Sociodemographic and Behavioral Factors Associated With Hypertension and Depression in 4 Rural Communities in Northern Ghana: A Cross-Sectional Study.

OBJECTIVES: The prevalences of hypertension and depression in sub-Saharan Africa are substantial and rising, despite limited data on their sociodemographic and behavioral risk factors and their interactions. We undertook a cross-sectional study in 4 communities in the Upper East Region of Ghana to identify persons with hypertension and depression in the setting of a pilot intervention training local nurses and health volunteers to manage these conditions. METHODS: We quantified hypertension and depression prevalence across key sociodemographic factors (age, sex, occupation, education, religion, ethnicity, and community) and behavioral factors (tobacco use, alcohol use, and physical activity) and tested for association by multivariable logistic regression. RESULTS: Hypertension prevalence was higher in older persons (7.6% among 35- to 50-year-olds vs 16.4% among 51- to 70-year-olds) and among those reporting alcohol use (18.9% vs 8.5% between users and nonusers). In multivariable models, only older age (AOR 2.39 [1.02, 5.85]) and residence in the community of Wuru (AOR 7.60 [1.81, 32.96]) were independently associated with hypertension, and residence in Wuru (AOR 23.58 [7.75-78.25]) or Navio (AOR 7.41 [2.30-24.74]) was the only factor independently associated with depression. CONCLUSIONS: We report a high prevalence of both diseases overall and in select communities, a trend that requires further research to inform targeted chronic disease interventions.

Emotional and Financial Stressors in New York City During the COVID-19 Pandemic: A Consecutive Cross-Sectional Analysis.

Mental and financial hardship during the COVID-19 pandemic in New York City was severe, but how vulnerable groups have been disproportionately impacted is incompletely understood. In partnership with community stakeholders, we administered a web-based survey to a convenience sample of New York City residents (18 + years) from May 2020 to April 2021 to evaluate their financial and emotional stressors. We analyzed outcomes by race, ethnicity, and education level. A total of 1854 adults completed the survey across three consecutive non-overlapping samples. Fifty-five percent identified other than non-Latinx White. Sixty-four percent reported emotional stress; 38%, 32%, and 32% reported symptoms of anxiety, depression, and post-traumatic stress disorder respectively; and 21% reported a large adverse financial impact. The leading unmet needs were mental health and food services (both 19%), and health services (18%). Need for both resources grew over time. Adverse financial impact directly correlated with presence of all four adverse mental health outcomes above. In multivariate analysis, non-White race and lack of college degree were associated with adverse financial impact, whereas LGBT identity and lack of college degree were associated with mental health impact. Throughout the COVID-19 pandemic, participants in this research demonstrated a large and growing mental and financial strain, disproportionately associated with lower education level, non-White race, and LGBT status. Our findings suggest an urgent need to differentially target COVID-19 mental health and resource support in New York City to persons in these vulnerable communities.

Bringing Generalists to Global Health: a Missed Opportunity and Call to Action.

The credo of the generalist physician has always been the promotion of health for all, in every aspect: not just multiple vulnerable organ systems, but multiple social, cultural, and political factors that contribute to poor health and exacerbate health inequity. In recent years, the field of global health has also adopted this same mission: working across both national and clinical specialty borders to improve health for all and end health disparities worldwide. Yet within the Society for General Internal Medicine, and among American generalists, engagement in global health, both within and outside the USA, remains uncommon. We see this gap as an opportunity, because in fact generalists in America already have the skills and experience that global health badly needs. SGIM could promote generalists to global health's vanguard, with three core steps. First, we generalists must continue to integrate health for the vulnerable into our domestic work, generating care models applicable in low-resource settings around the globe. Conversely, we must also engage with and implement international ideas and solutions for universal access to primary care for vulnerable patients in the USA. And lastly, we must build platforms to connect ourselves with colleagues worldwide to exchange these learnings.

Community perspectives on cardiovascular disease control in rural Ghana: A qualitative study.

BACKGROUND: Cardiovascular disease (CVD) prevalence is high in Ghana-but awareness, prevention, and treatment is sparse, particularly in rural regions. The nurse-led Community-based Health Planning and Services program offers general preventive and primary care in these areas, but overlooks CVD and its risk factors. METHODS: We conducted in-depth interviews with 30 community members (CM) in rural Navrongo, Ghana to understand their knowledge and beliefs regarding the causes and treatment of CVD and the potential role of community nurses in rendering CVD care. We transcribed audio records, coded these data for content, and qualitatively analyzed these codes for key themes. RESULTS: CMs described CVD as an acute, aggressive disease rather than a chronic asymptomatic condition, believing that CVD patients often die suddenly. Yet CMs identified causal risk factors for CVD: not only tobacco smoking and poor diet, but also emotional burdens and stressors, which cause and exacerbate CVD symptoms. Many CMs expressed interest in counseling on these risk factors, particularly diet. However, they felt that nurses could provide comprehensive CVD care only if key barriers (such as medication access and training) are addressed. In the interim, many saw nurses' main CVD care role as referring to the hospital. CONCLUSIONS: CMs would like CVD behavioral education from community nurses at local clinics, but feel the local health system is now too fragile to offer other CVD interventions. CMs believe that a more comprehensive CVD care model would require accessible medication, along with training for nurses to screen for hypertension and other cardiovascular risk factors-in addition to counseling on CVD prevention. Such counseling should build upon existing community beliefs and concerns regarding CVD-including its behavioral and mental health causes-in addition to usual measures to prevent CVD mortality such as diet changes and physical exercise.

Hypertension screening, prevalence, treatment, and control at a large private hospital in Kampala, Uganda: A retrospective analysis.

Adult hypertension prevalence in Uganda is 27%, but only 8% are aware of their diagnosis, accordingly treatment and control levels are limited. The private sector provides at least half of care nationwide, but little is known about its effectiveness in hypertension control. We analyzed clinical data from 39 235 outpatient visits among 17 777 adult patients from July 2017 to August 2018 at Uganda's largest private hospital. We calculated blood pressure screening rate at every visit, and hypertension prevalence, medication treatment, and control rates among the 5 090 patients with two or more blood pressure checks who received any medications from the hospital's pharmacy. We defined hypertension in this group as 1) an average of two blood pressure measurements at separate consecutive visits, higher than 140 mm Hg systolic or 90 mm Hg diastolic, 2) receipt of any antihypertensive medication, or 3) the use of a hypertension electronic medical record code. We deemed hypertension control as normotensive at the most recent check. 12 821 (72.1%) of patients received at least 1 blood pressure check. Among the 5 090 patients above, 2 121 (41.6%) had hypertension (33.4% age-standardized to a world population standard): 1 915 (37.6%) with elevated blood pressure, and 170 (3.3%) were normotensive but receiving medication. 838 (39.4%) of patients with hypertension received medication at least once. Overall, 18.3% of patients achieved control (27% of treated patients, and 15% of untreated patients). Hypertension is common and incompletely controlled in this Ugandan private-sector population, suggesting several avenues for novel interventions.

Social and demographic correlates of cardiovascular mortality in the Kassena-Nankana districts of Ghana: a verbal post-mortem analysis.

BACKGROUND: The burden of cardiovascular disease (CVD) in Ghana is rising, but details on its epidemiology are scarce. We sought to quantify mortality due to CVD in two districts in rural Ghana using verbal post-mortem (VPM) data. METHODS: We conducted a proportional sub-hazards analysis of 10 232 deaths in the Kassena-Nankana East and West districts from 2005 to 2012, to determine adult mortality attributed to CVD over time. We stratified results by age, gender and socio-economic status (SES), and compared CVD mortality among SES and gender strata over time. A competing risk model estimated the cumulative effect of eliminating CVD from the area. RESULTS: From 2005 to 2012, CVD mortality more than doubled overall, from 0.51 deaths for every 1000 person-years in 2005 to 1.08 per 1000 person-years in 2012. Mortality peaked in 2008 at 1.23 deaths per 1000 person-years. Increases were comparable in men (2.0) and women (2.3), but greater among the poorest residents (3.3) than the richest (1.3), and among persons aged 55-69 years (2.1) than those aged ≥70 years (1.8). By 2012, male and female CVD mortality was highest in middle-SES persons. We project that eliminating CVD would increase the number of individuals reaching age 73 years from 35% to 40%, adding 1.6 years of life expectancy. CONCLUSIONS: The burden of CVD on overall mortality in the Upper East Region is substantial and markedly increasing. CVD mortality has especially increased in lower-income persons and persons in middle age. Further initiatives for the surveillance and control of CVD in these vulnerable populations are needed.

Causes of medication non-adherence and the acceptability of support strategies for people with hypertension in Uganda: A qualitative study.

BACKGROUND: Hypertension is the most common non-communicable disease in Uganda and its prevalence is predicted to grow substantially over the next several years. Rates of hypertension control remain suboptimal, however, due in part to poor medication adherence. There is a significant need to better understand the drivers of poor medication adherence for patients with non-communicable diseases and to implement appropriate interventions to improve adherence. OBJECTIVE: The purpose of this study was two-fold. First, this study sought to understand what factors support or undermine patients' efforts to adhere to their hypertensive medications at baseline. Second, this study sought to explore the acceptability and feasibility of adherence interventions to both providers and patients. METHODS: This study was conducted at a large, urban private hospital in Kampala, Uganda. We conducted key informant interviews with both providers and patients. We explored their beliefs about the causes of medication non-adherence while examining the acceptability of support strategies validated in similar contexts, such as: daily text reminders, educational materials on hypertension, monthly group meetings (i.e. "adherence clubs") led by patients or providers, one-on-one appointments with providers, and modified drug dispensing at the hospital pharmacy. STUDY DESIGN AND PARTICIPANTS: Fifteen healthcare providers and forty-two patients were interviewed. All interviews were transcribed, and these transcripts were analyzed using the NVIVO software. We utilized a conventional content analysis approach informed by the Health Belief Model. RESULTS: Of the proposed interventions, participants expressed particularly strong interest in adherence clubs and educational materials. Participants drew connections between these interventions and previously underexplored drivers of non-adherence, which included the lack of symptoms from untreated hypertension, fear of medication side effects, interest in traditional herbal medicine, and the importance of family and community support. CONCLUSIONS: Both providers and patients at the facility recognized medication non-adherence as a major barrier to hypertension control and expressed interest in improving adherence through interventions that addressed context-specific barriers.

Constructing a Nurse-led Cardiovascular Disease Intervention in Rural Ghana: A Qualitative Analysis.

Background: Cardiovascular disease (CVD) is a growing burden in low- and middle-income countries. Ghana seeks to address this problem by task-shifting CVD diagnosis and management to nurses. The Community-Based Health Planning and Services (CHPS) initiative offers maternal and pediatric health care throughout Ghana but faces barriers to providing CVD care. We employed in-depth interviews to identify solutions to constraints in CVD care to develop a nurse-led CVD intervention in two districts of Ghana's Upper East Region. Objective: This study sought to identify non-physician-led interventions for the screening and treatment of cardiovascular disease to incorporate into Ghana's current primary health care structure. Methods: Using a qualitative descriptive design, we conducted 31 semistructured interviews of community health officers (CHOs) and supervising subdistrict officers (SDOs) at CHPS community facilities. Summative content analysis revealed the most common intervention ideas and endorsements by the participants. Findings: Providers endorsed three interventions: increasing community CVD knowledge and engagement, increasing nonphysician prescribing abilities, and ensuring provider access to medical and transportation equipment. Providers suggested community leaders and volunteers should convey CVD knowledge, marshaling established gathering practices to educate communities and formulate action plans. Providers requested lectures paired with experiential learning to improve their prescribing confidence. Providers recommended revising reimbursement and equipment procurement processes for expediting access to necessary supplies. Conclusions: Frontline CHPS primary care providers believe CVD care is feasible. They recommended a three-pronged intervention that combines community outreach, provider training, and logistical support, thereby expanding task-shifting beyond hypertension to include other CVD risk factors. This model could be replicable elsewhere.

Predictors of nursing leadership in Uganda: a cross-sectional study.

Evidence regarding the role of nurses-in-leadership and how to engage nurses in policy decisions is minimal in sub-Saharan Africa. The purpose of this study was: (1) to assess the leadership practices of nurses-in-leadership in Uganda (by self-report) and from the perspective of 'followers' (direct-report, peers, co-workers, other); and (2) to determine factors (positively) associated with leadership practices. We surveyed 480 nurses, 120 in leadership roles (Response Rate 57%) and 360 'followers' (Response Rate 60%), who were recruited from five hospitals in Kampala, Uganda. We used the Leadership Practice Inventory (Self and Observer), a project-specific demographic questionnaire and Denison's Organizational Culture Survey (DOCS). Sixty-three per cent of the respondents held a registered nursing certificate; 79% had received formal leadership training; 47% were based in private for-profit (PFP) hospitals, 28% in private not-for-profit (PNFP) and 25% in public hospitals. Among the five leadership practices, nurses-in-leadership used the practice of Model the Way (M = 8.27, SD = 1.30), Challenge the Process (M = 8.12, SD = 1.30) and Encourage the Heart (M = 8.04, SD = 1.51) more frequently (on a 10-point Likert Scale). Inspire a Shared Vision (M = 7.82, SD = 1.57) and Enable Others to Act (M = 7.62, SD = 1.66) practices were used less frequently. The same rank order was true for leadership scores from the perception of followers. However, leadership scores by followers were significantly lower (P < 0.01) than the nurse leader self-reported scores across all sub-scales. Leadership practice scores were higher in public than private hospitals (P < 0.0001). Organizational culture (OC) was associated (P < 0.001) with leadership practices. Although overall leadership practice scores were generally high, the less frequent use of Inspire and Enable practices suggests opportunities for targeted improvement. Moreover, differences between self-reported and leadership scores by followers suggest perception gaps between leaders and their followers. The positive relationship between public hospital settings and self-reported leadership practices among nurses-in-leadership suggests that important nursing leadership practices are possible even in a low-resource clinical setting.

Protecting the vulnerable during COVID-19: Treating and preventing chronic disease disparities.

The coronavirus disease 2019 (COVID-19) pandemic has exacerbated health disparities across ethnic and socioeconomic groups. Non-communicable diseases (NCDs) - such as hypertension, diabetes, and obstructive lung diseases - are key drivers of this widening gap, because they disproportionately afflict vulnerable populations. Vulnerable populations with non-communicable diseases, in turn, are disproportionately affected by COVID-19 itself - but also at increased risk of poor outcomes from those underlying conditions. Proven strategies for NCD control must be adapted to help vulnerable patients react to these dual threats. We detail six key policy interventions - task shifting, workforce protection, telehealth and mobile services, insurance restructuring and increased funding for NCDs, prescription policies for NCDs and community partnerships - to bridge this care gap. Long-term integration of these care models post-COVID-19 may prevent care shocks during future pandemics, bolstering emerging universal primary care models.

Two-drug fixed-dose combinations of blood pressure-lowering drugs as WHO essential medicines: An overview of efficacy, safety, and cost.

Cardiovascular diseases (CVD) are the world's leading cause of death. High blood pressure (BP) is the leading global risk factor for all-cause preventable morbidity and mortality. Globally, only about 14% of patients achieve BP control to systolic BP <140 mm Hg and diastolic BP <90 mm Hg. Most patients (>60%) require two or more drugs to achieve BP control, yet poor adherence to therapy is a major barrier to achieving this control. Fixed-dose combinations (FDCs) of BP-lowering drugs are one means to improve BP control through greater adherence and efficacy, with favorable safety and cost profiles. The authors present a review of the supporting data from a successful application to the World Health Organization (WHO) for the inclusion of FDCs of two BP-lowering drugs on the 21st WHO Essential Medicines List. The authors discuss the efficacy and safety of FDCs of two BP-lowering drugs for the management of hypertension in adults, relevant hypertension guideline recommendations, and the estimated cost of such therapies.

Adapting a nurse-led primary care initiative to cardiovascular disease control in Ghana: a qualitative study.

BACKGROUND: Cardiovascular Disease (CVD) is a growing cause of morbidity and mortality in Ghana, where rural primary health care is provided mainly by the Community-based Health Planning and Services (CHPS) initiative. CHPS locates nurses in community-level clinics for basic curative and preventive health services and provides home and outreach services. But CHPS currently lacks capacity to screen for or treat CVD and its risk factors. METHODS: In two rural districts, we conducted in-depth interviews with 21 nurses and 10 nurse supervisors to identify factors constraining or facilitating CVD screening and treatment. Audio recordings were transcribed, coded for content, and analyzed for key themes. RESULTS: Respondents emphasized three themes: community demand for CVD care; community access to CVD care; and provider capacity to render CVD care. Nurses and supervisors noted that community members were often unaware of CVD, despite high reported prevalence of risk factors. Community members were unable to travel for care or afford treatment once diagnosed. Nurses lacked relevant training and medications for treating conditions such as hypertension. Respondents recognized the importance of CVD care, expressed interest in acquiring further training, and emphasized the need to improve ancillary support for primary care operations. CONCLUSIONS: CHPS staff expressed multiple constraints to CVD care, but also cited actions to address them: CVD-focused training, provision of essential equipment and pharmaceuticals, community education campaigns, and referral and outreach transportation equipment. Results attest to the need for trial of these interventions to assess their impact on CVD risk factors such as hypertension, depression, and alcohol abuse.

Assessing Providers' Approach to Hypertension Management at a Large, Private Hospital in Kampala, Uganda.

Background: Hypertension is increasingly prevalent in Uganda and its clinical management remains suboptimal across the country. Prior research has elucidated some of the factors contributing to poor control, but little is known about providers' approaches to hypertension management and perceptions of barriers to care. This is particularly true in private health care settings - despite the fact that the private sector provides a substantial and growing portion of health care in Uganda. Objective: Our exploratory, pragmatic qualitative study aimed to examine the factors affecting the quality of hypertension care from the perspective of providers working in an urban, private hospital in Uganda. We focused on the organizational and system-level factors influencing providers' approaches to management in the outpatient setting. Methods: We conducted interviews with 19 health care providers working in the outpatient setting of a 110-bed, private urban hospital in Kampala, Uganda. We then coded the interviews for thematic analysis, using an inductive approach to generate the study's findings. Findings: Several themes emerged around perceived barriers and facilitators to care. Providers cited patient beliefs and behaviors, driven in part by cultural norms, as a key challenge to hypertension control; however, most felt their own approach to hypertension treatment aligned with international guidelines. Providers struggled to collaborate with colleagues in coordinating the joint management of patients. Furthermore, they cited the high cost and limited availability of medication as barriers. Conclusions: These findings offer important strategic direction for intervention development specific to this Ugandan context: for example, regarding culturally-adapted patient education initiatives, or programs to improve access to essential medications. Other settings facing similar challenges scaling up management of hypertension may find the results useful for informing intervention development as well.

Hypertension testing and treatment in Uganda and Kenya through the SEARCH study: An implementation fidelity and outcome evaluation.

BACKGROUND: Hypertension (HTN) is the single leading risk factor for human mortality worldwide, and more prevalent in sub-Saharan Africa than any other region [1]-although resources for HTN screening, treatment, and control are few. Most regional pilot studies to leverage HIV programs for HTN control have achieved blood pressure control in half of participants or fewer [2,3,4]. But this control gap may be due to inconsistent delivery of services, rather than ineffective underlying interventions. METHODS: We sought to evaluate the consistency of HTN program delivery within the SEARCH study (NCT01864603) among 95,000 adults in 32 rural communities in Uganda and Kenya from 2013-2016. To achieve this objective, we designed and performed a fidelity evaluation of the step-by-step process (cascade) of HTN care within SEARCH, calculating rates of HTN screening, linkage to care, and follow-up care. We evaluated SEARCH's assessment of each participant's HTN status against measured blood pressure and HTN history. FINDINGS: SEARCH completed blood pressure screens on 91% of participants. SEARCH HTN screening was 91% sensitive and over 99% specific for HTN relative to measured blood pressure and patient history. 92% of participants screened HTN+ received clinic appointments, and 42% of persons with HTN linked to subsequent care. At follow-up, 82% of SEARCH clinic participants received blood pressure checks; 75% received medication appropriate for their blood pressure; 66% remained in care; and 46% had normal blood pressure at their most recent visit. CONCLUSION: The SEARCH study's consistency in delivering screening and treatment services for HTN was generally high, but SEARCH could improve effectiveness in linking patients to care and achieving HTN control. Its model for implementing population-scale HTN testing and care through an existing HIV test-and-treat program-and protocol for evaluating the intervention's stepwise fidelity and care outcomes-may be adapted, strengthened, and scaled up for use across multiple resource-limited settings.

Assessment of Barriers and Facilitators to the Delivery of Care for Noncommunicable Diseases by Nonphysician Health Workers in Low- and Middle-Income Countries: A Systematic Review and Qualitative Analysis.

Importance: Cardiovascular disease, cancer, and other noncommunicable diseases (NCDs) are the leading causes of mortality in low- and middle-income countries. Previous studies show that nonphysician health workers (NPHWs), including nurses and volunteers, can provide effective diagnosis and treatment of NCDs. However, the factors that facilitate and impair these programs are incompletely understood. Objective: To identify health system barriers to and facilitators of NPHW-led care for NCDs in low- and middle-income countries. Data Sources: All systematic reviews in PubMed published by May 1, 2018. Study Selection: The search terms used for this analysis included "task shifting" and "non-physician clinician." Only reviews of NPHW care that occurred entirely or mostly in low- and middle-income countries and focused entirely or mostly on NCDs were included. All studies cited within each systematic review that cited health system barriers to and facilitators of NPHW care were reviewed. Data Extraction and Synthesis: Assessment of study eligibility was performed by 1 reviewer and rechecked by another. The 2 reviewers extracted all data. Reviews were performed from November 2017 to July 2018. All analyses were descriptive. Main Outcomes and Measures: All barriers and facilitators mentioned in all studies were tallied and sorted according to the World Health Organization's 6 building blocks for health systems. Results: This systematic review and qualitative analysis identified 15 review articles, which cited 156 studies, of which 71 referenced barriers to and facilitators of care. The results suggest 6 key lessons: (1) select qualified NPHWs embedded within the community they serve; (2) provide detailed, ongoing training and supervision; (3) authorize NPHWs to prescribe medication and render autonomous care; (4) equip NPHWs with reliable systems to track patient data; (5) furnish NPHWs consistently with medications and supplies; and (6) compensate NPHWs adequately commensurate with their roles. Conclusions and Relevance: Although the health system barriers to NPHW screening, treatment, and control of NCDs and their risk factors are numerous and complex, a diverse set of care models has demonstrated strategies to address nearly all of these challenges. These facilitating approaches-which relate chiefly to strong, consistent NPHW training, guidance, and logistical support-generate a blueprint for the creation and scale-up of such programs adaptable across multiple chronic diseases, including in high-income countries.

Multiple chronic conditions at a major urban health system: a retrospective cross-sectional analysis of frequencies, costs and comorbidity patterns.

OBJECTIVE: To (1) examine the burden of multiple chronic conditions (MCC) in an urban health system, and (2) propose a methodology to identify subpopulations of interest based on diagnosis groups and costs. DESIGN: Retrospective cross-sectional study. SETTING: Mount Sinai Health System, set in all five boroughs of New York City, USA. PARTICIPANTS: 192 085 adult (18+) plan members of capitated Medicaid contracts between the Healthfirst managed care organisation and the Mount Sinai Health System in the years 2012 to 2014. METHODS: We classified adults as having 0, 1, 2, 3, 4 or 5+ chronic conditions from a list of 69 chronic conditions. After summarising the demographics, geography and prevalence of MCC within this population, we then described groups of patients (segments) using a novel methodology: we combinatorially defined 18 768 potential segments of patients by a pair of chronic conditions, a sex and an age group, and then ranked segments by (1) frequency, (2) cost and (3) ratios of observed to expected frequencies of co-occurring chronic conditions. We then compiled pairs of conditions that occur more frequently together than otherwise expected. RESULTS: 61.5% of the study population suffers from two or more chronic conditions. The most frequent dyad was hypertension and hyperlipidaemia (19%) and the most frequent triad was diabetes, hypertension and hyperlipidaemia (10%). Women aged 50 to 65 with hypertension and hyperlipidaemia were the leading cost segment in the study population. Costs and prevalence of MCC increase with number of conditions and age. The disease dyads associated with the largest observed/expected ratios were pulmonary disease and myocardial infarction. Inter-borough range MCC prevalence was 16%. CONCLUSIONS: In this low-income, urban population, MCC is more prevalent (61%) than nationally (42%), motivating further research and intervention in this population. By identifying potential target populations in an interpretable manner, this segmenting methodology has utility for health services analysts.

Exploring patient experiences with and attitudes towards hypertension at a private hospital in Uganda: a qualitative study.

BACKGROUND: Hypertension is the leading risk factor for mortality worldwide and is more common in sub-Saharan Africa than any other region. Work to date confirms that a lack of human and material resources for healthcare access contributes to this gap. The ways in which patients' knowledge and attitudes toward hypertension determine their engagement with and adherence to available care, however, remains unclear. METHODS: We conducted an exploratory, qualitative descriptive study to assess awareness, knowledge, and attitudes towards hypertension and its management at a large private hospital in Kampala. We interviewed 64 participants (29 with hypertension and 34 without, 1 excluded) in English. General thematic analysis using the Integrated Conceptual Health Literacy Model was used to iteratively generate themes and categories. RESULTS: We identified three main themes: Timing of Hypertension Diagnosis, Aiming for Health Literacy, and the Influence of Knowledge on Behavior. Most participants with hypertension learned of their condition incidentally, speaking to the lack of awareness of hypertension as an asymptomatic condition. Drove nearly all participants to desire more information. However, many struggled to translate knowledge into self-management behaviors due to incomplete information and conflicting desires of participants regarding lifestyle and treatment. CONCLUSIONS: Internal patient factors had a substantial impact on adherence, calling attention to the need for educational interventions. Systemic barriers such as cost still existed even for those with insurance and need to be recognized by treating providers.