Article Analysis

ORIGINAL PAPER

The Coping Mechanisms and Strategies of Hypertension Patients in Ghana: The Role of Religious Faith, Beliefs and Practices

Frederick Anyan1 • Birthe Loa Knizek2

Published online: 6 November 2017 � Springer Science+Business Media, LLC 2017

Abstract This qualitative study explored the role of religious faith, belief and practice systems in the coping mechanisms and strategies of essential hypertension patients in

Accra, Ghana. Six participants were recruited for participation, of which five were

Christians and one was a Muslim. Interviews were conducted and interpretative phe-

nomenological analysis was used to analyze the data. Results showed that participants used

their religious faith, beliefs and practices as coping resources. Participants used a defer-

ring-collaborative style of religious coping, which seemed to have provided them with an

avoidance strategy that protected the participants from conscious confrontation with their

illness. Religious faith and beliefs also afforded the participants a sense of coherence that

enabled the participants to manage their stress, reflect on their external and internal

resources to promote effective coping and adaptive functioning in a health promoting

manner. Implications of a deferring-collaborative style of religious coping and religious re-

appraisal are discussed.

Keywords Religion � Collaborative coping � Deferring coping � Sense of coherence

Introduction

In the USA, the notion of linking religious and medical interventions has become widely

popular in the not only complex history but also complex present of the relationship

between religion and science (Sloan et al. 1999). In Ghana, religious practices take a

central place in the life of many people and religion is considered a relevant social force

& Frederick Anyan [email protected]

1 Department of Psychology, Norwegian University of Science and Technology (NTNU), 7491 Trondheim, Norway

2 Faculty of Nursing, Sør-Trøndelag University College, Trondheim, Norway

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J Relig Health (2018) 57:1402–1412 https://doi.org/10.1007/s10943-017-0517-7

reflected in everyday life experience (Assimeng 2010; Yirenkyi 2000). The 2010 popu-

lation and housing census by the Ghana Statistical Service (2012) reported a total popu-

lation of about 24 million people in Ghana. Population by religious affiliation showed that

there are about 71.15% Christians, 17.62% Muslims and 5.15% Traditionalists. Relatively,

few (0.80%) people adhere to other religious bodies such as Hinduism and Buddhism and

5.30% do not have any religious affiliations.

A number of studies, both qualitative and quantitative, have explored the relationship

between religion and health in Ghana (see Akotia et al. 2014; Osafo et al. 2013, 2014), but

a lot more remains to be done in studies that exclusively focus on the separate religious

groups’ faiths, beliefs and practices on health. One of such previous studies (Asamoah

et al. 2014) examined the views of 20 male Pentecostal clergy on the role of their churches

in mental healthcare delivery. Using thematic analyses, the authors found that, from the

clergy’s perspective, the churches’ role in mental health delivery was threefold namely,

exorcism, provision of social support, and health education. The authors contended that

exorcism was borne out of a prevailing supernatural belief system in cultural traditions in

Ghana. Social support and health education were the results of both classical and modern

roles of faith-based groups around the world, with social support reflecting the caring role

and health education reflecting a public health role of religion. Studies of specific religious

faiths, beliefs and practices on health are particularly important because not all the reli-

gious groups in Ghana share a common faith, belief and practice systems. For example, a

predominant belief in the traditional religion is that the etiology of certain diseases and

illness may be ascribed to forces of angered ancestral spirits, evil spirits or the machination

of witchcraft. Therefore, Western medicines can neither provide an explanation nor a cure

(Awusabo-Asare and Anarfi 1997).

Acquah (2011) discussed an account of a Methodist catechist and a historian of Mfantse

people (anglicized as Fantis) by name J. B. Crayner who recounted that at a time in history

the Mfantse ethnic group was almost wiped out by a deadly plague and it was only through

consultation with the shrine gods which ‘‘revealed that human sacrifices was needed in

order to stop it’’ (p. 67), whereas Christianity rejected ‘‘sacrifices to the ancestors and other

spirits’’ (p. 184). In modern days, certain traditional ‘‘religious rituals such as animal

sacrifices have been removed from public spaces to certain excluded traditional sacred

grounds’’ (p. 214).

A recent study in Ghana about suicide attempters reported that violations of religious

practices were perceived as injurious to personal relationship with God and therefore

required a responsibility to re-establish the injured relationship by pleading for forgiveness

and guilt feeling. Consequently, regular abidance to religious practices such as church

attendance was perceived as a protective resource which can enhance an individual’s

coping resources during crises in life (Akotia et al. 2014). During crises in life, one way in

which people could withstand is through religious faith. Prayers could serve as a means by

which people can reach a divine Deity (God) for support during crises in life. Suicidal

behavior was accordingly perceived as a consequence of having disregarded religious faith

(Osafo et al. 2013).

The present study aimed to explore the role of religious faiths, beliefs and practices in

the coping mechanisms of essential hypertension (hypertension that has no specific

underlying cause) patients. This aim was just one of four aims of a larger study which

explored the sick role behavior of essential hypertension patients in Accra.

J Relig Health (2018) 57:1402–1412 1403

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Methods

A qualitative method approach was chosen in order to study in-depth perceptions and

experiences of essential hypertension patients about their coping mechanisms in their life

worlds (Willig 2013). The approach in this study was the interpretative phenomenological

analysis (Smith et al. 2009). IPA enables detailed exploration of the lived experiences of

participants and the sense they make of those experiences. In exploring participants sub-

jective reflected personal experiences, IPA has been found to be a suitable approach (Smith

and Osborne 2003).

Participants and Procedure

In all, there were six participants aged between 45 and 60 years. Only one was a Muslim

and the other five were Christians. Since there was only one Muslim participant whose

responses were significantly different from the other five, he was not included in the final

analyses. Essential hypertension patients were purposively selected with permission from

the head of Korle Bu Polyclinic (KBP) to assist in the recruitment. Self-addressed stamped

envelopes with information letters and consent forms were handed out to prospective

participants by the head of KBP. Participants were instructed to return completed consent

forms by post mail but only one did so, while the rest hand delivered their consent forms to

the head of KBP. With permission from the participants, the interviews were audio-

recorded and later transcribed verbatim. The study was approved by the Regional Com-

mittee for Medical and Health Research Ethics in Central Norway and the Korle Bu

Teaching Hospital (KBTH) Medical Directorate in Ghana.

The Study Site—Ghana

The capital of Ghana, Accra, was chosen as the site for the study. The study took place at

the Korle Bu Polyclinic which is a subdivision of the Korle Bu Teaching Hospital. Ghana

was chosen because hypertension was considered nonexistent or rare in most African

societies but has emerged as a challenging force to reckon with particularly in sub-Saharan

Africa (Agyemang 2006; Van der Sande et al. 2000). Blood pressure levels and hyper-

tension rates in Ghana are among the highest in Africa (Cappuccio et al. 2004). Secondly,

as a developing nation many factors such as low income, low levels of education, large

household sizes and unemployment have been found to be associated with mental health

problems (Dzator 2013). Despite these challenges which negatively impact psychological

health, some studies (see Boyce et al. 2009; Songsore and McGranahan 1993) have found

that strong social support networks such as affiliations with religious bodies and organi-

zations in Ghana mediate socioeconomic challenges and psychological health outcomes.

Instrument for Data Collection

Interviews were conducted with a semi-structured interview guide, which was designed to

explore the different contexts and action radii for coping. For example, a question about

coping was ‘‘How are you dealing with your condition?’’ which was followed by probing

questions such as ‘‘Do you have particular strategies for helping yourself to deal with the

condition and ways of coping.’’ The interview guide was translated into Ga and Hausa

since two of the participants could not satisfactorily communicate in English and preferred

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their local language. The two translators were carefully selected based on their proficiency

in and wider knowledge of indigenous social and cultural practices relating to the two

languages. Some terms such as medical regimen and medical schedules which were

originally used in the interview guide were reformulated to a common term such as

‘‘prescriptions’’ and ‘‘check-ups,’’ respectively, before translating the interview guide.

Analyses

Two of the interviews were done and transcribed with the assistance of the translators and

marked to distinguish first-hand information from what had been translated afterward.

Transcripts were generated from the audio recordings. The aim in the analyses was to

understand ‘‘what it is like’’ from the point of view of the participants. That is, the double

hermeneutical analysis of IPA suggests that ‘‘participants are trying to make sense of their

world’’ and the researcher is trying to make sense of the participants trying to make sense

of their world (Smith and Osborne 2003). As such, the researcher is thought to assume an

insider perspective where he/she produces a report by means of standing in the shoes of the

participants.

The analyses began by identifying central themes and summarizing associations and

connections in the first case and proceeded to subsequent cases, looking out for what

themes cut across the group. Recurrent themes were then summarized and quotes were

selected to represent them as emergent themes, followed by making logical connections

between these themes to create a lucid theoretical and analytical framework for general

categorization (Smith and Osborne 2003). The major themes were:

• Christian religious faiths, beliefs and practices provide optimism and hope for coping. • Christian religious faiths, beliefs and practices engender sense of coherence.

More commonly, rather than nomothetic studies, IPA is described as a an idiographic

mode of inquiry conducted on small samples to ensure a painstaking analysis of cases of

participant’s personal experiences, understandings and perceptions in a fairly homogenous

sample (Smith and Osborne 2003). As Dibley (2011) puts it, IPA involves collecting rich

(quality) and thick (quantity) data that initiates the data saturation process. In addition,

structuring interview questions in a way to enable follow-up questions and interviewing

multiple participants consolidates data saturation (Guest et al. 2006). In the present study,

the approach of IPA sacrifices the breadth of the data for the depth of the data (Smith and

Osborne 2003). In addition, interview questions were structured in a way to enable follow-

up questions; the semi-structured interview guide that was used was tested and piloted to

explore different contexts and action radii for coping. The second author and other

members of the academic staff connected to similar research themes have thoroughly

interrogated and debated every stage of this study and the depth of the data with the first

author who is a native of Ghana to ensure the exhaustion of all findings.

Results

Christian Religious Faith Belief and Practices Provide Optimism and Hope for Coping

The findings are based on the five Christian participants who exhibited consistent pattern of

responses and behaved similarly to each other. There were emphatic responses that showed

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that participants deferred their condition to an active and a divine Deity (God), thereby

taking a less active role in the coping process. It seemed that after turning over the

condition to God the participants re-appraised their condition in spiritual (religious) terms

which were engendered by participants’ identification with and involvement in religious

faiths, beliefs and practices. This re-appraisal seemed to have provided some relief to the

participants. The participants also seemed to be convinced that God is responsive and all

powerful, and therefore, through collaboration God could be influenced to act on their

behalf to enable them to cope with the illness. Two forms of coping were found: a

deferring form, where participants took on a less active role and waited for God after

turning over their condition to God, and a collaborative form, where participants engaged

God in a mutual problem-solving process. It seemed that after participants have turned over

their illness to God they followed it by collaborating with God to resolve their situation

(provide healing). While it appears that a deferring style is associated with a reduced sense

of control and personal competence in coping, a collaborative style appears to foster a

sense of empowerment in the face of a difficult life situation (Pargament and Park 1995).

Christian religious faith and practices seemed to create a relationship between a person

and an active Deity (God) in whom an individual can perceive that some help could come

from (Osafo et al. 2013). Levin (2010) suggested that there is a considerable evidence to

conclude that people’s involvement in and identification with religious faith and practices

seems to suggest optimism about their coping behavior. By this, Levin argued that a

person’s religious life has something to say about his/her coping behavior. When a

question was posed about how patients coped with their condition, this was the response

from one participant.

I make sure to pray always…well everything is in the hands of God, God does everything or am I lying?… but yourself you know what you want, but God has the power….so it is in the hands of God; the future is unknown and so you just have to leave everything for God to take care of you (Participant V, 55 years).

In the quote above, the participant indicated that she makes sure to pray always as a

way of coping with her condition. Leaving everything to God to take care suggests

deferring the condition to God, while making sure to pray always suggests collaborating

with God. Prayer seemed to be a way of expressing a personal relatedness with a

benevolent God who is perceived as an active Deity and from whom some help could

come. Prayer is a coping behavior which reduces the sense of isolation and increases a

patient’s sense of control over the illness (Gall et al. 2005; Koenig et al. 2001). For this

participant, it seemed to imply that it will depend on God to regain control over her

condition and fully recover from her illness. She indicated that God has the power to

regulate the situation. Therefore, she has to leave everything to God since God can take

care of her.

She also demonstrated future optimism and the need to not worry by adding that ‘‘so it

is in the hands of God; the future is unknown and so you just have to leave everything for

God to take care of you.’’ It is important to notice that sometimes patients have little

control over their health conditions which can create anxiety and relentless attempts to

regain control. Koenig (2002) noted that religious faith seemed to provide an indirect form

of control by breaking the cycle of anxiety and relentless attempts to regain control. In the

present study, it seemed that Christian religious belief and practices seemed to be a useful

utility that interrupted the cycle of anxiety and relentless attempts to regulate the distress

associated with participants’ illness. Gall et al. (2005) contended that in the case of trusting

and believing in God, as exemplified by Participant V, the belief constitutes a coping

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resource and that such religious beliefs may reduce the sense of loss of control and

helplessness; it provides a cognitive framework that can reduce suffering and increase

one’s purpose and meaning in his/her condition (Koenig et al. 2001). Another participant

emphasizes that Christian religious faith and belief can be a useful utility in coping and

gaining control over the condition,

Mm….I know God will help me and I know God…Not exactly so, but you have to pray and pray and worship God, because God is watching over me and if I have faith

in Him; He can do all things…I have faith that I will be fine… (Participant IV, 46 years).

This participant seemed to imply that since God is almighty she will be fine and did not

need to worry about her condition. God is all powerful and responsive to her needs;

therefore, having faith in God and trusting God could ultimately lead to influencing God to

act on her behalf. This participant has turned her health situation over to God which

interrupted the otherwise cycle of trying to regain control over the condition and the

participant stopped ruminating and worrying about the illness. Another participant had this

to say:

It (learning of the illness) was a bit surprising but it was OK; even though, truly, it

was worrying to me…my wife too confronted me and told me not to be thinking about it too much, because God was going to heal me (Participant II, 58 years).

Participant II indirectly admitted to the expression of God’s benevolence and all-

powerfulness through his wife as his way of coping with his condition. It seemed that even

though he was initially worried about his condition, his wife reminding him of God’s

power to heal him persuaded him to stop worrying about the illness. His belief coupled

with a shared responsibility by praying to God, while God watches over him in return

relieved him from his worries. This shared responsibility fostered a dyadic coping style: a

deferring-collaborative style in which a person turns a health condition over to God, and

while waiting for God to act on the person’s behalf, the person collaborates with God

through prayers in order to influence and validate an entitlement from God to act on his/her

behalf.

One way religion helps patients to cope is by reducing the sense of losing control while

increasing one’s hope in the face of challenging health conditions (Koenig et al. 2001). The

participants in the present study suggested that they can survive the future by means of

their religious faiths, beliefs and the practices of prayer and worshipping God. This finding

is similar to the findings by Osafo et al. (2013) who found that the kind of hope exuded by

the participants in their study was different from what existed in the literature. Similar to

the hope found in the present study, Osafo et al. (2013) found that the hope of the

participants in their study stemmed from a religious perspective in which the participants

perceived a connection between living and hope and also between death and hopelessness.

Christian Religious Faiths, Beliefs and Practices Engender Sense of Coherence

Religion seems to convey a sense of meaningfulness that provided a buffer for the par-

ticipants against ruminating, loss and hopelessness. Religion contributed to elevate par-

ticipants’ purposes and meanings in their condition through benevolent re-appraisal. The

search for meaning and purpose is important for survival and coping in difficult circum-

stances (Gunnestad and Thwala 2011). Antonovsky’s sense of coherence (SOC)

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(Antonovsky 1987, 1996) posits that if a person understands what is happening to him

(comprehensibility), believes that the resources to cope are available to do something

(manageability) and is motivated to cope (meaningfulness), he/she will have more strength

to resist the stressor and be able to cope. When a question was posed about how partici-

pants see their life as essential hypertension patients and their efforts to cope, one had this

to say:

…I believe in God. God can do all things that you ask Him to do for you. Every day, every day but you see I also add a lot of prayers to this. For me I know by the grace

of God I certainly will be healed and be happy too someday to come (Participant I,

55 years).

In this and other instances, the participants seem to be optimistic about their coping

through their religious faith and beliefs. It seemed that it is their religious faith and belief

that served as a means by which they make sense of their condition; their belief is more

powerful than anything else and shapes their worldview. Participant I shows that he is

waiting for God and implies that it is his faith in God which influences God to watch over

him and to act on his behalf through collaboration—by praying. And this is how he

manages his condition by doing something to influence his condition positively in addition

to his positive outlook that gives him meaning in life despite his illness. Religion for this

participant seemed to convey a sense of meaning in life and thereby provide a pathway to

adaptive functioning. In the other similar instances, we can argue that the participants

demonstrated a sense of coherence based on religion. This forms a resource that seems to

have enabled the participants to manage their stress, reflect on their external and internal

resources to mobilize them to promote effective coping and adaptive functioning in a

health promoting manner.

In the quote by Participant I, was shown optimism and confidence when he implied that

‘‘…by the grace of God [he] certainly will be healed and be happy too someday to come.’’ He shows that he has the available resources that enable him to do something about his

condition through his faith in God and by praying. In Ghana, Osafo et al. (2013) found that

prayers provided a means by which people reach God for support. Prayer is a coping

behavior (Gall et al. 2005) which increases a person’s relatedness with God and thereby

prevents isolation (Koenig et al. 2001). Perceiving the benevolence and all-powerfulness of

God, this participant seemed to indicate that the demands of the condition are worthy of

engagement and commitment, hence his resort to ‘‘…add a lot of prayers…’’ This is also because the participant’s religious faiths and beliefs provided an understanding of his

condition and the resources to meet the demands of his condition that motivate him to

sustain a health promoting agenda. According to Langeland et al. (2007), participants have

a greater sense of meaningfulness (and typically a greater sense of the other two—com-

prehensibility and manageability) when they perceive the demands of a situation/condition

worthy of investment and engagement.

Our participants showed that through faith, belief and collaboration with God, they

could not only do something about their condition but also access sufficient resources to

cope. For instance, one participant answered how he would describe his way of coping,

I have no choice but to wait upon God…to help me find a proper medication to ease me of the illness and to protect myself (Participant III, 48 years).

This response was probed further to ascertain whether the participant did not believe

that the medicines provided by the clinic were effective enough for treatment.

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Yes…..but it does not mean what I get from this hospital is not good. It is very good for me and I mean that I can get even a better one (Participant III, 48 years).

For Participant III, it seemed that the medication provided was insufficient for treat-

ment. He seemed to imply that religious faith could lead him to obtain a better solution

than the medication that is provided to him. Even though he does not downgrade the

efficacy of the medication, it appears that he expects a better outcome of his condition by

waiting upon God. This appears to be health promoting by retaining and preserving his

hope for effective coping. He seemed to suggest a potential pathway to recovery by waiting

upon God in addition to using medications.

Discussion

Generally, Ghanaians have been described as religious at the core of their being (Pobee

1992) and they observe religion in every aspect of their life from child naming to funeral

(Acquah 2011). Their strong religious faith is embedded within their cultural framework.

As a major cultural manifestation and a powerful social force (Assimeng 2010), it is

religion more than anything else that pervasively shapes the worldview and participation in

the sociocultural life of Ghanaians (Kwame 1996). For the participants in the present study,

religion provided an opportunity to turn over their health condition to God and to follow it

up by collaborating with God through prayers. This deferring-collaborative style of reli-

gious coping served a context-specific behavior in times of illness that provided an

avoidance strategy to protect from conscious confrontation with a health condition.

Christian religions in a way served as a coping mechanism and also as a resource that

enabled the participants to manage their stress, reflect on their external and internal

resources to promote effective coping.

When a stressor is appraised as controllable and a person has positive beliefs about self-

efficacy and efficacy expectation, he or she is more likely to use effective coping strategies

(Glanz and Schwartz 2008). How an individual views an event or a stressor is more likely

to influence the type of coping strategy adopted. This means that when a person believes

that he/she has the personal abilities to regulate and control a specific stressor and also has

the belief that he/she is capable of performing the required behavior in order to regulate

and control that specific stressor, then, ultimately, that person is more likely to use

effective thoughts and behaviors to regulate the distress to gain control over the situation. It

seemed from the interpretations of the study results that Christian religious faith and

practices influenced how the participants in this study viewed their condition—appraisal,

and the mechanism adopted to regulate and control their condition—coping. How the

participants in the present study viewed and interpreted their condition and subsequently

the type of coping strategy that was adopted (in reaction to how the condition was viewed

by the participants) seemed to have some overarching Christian religious influence.

The belief in Christian religious practices replaced the belief about personal abilities to

regulate and control the illness. Thus, self-efficacy—which focuses on personal abilities

with regard to a specific condition, was replaced by personal beliefs in Christian religious

practices. Additionally, efficacy expectation—which is the belief that one is capable of

performing a behavior required to influence an outcome in a specific condition, was

deferred to God to influence the outcome of the illness. The latter, in the broader religious

coping framework, was described by Pargament (2001). Pargament suggested that reli-

gious people seek control of their condition by cooperating with God and engaging God in

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a mutual problem-solving process, which is referred to as collaborative religious coping.

Waiting upon God also seemed to enable participants to reflect on their internal and

external resources to identify and mobilize them to promote effective coping and adaptive

functioning in a health promoting manner.

It also seemed that the personal beliefs about religious faith and practices enabled the

participants to construct positive meanings out of their conditions which in turn provided

hope and optimism for their coping process. Pargament and Cummings (2010) argued that

in religious coping, constructions of positive religious meanings are made out of a con-

dition and associated with re-appraising the situation in religious term so that it is less

threatening. This re-appraisal helps a person to not deny the illness but to accept it, which

also reduces the threat of the illness.

To conclude, Christian religious faith, beliefs and practices seemed to have provided the

participants with an avoidance strategy (albeit participants’ compliance with the medical

regimen), which protected the participants from conscious confrontation with their illness.

The participants turned over their health condition to God and collaborated with God, and

while waiting for God to resolve their situation, they re-appraised their condition in a

spiritual (religious) way, reflected on and identified internal and external resources and

mobilized them for effective coping. The re-appraisal seemed to reduce the impact of the

illness on the participants. Turning over the health condition to God did not only result in a

spiritual (religious) benevolent re-appraisal and some relief of the impact of the condition

but also a belief in an ‘‘all powerful loving and responsive God [gave the participants] the

sense that they can influence their own condition by possibly influencing God to act on

their behalf’’ (Koenig et al. 2001, p. 355).

Recommendations

Through the use of a qualitative approach in this study, the role of Christian faith, belief

and practice system in coping mechanisms and strategies has been highlighted. It is rec-

ommended that further studies explore the role of other religious faith belief and practice

systems in coping mechanisms such as Islam and traditional religions. Engaging religious

patients in religious coping would be a culturally relevant step in contributing meaning-

fully to the coping strategies and mechanisms of patients in Ghana. This should be

exercised with caution since the religious coping framework requires adequate longitudinal

studies to test the potential of mobilizing religious factors for coping across time

(Pargament 2001).

Acknowledgements This study was funded by the Department of Psychology at the Norwegian University of Science and Technology.

Compliance with Ethical Standards

Conflict of interest The authors declare that they have no conflict of interest.

Ethical Approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed Consent Informed consent was obtained from all individual participants included in the study.

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