Abstract
Background
Hypertension is a growing public health emergency in rural sub-Saharan Africa. Based on the known influence of religious leaders in rural sub-Saharan Africa and our prior research, we explored perspectives of religious leaders on hypertension and potential strategies to improve hypertension control in their communities.
Methods
We conducted 31 in-depth interviews with Christian (n = 17) and Muslim (n = 14) religious leaders in rural Tanzania. Interviews focused on religious leaders’ perceptions of hypertension and how they could play a role in promoting blood pressure reduction. We used interpretative phenomenological analysis, a qualitative research method, to understand religious leaders’ perspectives on, and experiences with, hypertension.
Results
Three main themes emerged during analysis. First, we found that perceptions about causes, treatment, and complications of hypertension are influenced by religious beliefs. Second, religious beliefs can enable engagement with hypertension care through religious texts that support the use of biomedical care. Third, religious leaders are enthusiastic potential partners for promoting hypertension control in their communities. These themes were consistent between religion and gender of the religious leaders.
Conclusions
Religious leaders are eager to learn about hypertension, to share this knowledge with others and to contribute to improved health in their communities.
Keywords: blood pressure, community, hypertension, hypertension diagnosis, hypertension prevention and control, religion
Hypertension is the leading modifiable risk factor for early mortality worldwide.1 The age-standardized prevalence of hypertension among adults is highest in sub-Saharan Africa.2 In Tanzania, 28% of adults aged 35 and above have hypertension but only 2% of these are aware of their hypertension.3 Barriers to hypertension awareness and treatment include low trust in biomedical care, unhealthy norms for diet and exercise, and prioritization of spiritual over physical health.4 Religious leaders, who have previously demonstrated their capacity to increase male circumcision for HIV prevention,5 may be ideal community partners to promote healthy behavior in sub-Saharan Africa, where 76% of people report confidence in religious institutions, vs. 51% in health systems and 44% in government.6 However, limited data exist documenting the perspectives of religious leaders on addressing the problem of hypertension. Therefore, this study sought to bridge this knowledge gap by exploring whether religious leaders might be positioned to address barriers to blood pressure reduction in their communities.
METHODS
In January and February 2021, we conducted in-depth interviews in rural areas of the Mwanza region of Tanzania, near Lake Victoria, with religious leaders from the country’s 2 major religions, Christianity and Islam. Participants were purposively sampled by visiting each church and mosque in 2 areas and requesting introductions to leaders of both sexes and varying ages within that institution, followed by snowball sampling through religious leaders’ referrals. Trained interviewers of the same gender as interviewees performed one-on-one interviews in Kiswahili. Interviews used open-ended questions to explore perspectives on hypertension and roles religious leaders could play in promoting hypertension control. Guided by the social ecological framework, we sought to understand how engaging religious leaders to address hypertension in their communities would impact individuals, family members and peers, and the community and social environment.7,8
Interviews were digitally recorded, transcribed verbatim, and translated into English. Two investigators (VL and GK) fluent in both Kiswahili and English reviewed transcripts to ensure accuracy of translations. Transcripts were coded using NVivo version 12 (Doncaster, Australia). We used an interpretative phenomenological analysis, a qualitative research method, to understand religious leaders’ perspectives on, and experiences with, hypertension.9,10 Three investigators (VL, GK, and JD) independently read and coded 3 transcripts each to identify in vivo codes. Through a collaborative group process, this initial list of codes was refined and applied to all transcripts. Finally, codes were organized into overarching themes to produce a thematic survey with illustrative quotations selected. Ethical permission to conduct this study was obtained from the National Institute for Medical Research (Tanzania) and Weill Cornell Medicine (New York, NY).
RESULTS
We interviewed 31 religious leaders, with a median age of 44 years (range 19–77). Among these leaders, 17 identified as Christians and 14 as Muslims; 14 were female and 17 were male (Supplementary Table S1 online). Only 12/31 (39%) reported ever having their blood pressure measured, although almost all were open to doing so if given the opportunity. Of those who had prior blood pressure measurement, 10/12 (83%) were tested because they were sick or experiencing perceived symptoms of hypertension such as sharp pain in the chest area, rapid heartbeats, fatigue, or shortness of breath.
Major themes that emerged during analysis were: (i) perceptions of hypertension are influenced by religious beliefs, (ii) religious beliefs can enable engagement with hypertension care, and (iii) religious leaders as potential partners for promoting hypertension control in communities (Table 1). These themes were consistent between those who had, and who had not had, their blood pressure measured at least once in their lifetime.
Table 1.
Key themes and subthemes from religious leaders’ perspectives about hypertension in their communities
| Themes | Frequency (n = 31) | Representative quotes |
|---|---|---|
| A. Perceptions of hypertension are influenced by religious beliefs | ||
| Perceptions of the causes of hypertension influenced by religion | 19 | i. “Maybe hypertension is caused by a lot of challenges. A person thinks a lot and a lot of problems have happened to him in his life. So, when he keeps on thinking about them, he gets hypertension.” (Muslim woman, age 38) “[The source of hypertension] for how I understand, maybe it is just poverty or a difficult situation… I mean it results in a person having stress, thinking of what I can do when my income is low. Then it causes something like hypertension.” (Muslim woman, age 52) ii. “[I don’t plan to be tested for hypertension because] I believe in God, and I do not have depression.” (Christian woman, age 39) |
| Perceptions of hypertension treatment influenced by religion | 10 | iii. “Let me say that it can be treated when you first reduce stress… You have to agree with… the things that have already happened. First, you have to accept the sources which caused you to have that situation and leave it to God.” (Muslim man, age 40) iv. “For us who are teaching things about faith, we believe that through prayers and believing in God and praying to God [hypertension] can be treated.” (Christian man, age 42) “What we are emphasizing is to pray to God so that he can help us with this problem of pressure” (Christian woman, age 44) |
| Perceptions of complications of hypertension influenced by religion | 13 | v. “When that situation happens during the mass, most [people] will interpret it as superstitious. And we always pray for them and some of them get better…. When you see that you are praying for him but there are no demons coming out, you then pour some water on him and place a fan near him.” (Christian man, age 50) “I think most of the people will think that [an individual losing consciousness in church] is witchcraft.” (Christian woman, age 51) vi. “When my mosque members knew about [my hypertension], most of them thought that the demons might have attacked me, but the more I was explaining to them, they got to understand that was a problem of hypertension.” (Muslim man, age 64) |
| B. Religious beliefs can enable engagement with hypertension care | ||
| Religious texts relevant to hypertension | 14 | i. “The Bible has prophesized that Jesus Christ talked about diseases with no cure. Hypertension has the medicines of controlling it, but not a cure.” (Christian man, age 40) “These scriptures were prophesized by the earlier prophets… even in the Qur’an they are there because these times were prophesied as the end times. That there will be different diseases and there will be no cure for them. One of the diseases is hypertension which has now arisen rapidly.” (Muslim woman, age 56) “There are a lot of diseases mentioned in the Qur’an. Even that one [hypertension] is there.” (Muslim man, age 64) |
| Potential for religious beliefs to promote biomedical care | 5 | ii. “We should not put God far away; he should be the first one. We should pray to [God] to bless us, but the second step is to check our health.” (Christian man, age 42) “Most of the scriptures encourage the use of medicine. Do not relax. And it is a very serious problem if you don’t use medicine.” (Muslim man, age 64) “You can be prayed for so that God can make [bearing the illness] easier. When he goes to the hospital, God can just put him at ease until he has healed.” (Muslim man, age 40) |
| C. Religious leaders as potential partners for promoting hypertension control in communities | ||
| Religious leaders stated their knowledge of hypertension was incomplete and they could benefit from further education | 11 | i. “My understanding about blood pressure, it is a disease which I hear about it but I have never seen a patient with a problem like that. But from the explanations I am hearing, I hear that it is a disease which attacks old people. Now from there, I have not gotten any more explanation about what is the source and how does it affect people.” (Christian man, age 57) “In the past I just knew that is only a fat person who gets pressure maybe because he has a lot of fats in his body… But after [I was diagnosed with hypertension], I had to ask myself depending on the body size I had, it was just a normal body size. So, I had to ask them why did I get pressure while I am not fat?” (Christian woman, age 48) |
| Religious leaders’ readiness to be educated and become educators | 24 | ii. “I have benefited to know what is hypertension, and I need enough education. More education so that I can go and be a leader to other people.” (Muslim woman, age 38) “I can do it anywhere even in the church. After receiving the training, I will gather people of different kind and I will explain to them and also educate them.” (Christian woman, age 44) “We pick a certain day and come to educate ourselves that there is this problem and get the knowledge and understand and also explain to other people about this information.” (Muslim man, age 41) “I have gotten education that personally I am supposed to check my health. That means I will be a good ambassador to other people to make them also check their health and to protect themselves from these complications of hypertension because I have also seen a lot of complications here.” (Christian woman, age 38) iii. “I think as a leader; a perfect place is a place of worship because it is where a lot of people meet. It is easy for me to get them and educate them because it is a place where people come together more often than other places.” (Christian woman, age 38) |
| Congregants’ readiness to receive education about hypertension | 21 | iv. “From what I understand about mosque members, they will be grateful because [hypertension] has been a problem. It has killed a lot of our relatives. It has brought challenges because people connect it with witchcraft.” (Muslim woman, age 56) “[Congregants] will feel good because I have given them knowledge about the disease of hypertension.” (Christian woman, age 32) “I think they will receive this well because when you are educating someone to avoid something dangerous for his life. He will receive that very well” (Christian man, age 50) |
| Religious leaders’ influence as trusted community messengers | 3 | v. “When they have come to pray… then they will be told [about hypertension] because that is the place where a lot of people gather…everyone makes an effort to come on Friday, so you can explain to the ones who will be there. Then when they return home, they will also explain to the people who remained at home that there is this and this about hypertension.” (Muslim man, age 52) vi. “Religious leaders have a huge contribution to the society because they are the people with an influence… when they talk about something, it can be received quickly.” (Muslim man, age 40) “But because I am a leader, I treated myself and I got better. They then believed that it can be treated.” (Muslim man, age 64) |
Perceptions of hypertension are influenced by religious beliefs
Three subthemes emerged when participants described their perceptions of the causes, treatment, and complications of hypertension.
Perceptions of the causes of hypertension influenced by religion
A majority of religious leaders reported that the major cause of hypertension is stress, shock, or depression: “Hypertension is caused by a lot of challenges. A person thinks a lot and a lot of problems have happened to him in his life, so when he keeps on thinking about them, he gets hypertension” (Muslim woman, age 38). This belief further affected people’s perceived risk of hypertension (Table 1, A.ii).
Perceptions of hypertension treatment influenced by religion
The prevalent concept that hypertension was caused by stress or depression frequently led to spiritualized understandings of how to manage hypertension. Hence, many believed that reducing stress was effective treatment: “Let me say that it can be treated when you first reduce stress…You have to agree with…the things that have already happened. First, you have to accept the sources which caused you to have that situation and leave it to God” (Muslim man, age 40). In addition, some religious leaders reported that prayers could treat hypertension (Table 1, A.iv).
Perceptions of complications of hypertension influenced by religion
When asked about a hypothetical scenario of a person with hypertension losing consciousness in a church or mosque, both Christian and Muslim leaders stated that their congregants would believe this person had been attacked by demons. Consequently, some leaders stated that the first response to a person losing consciousness would be collective prayer: “When that situation happens during the mass, most [people] will interpret it as superstitious. And we always pray for them and some of them get better…When you see that you are praying for him but no demons are coming out, you then pour some water on him and place a fan near him” (Christian man, age 50). Leaders also described perceptions of demonic forces causing hypertension even in the absence of health emergencies (Table 1, A.vi).
Religious beliefs can enable engagement with hypertension care
In contrast to perceptions of hypertension described above, religious leaders also pointed to specific religious texts and general religious beliefs that could enable biomedical care for hypertension.
Religious texts relevant to hypertension
When asked if there were any religious texts that reference hypertension, leaders frequently stated that the Bible or the Qur’an talk about hypertension, classifying it under “diseases with no cure” (Table 1, B.i): “These scriptures were prophesized by the earlier prophets…even in the Qur’an…these times were prophesized as the end times. That there will be different diseases and there will be no cure for them. One of the diseases is hypertension which has now arisen rapidly” (Muslim woman, age 56).
Potential for religious beliefs to promote biomedical care
Several religious leaders stated that an individual can rely on God for help and guidance while seeking biomedical care (Table 1, B.ii): “We should not put God far away; he should be the first one. We should pray to [God] to bless us, but the second step is to check our health” (Christian man, age 42).
Religious leaders as potential partners for promoting hypertension control in communities
Almost all religious leaders stated that they planned to seek testing for hypertension themselves, that their knowledge of hypertension was incomplete, and that hypertension was a major problem in their communities. Additionally, they recognized their potential to partner with health initiatives to address hypertension in their places of worship and broader communities.
Religious leaders reported incomplete knowledge about hypertension. Many religious leaders admitted that they could benefit from more education about hypertension (Table 1, C.i). For example, 1 Christian man stated, “My understanding about blood pressure, it is a disease which I hear about, but I have never seen a patient with a problem like that. But from the explanations I am hearing, I hear that it is a disease which attacks old people. Now from there, I have not gotten any more explanation about what is the source, and how does it affect people” (age 57).
Religious leaders’ readiness to be educated and become educators
All religious leaders expressed a desire to learn and educate their congregations on hypertension (Table 1, C.ii): “I have benefited to know what is hypertension, and I need enough education. More education so that I can go and be a leader to other people” (Muslim woman, age 38). Others reiterated this sentiment, stating that religious meetings can be ideal settings to educate communities about health because they leverage already-existing gatherings to reach large audiences (Table 1, C.iii).
Congregants’ readiness to receive education about hypertension
Leaders also reported that members of their congregations would welcome and benefit from being educated about hypertension (Table 1, C.iv): “From what I understand about my mosque members, they will be grateful because [hypertension] has been a problem. It has killed a lot of our relatives. It has brought challenges because people connect it with witchcraft” (Muslim woman, age 56).
Religious leaders’ influence as trusted community messengers
Religious leaders anticipated dissemination of education provided during religious services to reach people who had not even attended the services: “When they have come to pray…then they will be told [about hypertension] because that is the place where a lot of people gather…everyone makes an effort to come on Friday, so you can explain to the ones who will be there. Then when they return home, they will also explain to the people who remained at home that there is this and this about hypertension” (Muslim man, age 52).
Furthermore, some leaders recognized the strong influence they had within their communities (Table 1, C.vi): “Religious leaders have a huge contribution to the society because they are the people with an influence…when they talk about something, it can be received quickly” (Muslim man, age 40).
Discussion
Our data illustrate that religious leaders want to learn about hypertension and have high potential to transform religious beliefs from impediments to impetus for hypertension control in communities. Both Christian and Muslim leaders’ enthusiasm and perceived community readiness to receive teaching about hypertension highlight the feasibility and acceptability of partnerships with leaders from both religions to improve health. Our findings build on reports from Ghana, Nigeria, the Democratic Republic of Congo, and Uganda describing similar religious misconceptions about hypertension.11–14 These misconceptions about hypertension are known to delay care-seeking.15 Religious leaders are ideally positioned to confront these misconceptions and convey accurate messages regarding hypertension to their communities both in Tanzania and in other countries in sub-Saharan Africa, particularly in rural communities.16 Our data support Pan-African Society of Cardiology guidelines, which encourage face-to-face education by religious leaders to reduce hypertension.17
We report that religious leaders are trusted messengers who, via their wide influence and platform for regular communication, are uniquely equipped to bring health information to their communities. Religious institutions provide both an established place and a strong social network for promoting sustainable, community-wide change. The World Health Organization recently recommended engaging religious leaders as a key action to promote male circumcision in Africa, citing our team’s randomized trial that demonstrated the effectiveness of this strategy.5,18 In this trial and our other work, both Christian and Muslim leaders consistently recognized their influence and the eagerness of their communities to receive health teaching from them.5,19 As previously reported by Christians with hypertension in Ghana,20 our data illustrate ways that leaders can encourage people with hypertension to draw on their faith to find realistic hope and self-efficacy for living healthy lives with hypertension.
Controlling hypertension is among the most cost-effective strategies for preventing premature mortality, and effective interventions are urgently needed.21,22 A systematic review and meta-analysis examining the impact of hypertension prevention interventions in sub-Saharan Africa reported low to medium quality evidence that reducing sodium intake, mass media education campaigns, and physical activity promotion may lead to blood pressure reduction in African adults.23 Based on our findings and prior experience working with religious leaders for promotion of other health interventions, we hypothesize that leveraging the influence of religious leaders as trusted community messengers can further augment the blood pressure reductions achieved with other blood pressure-reducing interventions in sub-Saharan Africa.
We acknowledge the limitation that our data were collected from only 1 region in Tanzania. However, given our findings’ compatibility with prior studies from Tanzania and beyond, and inclusion of leaders from multiple branches of Christianity and Islam, we anticipate these data are broadly representative.
In conclusion, we report that religious leaders are eager to learn about hypertension, to share this knowledge with others, and to contribute to improved health in their communities. Our data support the potential impact of partnerships with religious leaders as trusted community members to promote awareness, treatment, and control of hypertension in sub-Saharan Africa.
Supplementary Material
ACKNOWLEDGMENTS
We thank Dr Mubarakali Janmohamed, MD, MBBS, MRCP for his thoughtful comments on an earlier draft of this manuscript.
FUNDING
We thank the John Templeton Foundation and Weill Cornell Medicine for supporting this project.
DISCLOSURE
The authors declared no conflict of interest.
DATA AVAILABILITY
The data underlying this article cannot be shared publicly due to the possibility of identifying study participants with a unique story and identifying characteristics. Redacted data will be shared with qualified researchers upon reasonable request to the corresponding author.
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The data underlying this article cannot be shared publicly due to the possibility of identifying study participants with a unique story and identifying characteristics. Redacted data will be shared with qualified researchers upon reasonable request to the corresponding author.