertension management and it has also been associated to some antiviral activity which it is said could inhibit the replication of HIV-1 [64, 65]. The leaves are also important source of nutrients having 17 amino acids with adequate mineral composition like potassium, magnesium, phosphorus, calcium, sodium, zinc, manganese, and iron [65]. Participants in our study strongly believe that this herb helps them to control their elevated blood pressure. Some of the participants eat it before their clinic visits to maintain low blood pressure levels. A further study is required to evaluate whether hypertensive adults replace antihypertensive medication with Nkaka to lower their high blood pressure. This wild herb could be considered as an important component of dietary education for hypertension control in the area under study; however, further studies are also required to evaluate its effectiveness in lowering elevated blood pressure.

Strengths and limitations

This study provides important in-depth cultural and social contexts to the implementation of public health interventions for adults with hypertension in a rural African setting. It provides a broad description of key determinants of physical activity and dietary considerations that strongly influence rural-based hypertension lifestyle interventions. As limitations we understand that in any focus group discussion, the inclusion of multiple people in one discussion does not guarantee full participation of everyone. For this reason we probe those participants who seemed to contribute less during the discussions in order to have the most from the group. In addition, all participants included in this study are part of an on-going cohort study on health in older population and have also been involved in other studies which may have influenced their perceptions and knowledge on the topic. This population might be more aware of health issues such as hypertension due to the regular study visits and clinic referrals, and may, therefore, not be representative of the general population. For individuals who declined to participate in our study, we did not ask reasons for non-participation, which creates a potential bias for non-response.

Conclusion

This study provides useful insight for public health community-based interventions on physical activity and dietary sociocultural perceptions to be used when developing hypertension control interventions in rural African settings. We also highlight the need to design context specific interventions which make use of existing daily physical activity and dietary behaviour.

Data availability

The datasets used and/or analyzed during the current study include only transcripts of the interviews. Deidentified data may be made available from the corresponding author on reasonable request.

Abbreviations

DASH:

Dietary Approaches to Stop Hypertension

FGD:

Focus Group Discussion

HDSS:

Health and Demographic Surveillance System

HPT:

Hypertension

LMIC:

Low- and middle- income countries

MRC:

Medical Research Center

PA:

Physical Activity

References

  1. World Health Organization. Global action plan for the prevention and control of noncommunicable diseases 2013–2020. World Health Organization; 2013.

  2. Zhou B, Bentham J, Di Cesare M, Bixby H, Danaei G, Cowan MJ, et al. Worldwide trends in blood pressure from 1975 to 2015: a pooled analysis of 1479 population-based measurement studies with 19· 1 million participants. Lancet. 2017;389(10064):37–55.

    Article  Google Scholar 

  3. Parati G, Lackland DT, Campbell NRC, Ojo Owolabi M, Bavuma C, Mamoun Beheiry H, et al. How to improve awareness, treatment, and Control of Hypertension in Africa, and how to reduce its consequences: a call to Action from the World Hypertension League. Hypertension. 2022;79(9):1949–61.

    Article  CAS  PubMed  Google Scholar 

  4. Mills KT, Stefanescu A, He J. The global epidemiology of hypertension. Nat Rev Nephrol. 2020;16(4):223–37.

    Article  CAS  PubMed  Google Scholar 

  5. Peltzer K, Phaswana-Mafuya N. Hypertension and associated factors in older adults in South Africa: cardiovascular topics. Cardiovasc J Afr. 2013;24(3):66–71.

    Article  Google Scholar 

  6. Lloyd-Sherlock P, Beard J, Minicuci N, Ebrahim S, Chatterji S. Hypertension among older adults in low-and middle-income countries: prevalence, awareness and control. Int J Epidemiol. 2014;43(1):116–28.

    Article  PubMed  Google Scholar 

  7. Ibrahim MM, Damasceno A. Hypertension in developing countries. Lancet. 2012;380(9841):611–9.

    Article  PubMed  Google Scholar 

  8. Ntuli ST, Maimela E, Alberts M, Choma S, Dikotope S. Prevalence and associated risk factors of hypertension amongst adults in a rural community of Limpopo Province, South Africa. Afr J Prim Health Care Fam Med. 2015;7(1).

  9. Clark SJ, Gómez-Olivé FX, Houle B, Thorogood M, Klipstein-Grobusch K, Angotti N, et al. Cardiometabolic disease risk and HIV status in rural South Africa: establishing a baseline. BMC Public Health. 2015;15(1):1–9.

    Article  Google Scholar 

  10. Ahaneku GI, Osuji CU, Anisiuba BC, Ikeh VO, Oguejiofor OC, Ahaneku JE. Evaluation of blood pressure and indices of obesity in a typical rural community in eastern Nigeria. Ann Afr Med. 2011;10(2).

  11. Hendriks ME, Wit FWNM, Roos MTL, Brewster LM, Akande TM, De Beer IH, et al. Hypertension in sub-saharan Africa: cross-sectional surveys in four rural and urban communities. PLoS ONE. 2012;7(3):e32638.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Williams EA, Keenan KE, Ansong D, Simpson LM, Boakye I, Boaheng JM, et al. The burden and correlates of hypertension in rural Ghana: a cross-sectional study. Diabetes Metabolic Syndrome: Clin Res Reviews. 2013;7(3):123–8.

    Article  Google Scholar 

  13. Jardim TV, Reiger S, Abrahams-Gessel S, Gomez-Olive FX, Wagner RG, Wade A, et al. Hypertension management in a population of older adults in rural South Africa. J Hypertens. 2017;35(6):1283.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. Abrahams-Gessel S, Gómez-Olivé FX, Tollman S, Wade AN, Du Toit JD, Ferro EG, et al. Improvements in hypertension control in the rural longitudinal HAALSI cohort of South African adults aged 40 and older, from 2014 to 2019. Am J Hypertens. 2023;36(6):324–32.

    Article  PubMed  Google Scholar 

  15. Cook I. Physical activity in rural South Africa-are current surveillance instruments yielding valid results? South Afr Med J. 2007;97(11):1072–3.

    Google Scholar 

  16. Roos R, Myezwa H, van Aswegen H, Musenge E. Physical activity and risk factors screening for Ischaemic Heart Disease in South African Individuals Living with HIV.

  17. Temple NJ, Steyn NP, Fourie J, De Villiers A. Price and availability of healthy food: a study in rural South Africa. Nutrition. 2011;27(1):55–8.

    Article  PubMed  Google Scholar 

  18. Faber M, Wenhold F. Food intake and sources of food of poor households in rural areas of South Africa. Water use and nutrient content of crop and animal food products for improved household food security: A scoping study WRC Report no TT. 2012;537(12):24–57.

  19. Lloyd-Sherlock P, Gómez-Olivé FX, Ngobeni S, Wagner RG, Tollman S. Pensions and low sodium salt: a qualitative evaluation of a new strategy for managing hypertension in rural South Africa. Curr Aging Sci. 2018;11(2):140–6.

    Article  PubMed  Google Scholar 

  20. Dhar L, Earnest J, Ali M. A systematic review of factors influencing medication adherence to hypertension treatment in developing countries. Open J Epidemiol. 2017;7(03):211–50.

    Article  Google Scholar 

  21. Ferrans CE, Zerwic JJ, Wilbur JE, Larson JL. Conceptual model of health-related quality of life. J Nurs Scholarsh. 2005;37(4):336–42.

    Article  PubMed  Google Scholar 

  22. Shackleton CM, Shackleton SE, Buiten E, Bird N. The importance of dry woodlands and forests in rural livelihoods and poverty alleviation in South Africa. Policy Econ. 2007;9(5):558–77.

    Article  Google Scholar 

  23. Awumbila M. Drivers of migration and urbanization in Africa: key trends and issues. Int Migration. 2017;7(8).

  24. Bertram MY, Tollman S, Hofman KJ, Steyn K, Wentzel-Viljoen E. Reducing the sodium content of high-salt foods: effect on cardiovascular disease in South Africa. South Afr Med J. 2012;102(9):743–5.

    Article  CAS  Google Scholar 

  25. He FJ, Li J, MacGregor GA. Effect of longer term modest salt reduction on blood pressure: Cochrane systematic review and meta-analysis of randomised trials. BMJ. 2013;346.

  26. Lin JS, O’Connor EA, Evans CV, Senger CA, Rowland MG, Groom HC. Behavioral counseling to promote a healthy lifestyle for cardiovascular disease prevention in persons with cardiovascular risk factors. an updated systematic evidence review for the US Preventive Services Task Force; 2014.

  27. Kahn K, Collinson MA, Gómez-Olivé FX, Mokoena O, Twine R, Mee P, et al. Profile: Agincourt health and socio-demographic surveillance system. Int J Epidemiol. 2012;41(4):988–1001.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Gomez-Olive FX, Montana L, Wagner RG, Kabudula CW, Rohr JK, Kahn K, et al. Cohort profile: health and ageing in Africa: a longitudinal study of an indepth community in South Africa (HAALSI). Int J Epidemiol. 2018;47(3):689–j690.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Stahl NA, King JR. Expanding approaches for research: understanding and using trustworthiness in qualitative research. J Dev Educ. 2020;44(1):26–8.

    Google Scholar 

  30. Basit T. Manual or electronic? The role of coding in qualitative data analysis. Educational Res. 2003;45(2):143–54.

    Article  Google Scholar 

  31. Mattimoe R, Hayden MT, Murphy B, Ballantine J. Approaches to analysis of qualitative research data: A reflection on the manual and technological approaches. Accounting, Finance, & Governance Review. 2021;27(1).

  32. Maher C, Hadfield M, Hutchings M, De Eyto A. Ensuring rigor in qualitative data analysis: a design research approach to coding combining NVivo with traditional material methods. Int J Qual Methods. 2018;17(1):1609406918786362.

    Article  Google Scholar 

  33. Braun V, Clarke V. Thematic analysis. American Psychological Association; 2012.

  34. Hacking D, Haricharan HJ, Brittain K, Lau YK, Cassidy T, Heap M. Hypertension health promotion via text messaging at a community health center in South Africa: a mixed methods study. JMIR Mhealth Uhealth. 2016;4(1):e4569.

    Article  Google Scholar 

  35. Haricharan HJ, Heap M, Hacking D, Lau YK. Health promotion via SMS improves hypertension knowledge for deaf South africans. BMC Public Health. 2017;17(1):1–17.

    Article  Google Scholar 

  36. Rampamba EM, Meyer JC, Helberg E, Godman B. Knowledge of hypertension and its management among hypertensive patients on chronic medicines at primary health care public sector facilities in South Africa; findings and implications. Expert Rev Cardiovasc Ther. 2017;15(8):639–47.

    Article  CAS  PubMed  Google Scholar 

  37. Jongen VW, Lalla-Edward ST, Vos AG, Godijk NG, Tempelman H, Grobbee DE, et al. Hypertension in a rural community in South Africa: what they know, what they think they know and what they recommend. BMC Public Health. 2019;19(1):1–10.

    Article  Google Scholar 

  38. Chimberengwa PT, Naidoo M. Group cooperative inquiry. Knowledge, attitudes and practices related to hypertension among residents of a disadvantaged rural community in southern Zimbabwe. PLoS ONE. 2019;14(6):e0215500.

    Article  CAS  PubMed  Google Scholar 

  39. Agyei-Baffour P, Tetteh G, Quansah DY, Boateng D. Prevalence and knowledge of hypertension among people living in rural communities in Ghana: a mixed method study. Afr Health Sci. 2018;18(4):931–41.

    Article  PubMed  Google Scholar 

  40. De Wet H, Ramulondi M, Ngcobo ZN. The use of indigenous medicine for the treatment of hypertension by a rural community in northern Maputaland, South Africa. South Afr J Bot. 2016;103:78–88.

    Article  Google Scholar 

  41. Forman JP, Stampfer MJ, Curhan GC. Diet and lifestyle risk factors associated with incident hypertension in women. JAMA. 2009;302(4):401–11.

    Article  CAS  PubMed  Google Scholar 

  42. Carey RM, Whelton PK. Committee* 2017 ACC/AHA Hypertension Guideline Writing. Prevention, detection, evaluation, and management of high blood pressure in adults: synopsis of the 2017 American College of Cardiology/American Heart Association Hypertension Guideline. Ann Intern Med. 2018;168(5):351–8.

    Article  PubMed  Google Scholar 

  43. Aronow WS. Association of obesity with hypertension. Ann Transl Med. 2017;5(17).

  44. Kaneva AM, Bojko ER. Sex differences in the association between obesity and hypertension. Arch Physiol Biochem. 2023;129(3):682–9.

    Article  CAS  PubMed  Google Scholar 

  45. Oyewumi O. African gender studies: a reader. Springer; 2016.

  46. Biernat E, Piątkowska M. Leisure time physical activity among employed and unemployed women in Poland. Hong Kong J Occup Therapy. 2017;29(1):47–54.

    Article  Google Scholar 

  47. Francis D, Webster E. Poverty and inequality in South Africa: critical reflections. Dev South Afr. 2019;36(6):788–802.

    Article  Google Scholar 

  48. Appel LJ, Moore TJ, Obarzanek E, Vollmer WM, Svetkey LP, Sacks FM, et al. A clinical trial of the effects of dietary patterns on blood pressure. N Engl J Med. 1997;336(16):1117–24.

    Article  CAS  PubMed  Google Scholar 

  49. Steinberg D, Bennett GG, Svetkey L. The DASH diet, 20 years later. JAMA. 2017;317(15):1529–30.

    Article  PubMed  Google Scholar 

  50. Santos PCJL, Krieger JE, Pereira AC. Renin–angiotensin system, hypertension, and chronic kidney disease: pharmacogenetic implications. J Pharmacol Sci. 2012;120(2):77–88.

    Article  PubMed  Google Scholar 

  51. Desalegn BB, Lambert C, Riedel S, Negese T, Biesalski HK. Ethiopian orthodox fasting and lactating mothers: longitudinal study on dietary pattern and nutritional status in rural Tigray, Ethiopia. Int J Environ Res Public Health. 2018;15(8):1767.

    Article  PubMed  PubMed Central  Google Scholar 

  52. Adeyeye SAO. The role of food processing and appropriate storage technologies in ensuring food security and food availability in Africa. Nutr Food Sci. 2017;47(1):122–39.

    Article  Google Scholar 

  53. Labadarios D, Mchiza ZJR, Steyn NP, Gericke G, Maunder EMW, Davids YD, et al. Food security in South Africa: a review of national surveys. Bull World Health Organ. 2011;89(12):891–9.

    Article  PubMed  PubMed Central  Google Scholar 

  54. Statistics South Africa. www.statssa.gov.za. 2023 [cited 2023 May 16]. Beyond unemployment - Time-related underemployment in the SA labour market. www.statssa.gov.za.

  55. Charlton KE, Steyn K, Levitt NS, Peer N, Jonathan D, Gogela T, et al. A food-based dietary strategy lowers blood pressure in a low socio-economic setting: a randomised study in South Africa. Public Health Nutr. 2008;11(12):1397–406.

    Article  PubMed  Google Scholar 

  56. Ware LJ, Charlton K, Schutte AE, Cockeran M, Naidoo N, Kowal P, Nutrition. Metabolism Cardiovasc Dis. 2017;27(9):784–91.

    Article  CAS  Google Scholar 

  57. Charlton KE, Corso B, Ware L, Schutte AE, Wepener L, Minicuci N, et al. Effect of South Africa’s interim mandatory salt reduction programme on urinary sodium excretion and blood pressure. Prev Med Rep. 2021;23:101469.

    Article  PubMed  PubMed Central  Google Scholar 

  58. Du Toit JD, Kapaon D, Crowther NJ, Abrahams-Gessel S, Fabian J, Kabudula CW, et al. Estimating population level 24-h sodium excretion using spot urine samples in older adults in rural South Africa. J Hypertens. 2023;41(2):280.

    Article  CAS  PubMed  Google Scholar 

  59. Organization WH. Guideline: potassium intake for adults and children. World Health Organization; 2012.

  60. Guwatudde D, Nankya-Mutyoba J, Kalyesubula R, Laurence C, Adebamowo C, Ajayi I, et al. The burden of hypertension in sub-saharan Africa: a four-country cross sectional study. BMC Public Health. 2015;15(1):1–8.

    Article  Google Scholar 

  61. Chobanian AV. Guidelines for the management of hypertension. Med Clin. 2017;101(1):219–27.

    Google Scholar 

  62. World Health Organization. Guideline for the pharmacological treatment of hypertension in adults. World Health Organization; 2021.

  63. Tussing-Humphreys L, Thomson JL, Mayo T, Edmond E. Peer reviewed: a church-based diet and physical activity intervention for rural, lower Mississippi Delta African American adults: Delta body and soul effectiveness study, 2010–2011. Prev Chronic Dis. 2013;10.

  64. Jandari S, Ghavami A, Ziaei R, Nattagh-Eshtivani E, Rezaei Kelishadi M, Sharifi S, et al. Effects of Momordica charantia L on blood pressure: a systematic review and meta-analysis of randomized clinical trials. Int J Food Prop. 2020;23(1):1913–24.

    Article  CAS  Google Scholar 

  65. Thakur GS, Bag M, Sanodiya BS, Bhadauriya P, Debnath M, Prasad G, et al. Momordica balsamina: a medicinal and neutraceutical plant for health care management. Curr Pharm Biotechnol. 2009;10(7):667–82.

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgements

The authors would like to acknowledge the Agincourt HDSS for allowing the study to access information through their surveillance system. The authors would also like to acknowledge the research assistants for their work with the data collection and to the colleagues of the first author for providing feedback on the coding process during data analysis.

Funding

This research was supported by the Consortium for Advanced Research Training in Africa (CARTA). CARTA is jointly led by the African Population and Health Research Center and the University of the Witwatersrand and funded by the Carnegie Corporation of New York (Grant No. G-19-57145), Sida (Grant No: 54100113), Uppsala Monitoring Center, Norwegian Agency for Development Cooperation (Norad), and by the Wellcome Trust [reference no. 107768/Z/15/Z] and the UK Foreign, Commonwealth & Development Office, with support from the Developing Excellence in Leadership, Training and Science in Africa (DELTAS Africa) programme. The research is also supported by the National Research Foundation (NRF) Thuthuka (Grant No: 129864). The statements made and views expressed are solely the responsibility of the Fellow. The statements made and views expressed are solely the responsibility of the Fellow.

Author information

Authors and Affiliations

  1. Department of physiotherapy, School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand, 7 York Road, Johannesburg, 2193, South Africa

    Kganetso Sekome

  2. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

    Francesc Xavier Gómez-Olivé

  3. School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, South Africa

    Kganetso Sekome, Lauren B. Sherar & Dale W. Esliger

  4. School of Therapeutic Science, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

    Hellen Myezwa

Authors
  1. Kganetso Sekome
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Francesc Xavier Gómez-Olivé
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Lauren B. Sherar
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Dale W. Esliger
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Hellen Myezwa
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

KS, FXG, LBS, DWE, and HM contributed to the design of the study. KS was involved in data collection and performed data analysis. FXG, LBS, DWE, and HM read and approved the generated themes and codes. KS drafted the manuscript and FXG, LBS, DWE, and HM read and approved the final manuscript. KS applied for and obtained the grants for the study.

Corresponding author

Correspondence to Kganetso Sekome.

Ethics declarations

Ethics approval and consent to participate

This study obtained clearance from two ethical bodies. The University of the Witwatersrand Human Research Ethics Committee (HREC - Medical) (clearance number: M 210282) and the local Provincial Department of Health Research and Ethics Committee (clearance number: MP_202106_001). Written informed consent for both participation and audio-recording of the discussion was obtained from each participant. The right to withdraw from the discussion at any point and confidentiality issues were explained to the participants prior to the beginning of each focus group discussion. Respect for all participants and protection of their privacy was adhered to.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Sekome, K., Gómez-Olivé, F.X., Sherar, L.B. et al. Sociocultural perceptions of physical activity and dietary habits for hypertension control: voices from adults in a rural sub-district of South Africa. BMC Public Health 24, 2194 (2024). https://doi.org/10.1186/s12889-024-19320-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12889-024-19320-0

Keywords

BMC Public Health

ISSN: 1471-2458

Contact us