ArticleBMJ public health2026
Qualitative study of barriers and facilitators to Dietary Approaches to Stop Hypertension (DASH) on the Caribbean island of Montserrat.
Article in BMJ public health, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
Introduction: Hypertension is the leading modifiable risk factor for cardiovascular disease, with high prevalence in the Eastern Caribbean. Dietary modification is central to prevention and management, with the Dietary Approaches to Stop Hypertension (DASH) diet supported by strong clinical evidence. DASH promotes increased consumption of fruits, vegetables, whole grains, nuts, seeds and pulses while limiting salt, sugar, high-fat meats and dairy, and refined carbohydrates. Although promoted in primary care in Montserrat, adherence may be limited by structural, social and cultural barriers. We aimed to explore the barriers and facilitators experienced by Montserratians attempting to follow the DASH eating plan. Methods: We conducted semi-structured interviews with 16 adults in Montserrat diagnosed with hypertension recruited through primary healthcare providers. Purposive sampling ensured representation across sex and country of birth. Interviews lasting 20-40 min were conducted between June and August 2025, audio-recorded, transcribed verbatim and anonymised. Using a topic guide developed with local and UK experts, participants discussed dietary practices, barriers, facilitators and suggested interventions. Data were analysed using the Theoretical Domains Framework (TDF) through deductive thematic analysis. Results: Participants (aged 40-79) identified five themes shaping DASH adherence: understanding of hypertension and DASH, access to healthy foods, skills and self-efficacy, cultural practices and readiness to change. While hypertension was seen as urgent, cost, availability and seasonality of fruits, vegetables and fish limited adherence. Cooking and cultivation skills supported adherence, though food label literacy was low. Cultural practices and family dynamics both enabled and constrained adherence, and taste preferences often posed barriers. Suggested interventions included nutrition education, financial support, agricultural coordination and peer support. Conclusions: Montserratian adults with hypertension are motivated to improve their diets, but DASH adherence is constrained by financial, logistical, cultural and knowledge barriers. Effective interventions must integrate structural supports with culturally appropriate strategies, developed collaboratively with stakeholders, to ensure feasibility, acceptability and sustainability.
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