Commonsense illness beliefs, adherence behaviors, and hypertension control among African Americans

A framework to evaluate the cultural appropriateness of intervention research

Marked racial disparities exist in the prevalence, mortality, and treatment of asthma, between African American and White children and adolescents, despite increases in intervention trials to improve asthma outcomes. Yet, interventions to improve African American children's health must be culturally appropriate. To date, limited frameworks are available to decide whether an intervention tested with a targeted minority population employs a culturally appropriate design. In this article, we applied Bernal, Bonilla, and Bellido's ecological validity model to examine the cultural appropriateness of 12 randomized controlled trials of asthma self-management interventions published from 2000 to 2010. Most frequently met criteria were culturally appropriate methods of development and/or adaptation of interventions and inclusion of theoretical models. Least often met criteria were incorporating metaphors pertinent to participants and application of the language dimension. Based on this analysis, it is clear that an overarching framework is needed to guide the development of culturally targeted interventions.

The practitioner proposes a treatment change and the patient declines: what to do next?

OBJECTIVE

This study describes how pain practitioners can elicit the beliefs that are responsible for patients' judgments against considering a treatment change and activate collaborative decision making.

METHODS

Beliefs of 139 chronic pain patients who are in treatment but continue to experience significant pain were reduced to 7 items about the significance of pain on the patient's life. The items were aggregated into 4 decision models that predict which patients are actually considering a change in their current treatment.

RESULTS

While only 34% of study participants were considering a treatment change overall, the percentage ranged from 20 to 70, depending on their ratings about current consequences of pain, emotional influence, and long-term impact. Generalized linear model analysis confirmed that a simple additive model of these 3 beliefs is the best predictor.

CONCLUSION

Initial opposition to a treatment change is a conditional judgment and subject to change as specific beliefs become incompatible with patients' current conditions. These beliefs can be elicited through dialog by asking 3 questions.

Patient factors, but not provider and health care system factors, predict medication adherence in hypertensive black men

The problem of medication adherence is pronounced in hypertensive black men. However, factors influencing their adherence are not well understood. This secondary analysis of the ongoing Counseling African Americans to Control Hypertension (CAATCH) randomized clinical trial investigated the patient, provider, and health care system factors associated with medication adherence among hypertensive black men. Participants (N=253) were aged 56.6±11.6 years, earned <$20,000 yearly (72.7%), and almost one half were on Medicaid (44%). Mean systolic blood pressure was 148.7±15.8 mm Hg and mean diastolic blood pressure was 92.7±9.8 mm Hg. Over one half of participants (54.9%) were nonadherent. In a hierarchical regression analysis, the patient factors that predicted medication adherence were age, self-efficacy, and depression. The final model accounted for 32.1% of the variance (F=7.80, df 10, 165, P<.001). In conclusion, age, self-efficacy, and depression were associated with antihypertensive medication adherence in black men followed in Community/Migrant Health Centers. Age is a characteristic that may allow clinicians to predict who may be at risk for poor medication adherence. Depression can be screened for and treated. Self-efficacy is modifiable and its implications for practice would be the development of interventions to increase self-efficacy in black men with hypertension.

Explanatory models of hypertension among Nigerian patients at a University Teaching Hospital

OBJECTIVE

To elicit the explanatory models (EM) of hypertension among patients in a hospital-based primary care practice in Nigeria. Design. Semi-structured in-depth individual interviews and focus groups were conducted with 62 hypertensive patients. Interviews and focus groups were audiotaped and transcribed verbatim. Data analysis was guided by phenomenology and content analysis using qualitative research software ATLAS.ti 5.0.

RESULTS

Patients expressed four categories of EM of hypertension: (1) perceptions of hypertension, (2) consequences, (3) effect on daily life, and (4) perception of treatment. Focus group discussions and individual interviews yielded a wide range of insights into the social and cultural factors influencing patients' beliefs and health behavior. Participants were aware of the risks of hypertension. There was disagreement between participants' own understanding of the serious nature of hypertension, the need for long-term treatment, and the desire to take long-term medication. Participants acknowledged the use of traditional medicine (e.g., teas and herbs) and healers. Different themes emerged for men versus women such that women often focused on family issues while men tended to discuss external stressors stemming from work as a cause of hypertension. Men were concerned with frequent urination, decreased libido, and erectile dysfunction.

CONCLUSION

Knowledge gained will inform development of patient-centered treatment plans and targeted behavioral and educational interventions.

Prevalence rates of hypertension self-care activities among African Americans

BACKGROUND

A comprehensive understanding of the self-care activities that contribute to blood pressure control may explain health disparities experienced by African Americans with hypertension. This study assessed the prevalence of self-care activities among African Americans with high blood pressure and examined differences between adherers and nonadherers to self-care activities.

METHODS

Interviews were conducted with 186 African Americans. Self-care activities were measured using the H-SCALE (Hypertension Self-Care Activity Level Effects), which was developed to assess the behavioral activities recommended for optimal management of high blood pressure.

RESULTS

More than half of participants reported adhering to medication recommendations and prescribed physical activity levels (58.6% and 52.2%, respectively). Following practices related to weight management was less frequent, (30.1%) and adherence to low-salt diet recommendations was also low (22.0%). Three-fourths were nonsmokers and 65% abstained from alcohol. Across the self-care activities, adherers were more likely to be older and female. Nonadherers were more likely to be uninsured.

CONCLUSIONS

Many African Americans still face challenges related to hypertension self-care, particularly with weight management and salt reduction. The H-SCALE was a valid and reliable measure of hypertension self-care activities. In addition to monitoring blood pressure, health care providers should assess patients' hypertension self-care activities using the H-SCALE.

Hypertension among the uninsured: tensions and challenges

PURPOSE

To explore the experience of living with hypertension (HTN) in uninsured Southern, Appalachian adults who receive care in a nurse practitioner-run clinic.

DATA SOURCES

Focus groups with 16 clients.

CONCLUSIONS

Living with hypertension encompassed living with many tensions and challenges. It was described by five organizing themes, each of which involved two basic themes held in tension. The organizing themes were: (a) centrality of HTN; (b) controllability of HTN; (c) visibility of HTN, (d) accessibility and quality of health care; and (e) existential reality.

IMPLICATIONS FOR PRACTICE

Interventions are needed to help clients deal with the tensions and challenges; these include a greater focus on partnering with clients, individual and group educational activities, and developing community partnerships.

High adherence and concordance within a clinical trial of antihypertensives

OBJECTIVES

To explore hypertensive patients' beliefs about their condition and its treatment and their adherence within the context of a clinical trial. To assess the degree of concordance between patients' beliefs about hypertension and the medical model of the condition.

METHODS

This was a questionnaire-based study, involving 230 patients participating in the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT), a randomized controlled trial comparing two pharmaceutical approaches to the management of hypertension. A comparison group of 106 hypertensive patients who were screened for ASCOT but did not meet the entry criteria was also recruited. Outcome measures were beliefs about hypertension and antihypertensive medication, and adherence to medication (self-report and tablet count).

RESULTS

Adherence to medication was higher than anticipated, with 45% participants reporting complete adherence over the 18-month study and a further 40% only rare non-adherence. Patients' beliefs about their condition and treatment were generally concordant with the medical model of hypertension. High concordance was associated with high medication adherence (p<0.001).

DISCUSSION

Clinical trial volunteers may have beliefs that are unusually concordant with the medical model of hypertension and may demonstrate atypically high adherence. This has implications for the transferability of trial findings to the general hypertensive population.

Research on integrative healthcare: context and priorities

It is important that integrative healthcare research be conducted to optimize the effectiveness, safety, costs, and social and economic impact of prospective, personalized, patient-centered, comprehensive, and holistic healthcare that focuses on well-being as well as disease management, and that the research itself be well understood. The scope of this research extends beyond evaluation of specific therapies, to include evaluations of multimodality whole system intervention, practitioner-patient relationships, patient goals and priorities, promoting self-care and resilience, personalized diagnostic and therapeutic measures, practitioner well-being, the comparative effectiveness of different educational and outreach strategies in improving health and healthcare, and the environmental/social causes and consequence of health and healthcare. In this paper, we describe the state of the science of research on integrative healthcare, research needs, and opportunities offered by cutting-edge research tools. We propose a framework for setting priorities in integrative health research, list areas for discussion, and pose a few questions on a future research agenda.

Health promotion behaviors of residents with hypertension in Iwate, Japan and North Carolina, USA

AIM

The aim of this study was to compare the health promotion practises of rural residents in northern Japan (n = 212) to those in south-eastern North Carolina, USA (n = 105), using the Health Promotion Lifestyle II (HPLP) scale.

METHODS

A comparative and descriptive design examined the relationships between health-related behaviors and demographic and physiological variables, and compared cross-cultural patterns.

RESULTS

The Japanese participants scored significantly higher on the total HPLP II score, as well as on the subscales of health responsibility, nutrition, interpersonal support, and stress management. No significant differences were found in the HPLP II subscales for spiritual growth or physical activity between the groups. The subscale scores for both the participants from Japan and the participants from North Carolina were lowest for physical activity. For the participants from North Carolina, the HPLP II subscale scores were highest for spirituality and interpersonal relationships. The predictive factors of variation in the scores of the HPLP II for the participants from North Carolina included being married and not working. No significant demographic predictor was found for the HPLP II scores of the Japanese participants.

CONCLUSIONS

The study's findings add to an increased understanding of the cultural variations in the health-promoting behaviors of persons with hypertension. Providing health promotion strategies for hypertension remains an urgent issue for nurses and other health-care providers in both Japan and North Carolina, USA.

Intergenerational transmission of chronic illness self-care: results from the caring for hypertension in African American families study

PURPOSE OF THE STUDY

African Americans often experience early onset of hypertension that can result in generations of adults managing high blood pressure concurrently. Using a model based on the Theory of Interdependence, this study examined whether intergenerational transmission of hypertension knowledge and self-efficacy would affect hypertension self-care of older parents and their adult children.

DESIGN AND METHODS

We recruited 95 African American older parent-adult child dyads with hypertension. We constructed separate logistic regression models for older parents and adult children with medication adherence as the outcome. Each model included individual demographic and health characteristics, the partner's knowledge, and self-efficacy to manage hypertension and dyad-related characteristics.

RESULTS

Parents were more adherent with medication than adult children (67.4% vs. 49.5%, p < .012). There were no significant factors associated with parent medication adherence. In adjusted models for adult children, medication adherence was associated with child's gender (odds ratio [OR] = 3.29, 95% confidence interval [CI] = 1.26-8.59), parent beliefs that the child had better hypertension self-care (OR = 4.36, 95% CI = 1.34-14.17), and child reports that the dyad conversed about hypertension (OR = 3.48, 95% CI = 1.18-10.29). Parental knowledge of hypertension and parent's self-efficacy were weakly associated with adult children's medication adherence (OR = 1.35, 95% CI = 0.99-1.84 and OR = 2.59, 95% CI = 0.94-7.12, respectively).

IMPLICATIONS

Interventions should consider targeting African American older adults to increase self-care knowledge and empower them as a primary influencer of hypertension self-care within the family.

Barriers to adult hemodialysis patients' self-management of oral medications

Hemodialysis patients use a variety of oral medications on a daily basis to control their kidney disease and comorbid illnesses. Under the new paradigm of kidney disease care for dialysis units outlined in the 2008 US Centers for Medicare & Medicaid Services Conditions for Coverage, there has been a formal shift in the role of the hemodialysis patient from a passive participant in care planning to a fully collaborative member of the interdisciplinary team. In the chronic disease care field, the focus from patient compliance or patient adherence to patient self-management complements this paradigm shift in dialysis care. In this narrative review, we discuss key barriers to adult hemodialysis patient self-management of oral medications that include pill burden, demographic and socioeconomic variables, psychosocial factors, health literacy, patient satisfaction, and health beliefs. We further examine these barriers in the context of the 2008 Medicare Conditions for Coverage. To promote hemodialysis patients' self-management of oral medication regimens, additional research and behavioral interventions are needed to help hemodialysis patients overcome obstacles that impede their ability to effectively manage chronic illness and improve health outcomes.

Self-reported influences of hopelessness, health literacy, lifestyle action, and patient inertia on blood pressure control in a hypertensive emergency department population

BACKGROUND

In response to almost universally recorded poor blood pressure (BP) control rates, we developed a novel health paradigm model to examine the mindset behind BP control barriers. This approach, termed patient inertia (PtInert), is defined as an individual's failure to take responsibility for health conditions and proactive change.

METHODS

PtInert was evaluated through a survey instrument conducted in 85 subjects with a prior history of hypertension seen in an emergency department. The survey tool encompassed the Wide Range Achievement Test 4, the brief symptom inventory, and a PtInert questionnaire.

RESULTS

Fifty percent of patients reported slight psychological distress (psychosomatic > anxiety > depression), with 61% possessing hopelessness surrounding complications from high BP no matter their actions. An unanticipated finding was that patients who had a low reading proficiency (83.1 + 16.4 Wide Range Achievement Test 4 standard score) self-reported high levels of hypertension health literacy. Less than half of patients transferred this health literacy into lifestyle changes in diet, exercise, and medication adherence. Although patients felt that they could control their BP and frequently thought about better BP control, 55% of the subjects had uncontrolled hypertension (>140/90 mm Hg).

CONCLUSION

Hypertensive patients visiting our emergency department perceive themselves to have adequate hypertension health-related literacy that was not transferred into hypertension health protective behavioral practices. Psychological distress and a sense of hopelessness surrounding BP control contribute to the lack of protective behavioral health practices. Further evaluations of PtInert methods to promote successful proactive change and adherence warrant further study.

Pilot testing of the PRAISEDD intervention among African American and low-income older adults

BACKGROUND AND RESEARCH OBJECTIVE

The incidence of cardiovascular disease (CVD) is particularly high among African American (AA) older adults, and these individuals are least likely to have access to CVD prevention activities. The purpose of this study was to test the feasibility of People Reducing Risk and Improving Strength through Exercise, Diet and Drug Adherence (PRAISEDD), which is geared at increasing adherence to CVD prevention behaviors among AA and low-income older adults.

METHODS

This feasibility study was conducted in a senior housing site, using a single-group repeated-measures design and testing physical activity, diet, medication adherence beliefs and behaviors, and blood pressure at baseline and after a 12-week intervention period. Of 22 participants, mean (SD) age was 76.4 (7.6) years, and most were female (64%) and AA (86%). An intention-to-treat analysis was used.

RESULTS

There were significant decreases in systolic (P = .02) and diastolic blood pressure (P = .01) and a nonsignificant trend toward improvement in cholesterol intake (P = .09). There were no changes in time spent in moderate-level physical activity, sodium intake, medication adherence, or self-efficacy and outcome expectations across all 3 behaviors.

CONCLUSION

The PRAISEDD intervention was feasible in a group of AA and low-income older adults and, after 12 weeks, resulted in improvements in blood pressure. Future research is needed to test a revised PRAISEDD intervention using a randomized controlled design, a larger sample, and a longer follow-up period. The PRAISEDD intervention should be revised to incorporate environmental and policy changes that influence CVD prevention behaviors and explore the impact of social networking as it relates to diffusion of the intervention among participants in low-income housing facilities.

A clinician's guide to the assessment and management of nonadherence in glaucoma

PURPOSE

To apply lessons learned in the treatment of systemic hypertension to the problem of nonadherence in glaucoma medical therapy.

CLINICAL RELEVANCE

Although physicians recognize that nonadherence with glaucoma medication is a problem, most lack the skill set to identify nonadherent patients, to identify the causes of nonadherence, and to provide solutions to address nonadherence.

METHODS

A PubMed search was conducted using the terms "adherence" OR "compliance" AND "hypertension," with the following limitations: title, English language, humans, from 2000 through 2009. Other studies identified outside of the PubMed search were included if relevant.

RESULTS

Studies from the systemic hypertension literature suggest that simplifying medication regimens, lowering costs, and patient education about the disease and the importance of taking medications are successful strategies for improving adherence. In addition, good family or social support, frequent physician visits, and pairing medication administration with specific activities (such as meals or brushing one's teeth) can help improve adherence.

CONCLUSIONS

The body of literature on adherence interventions in chronic diseases such as systemic hypertension shows that although many interventions have been tested and evaluated, only some are successful. Paradigms derived from behavioral medicine and nursing offer valuable lessons on how to motivate patients to change behavior, but these activities require skill sets not traditionally taught in medical school. Just as there are myriad causes of nonadherence, the interventions most likely will need to be multifaceted and tailored to the individual patient.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Advancing the Prevention and Control of Hypertension

Hypertension is on a worrisome public health trajectory. This review discusses some key contributing dynamics as well as considerations for progress toward the prevention and control of hypertension and its comorbidities.

Promoting Physical Activity in Minority Populations

This review discusses evidence-based perspectives on promoting physical activity in minority populations. Future directions for inquiry and empirically driven public policy initiatives also are addressed.

The Adherence Estimator: a brief, proximal screener for patient propensity to adhere to prescription medications for chronic disease

OBJECTIVE

To conceptualize, develop, and provide preliminary psychometric evidence for the Adherence Estimator--a brief, three-item proximal screener for the likelihood of non-adherence to prescription medications (medication non-fulfillment and non-persistence) for chronic disease.

RESEARCH DESIGN AND METHODS

Qualitative focus groups with 140 healthcare consumers and two internet-based surveys of adults with chronic disease, comprising a total of 1772 respondents, who were self-reported medication adherers, non-persisters, and non-fulfillers. Psychometric tests were performed on over 150 items assessing 14 patient beliefs and skills hypothesized to be related to medication non-adherence along a proximal-distal continuum. Psychometric tests included, but were not limited to, known-groups discriminant validity at the scale and item level. The psychometric analyses sought to identify: (1) the specific multi-item scales that best differentiated self-reported adherers from self-reported non-adherers (non-fulfillers and non-persisters) and, (2) the single best item within each prioritized multi-item scale that best differentiated self-reported adherers from self-reported non-adherers (non-fulfillers and non-persisters).

RESULTS

The two rounds of psychometric testing identified and cross-validated three proximal drivers of self-reported adherence: perceived concerns about medications, perceived need for medications, and perceived affordability of medications. One item from each domain was selected to include in the Adherence Estimator using a synthesis of psychometric results gleaned from classical and modern psychometric test theory. By simple summation of the weights assigned to the category responses of the three items, a total score is obtained that is immediately interpretable and completely transparent. Patients can be placed into one of three segments based on the total score--low, medium, and high risk for non-adherence. Sensitivity was 88%--of the non-adherers, 88% would be accurately classified as medium or high risk by the Adherence Estimator. The three risk groups differed on theoretically-relevant variables external to the Adherence Estimator in ways consistent with the hypothesized proximal-distal continuum of adherence drivers.

CONCLUSIONS

The three-item Adherence Estimator measures three proximal beliefs related to intentional non-adherence (medication non-fulfillment and non-persistence). Preliminary evidence of the validity of the Adherence Evidence supports its intended use to segment patients on their propensity to adhere to a newly-prescribed prescription medication. The Adherence Estimator is readily scored and is easily interpretable. Due to its brevity and transparency, it should prove to be practical for use in everyday clinical practice and in disease management for adherence quality improvement. Study limitations related to sample representation and self reports of chronic disease and adherence behaviors were discussed.