Cultural and behavioral barriers to compliance and incidence of heart disease in hypertensive patients in St. Croix, United States Virgin Islands
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Introduction: Approximately one in three Americans suffer from hypertension (HTN), which is the most common risk factor for the development of cardiovascular disease such as heart attack, heart failure and stroke. The pathophysiology behind the development of the disease, while multifactorial, is thought to stem primarily from genetic and behavioral factors such as diet and lack of exercise. Antihypertensive medication has been shown to be effective in lowering blood pressure and circumventing the incidence of development of heart disease, but remains ineffective against the non-compliant behavior of patients. Failure to comply with, or adhere to, a physician's medication regimen opens the patients to an increased risk of uncontrolled blood pressure and the development of heart disease. Unfortunately, it is far too common of a problem as it is estimated that over half of patients do not take antihypertensive medication. Reasons for non-compliant behavior include: the adverse side effects of medication, the prescription of more than one type of medication, the desire to not remain on medication for a long period of time and a preference for alternative treatments to pharmacological therapy. Non-compliance is also associated with race and age, as individuals who are African-American and younger than seventy five appear to be at an increased risk. It is thought that the reason African-Americans are more non-compliant has to due with the fear of losing their culture, as changing of their diet would equate to abandoning who they are. The United States Virgin Islands (USVI), an American territory with a population of mainly African descent, has a unique and distinct culture. Few studies have been done evaluating the contribution of cultural and behavioral practices on non-compliant behavior with medication within this population, and to date, no data is available on compliance and HTN. Methods: Forty-four hypertensive patients prescribed medication by a physician, were interviewed on cultural and behavioral practices on St. Croix, one island of the USVI. Patients were asked whether or not they took their medication as prescribed by a physician and were grouped according to compliance. Non-compliant and compliant patients were then compared on age, salt intake, use of herbal reh1edies for HTN, presence of co-morbidities and trust of pharmacological treatments. Patients were then divided based on whether or not they had heart disease and if they used herbal medication. Analyses were carried out using chi-square analysis and Fisher's exact test where applicable. Results: Out of the forty four patients, fifteen admitted to being non-compliant with their medication. There were no statistically significant differences between the compliance groups except with salt intake and trust of pharmacological medication. There was a marginally significant, but inconclusive, difference in relation to presence of other co-morbidities. Herbal medication use was found in both compliance groups. Discussion: Admitted non-compliance within the population of this study was around thirty four percent. Both participant groups, compliant and non-compliant, had individuals who used herbal remedies. Use of herbs, such as pomegranate, cattle's tongue and hawthorn, were viewed by some as more natural than pharmacological medication. Side effects associated with antihypertensive medication were the most common reason cited by patients for distrust of prescription medication. The significance of salt intake between compliant and non-compliant patients can be looked at from two perspectives. Compliant patients may be more inclined to give up salt because they may care more about the effect of salt on their health, or the behavior of non-compliant patients may be suggestive of the difficulty of giving up salt because of its use in cultural dishes. Future research with a larger population size should be conducted to look into the definitive nature culture has on behavioral and medicinal compliance within the USVI.
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