Of the 428 patients with hypertension, 32 were identified as of black Caribbean ethnicity. Nineteen agreed to participate: six men and 13 women. Fifteen were born in Jamaica, two in the UK of Jamaican parents, one in Guyana and one in Trinidad. Their ages ranged from 40 to 75 years (mean age 62 years). Thirteen patients — five men and eight women — declined to take part or could not be contacted.
Symptoms of hypertension
Fourteen participants reported that when their blood pressure was high they had symptoms, including pain in the head or chest, dizziness or feeling that their head was spinning. Participants described having had such unexplained symptoms prior to being diagnosed with hypertension and subsequently associated these symptoms with elevated blood pressure. Thus, a pattern for high blood pressure being identified with bodily sensations was established.
A minority of participants (n
= 4) relied on having symptoms or an absence of symptoms as an indicator of the need to take tablets or not:
‘Yes, because I feel the headache, then I will take them … I would take it straight off. I would have to take it straightaway because it is much more serious then … I feel that I'm okay and better … so I just ease off for a while…’ (Participant 030.)
Feeling well, with an absence of symptoms, was equated with being well:
‘Well I don't take something [medication], if I'm not sick, I don't take it. Would you take something if you don't feel sick?’ (Participant 029.)
‘Normal’ blood pressure and the need for prescribed medication
Participants' concepts of ‘high’ and ‘normal’ blood pressure informed the way they understood and managed their condition. Participants who had several measurements of what healthcare professionals described as ‘normal’ blood pressure questioned their doctors about stopping prescribed medication:
‘Well as I said, if you are “normal”, why take the tablets? … You only take it if you know you have it, but if you're normal I don't think it makes sense, I don't.’ (Participant 003.)
These participants equated normal blood pressure with being ‘better’ or cured, and with no need for prescribed medicine. In this context hypertension was seen as a condition with ‘flare-ups’, which only then needed treatment.
‘The body is mine, but …’
Although acknowledging doctors' expertise, participants distinguished between that and their own subjective experiences of health or ill health:
‘We never study our own body but the doctors, that's what they are there for, so we put our faith in them … the body is mine, but the doctor knows about the body more than I.’ (Participant 001.)
These participants reported that they acted on doctors' advice:
‘My doctor make it clear to me “If you don't take the tablets and something happen to you, you know this is bad and this is it.” So this is why I just follow. I believe in him, he knows what he knows.’ (Participant 001.)
One participant, however, rejected his doctor's advice to take prescribed medication. He reported that he had lost faith in his doctor, alleging that the doctor had not informed him about the side effects of his prescribed medication.
Prescribed drugs and traditional remedies ‘like my mother used to give us back home’
All participants were prescribed hypertensive medication, and seven reported taking it as prescribed. Reliance on doctors' advice, and the fact that prescribed drugs were rigorously tested were the main factors influencing their adherence:
‘The tablets I'm taking for the blood pressure, they are well tested and it's important … with the tablets you're sure …’ (Participant 002.)
Nine participants also used what many of them called ‘bush’ remedies. These were Caribbean herbal remedies such as medina, cerasee, banana leaf, breadfruit leaf and green papaya. Participants were reluctant to reveal their use of traditional remedies to health professionals, fearing disapproval.
These participants contrasted prescribed drugs with ‘bush’ remedies. ‘Bush’ was seen as more natural than pharmaceuticals, which ‘added impurities to the blood and body’. ‘Bush’ was also considered good for purifying blood that had been ‘polluted’ by pharmaceuticals, and bitter properties of ‘bush’ were viewed as especially potent:
‘We have a plant, we use the bark, it's very, very bitter … because it's that bitter … bitterness is good to purify the blood.’ (Participant 028.)
Of the nine people who used ‘bush’, eight used it as a remedy to purify the blood rather than as an antihypertensive. Only one participant, who visited a herbalist, used it as an antihypertensive.
‘Bush’ was also seen as more trustworthy than pharmaceuticals by nine participants because it was part of ‘traditional’ healing practices, with apparently beneficial results:
‘We are old fashioned, we grow up with it … In our days, younger coming up, we never have doctor to run to. Your parents boil herbal things and give [them] you. That's why many Jamaicans so [are] bloody strong!’ (Participant 026.)
This trust in ‘bush’ was mediated by generational familiarity with it. For example, one 40-year-old participant, born in the UK, did not use ‘bush’ because, unlike her Caribbean parents who did, she knew nothing of the variety of herbs or their use. Familiarity with ‘bush’ did not necessarily mean it was used, however; its effectiveness was questioned at times. For example, two 60-year-old participants who were familiar with ‘bush’, took prescribed medication only, stating that ‘bush’ use was a practice suitable for the Caribbean but not the UK.
Patterns of medication consumption
The 12 participants who reported that they did not use antihypertensives as directed made different decisions about how to use their medication, with various patterns of consumption evident (Box 1
). Reasons for decisions about medication use included a lack of symptoms or diagnoses of ‘normal’ blood pressure, experiencing medication side-effects, and fearing impurities or harmful long-term or side-effects from prescribed medication.
Box 1. Patterns of medication consumption.
- Antihypertensive medication used as prescribed
- Self-regulated reduction of prescribed dosage
- Medication used as prescribed but supplemented with ‘bush’ medicine
- Medication stopped when no symptoms experienced, resumed when symptomatic
- Medication stopped periodically to reduce perceived harmful side or long-term effects from it
- Medication replaced by ‘bush’ definitively
Participants described how their decisions about medication use varied over time. Two participants reported that they occasionally forgot to take medication, or left it at home when they went out and were therefore unable to take it as prescribed. Other participants gave examples of adopting ‘routinised’ strategies and cues to ensure they took their medicines.