The World Health Organization projects that in the African region, by 2030, non-communicable diseases (NCDs) will be the biggest cause of death (1). The relative burden of NCDs is expected to increase as both HIV/AIDS related mortality declines with the roll-out of antiretroviral therapy and the region continues to experience the rapid urbanization of communities (2). Hypertension, stroke, and ischaemic heart disease are amongst the most common NCDs causing premature deaths among adults living in South Africa (3). Over half of strokes and ischaemic heart disease in South Africa are caused by hypertension and these cardiovascular and cerebrovascular diseases are reported to be more prevalent in rural areas compared to urban areas (3).
The high prevalence of hypertension in South Africa will likely result in increased mortality and morbidity in rural compared to urban areas due, in part, to poorly organized health care systems, intermittent drug supply, and shortage of health care workers (4–6). Reduced salt and caloric intake and increase in physical activity are the widely recommended therapeutic approaches to meeting national hypertension targets (7–9).
There is a paucity of research that provides a profile of daily physical activity practices of rural South African adults living with hypertension. A study by (10) assessed physical activity for rural South Africans using short versions of physical activity subjective assessment which does not provide information about the domain of physical activity (transportation, job, leisure, and housework) performed each day. Another study using a short version physical activity questionnaire by (11) in the general population concluded that adults in rural Western Cape engaged in more physical activity than urban adults from the same province. A further study by (12) assessed physical activity for middle-aged and older rural adults and recommended that physical activity interventions should be targeted for adults from the age of 40 years in order to provide health benefits earlier in life.
Available literature on dietary practices of rural South African adults have provided successful intervention recommendations for hypertension but the recommendations are not sustained in the long run. For example, a study by (13) provided recommendations of food replacement which participants cannot afford. Another study by (14) reported that adults in rural South Africa have good nutrition knowledge but this did not translate into regular healthy nutrition practices. The literature on physical activity and diet practices for rural South African adults points to a need to have better understanding of the sociocultural influences so that interventions targeting the control of hypertension can consider the realities of this population.
To the authors’ knowledge there are no interventions to test whether adaptations in physical activity and diet focusing on a contextualized structured health promotion approach could lower high blood pressure in a rural South African adult population with hypertension (15, 16). There is a need for studies to investigate the feasibility of implementing such interventions. A contextualized intervention is one that is adapted to the local context of the target population and informed by the population needs. Many adults in rural South Africa are involved in daily manual labour as part of their activities of daily living but this is performed at low intensity and is not well documented (10). Common manual labour activities reported by adults living in rural South Africa include walking for wood collection, different aspects of farming, yardwork, walking as a means of transport, and housework. These activities are not adequate to paint a full picture of the daily routine practices of rural adults and need further exploration (15, 17). There is lack of information regarding the type, frequency, and intensity of physical activities performed by rural South African adults. Moreover, many diet based interventions are usually not affordable or not accepted by the rural adults, hence the need for tailor-made interventions that consider the contextual realities of the population (Faber & Wenhold, 2012; Temple et al., 2011).
We followed a systematic process to design an evidence and theory-informed contextualised 10 week physical activity and diet intervention which recommends adjusting routine physical activity and diet practices for the control of hypertension using the Intervention Mapping (IM) protocol (20) – HYPHEN (HYpertension control using PHysical activity and diEt in a rural coNtext). Intervention Mapping is used as a planning approach to develop theory- and evidence-based health promoting intervention programs. Intervention Mapping has been suggested as a useful and effective tool to further improve the development and application of theories to promote nutrition and physical activity (21). The tasks in the IM protocol are iterative with the program planner revisiting previous steps throughout the process so that all objectives, outcomes, and determinants are addressed. This process allows for the development and delivery of the intervention to be replicated
Aim and objectives.
The aim of this study is to design, implement, and evaluate the feasibility and acceptability of a contextually appropriate program for hypertension control in adults from a rural South African population.
The objectives of the feasibility study are:
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To present the social and cultural beliefs, perceptions and practices regarding physical activity and diet which may influence the development of an intervention for the control of hypertension adults living in rural South Africa.
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To develop and implement a contextually appropriate intervention programme for the control of hypertension using physical activity and diet.
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To determine recruitment, retention, and attrition rates, intervention uptake, engagement, adherence to the intervention and the evaluation measures.
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To present data on health-related indicators (blood pressure, physical activity, diet consumption, body mass index, urine sodium, and waist-hip ratio) before and after the intervention.