Topics in Minority Health Health Beliefs and Compliance with Prescribed Medication for Hypertension among Black Women -- New Orleans, 1985-86

In the United States, the prevalence of definite hypertension (i.e., having systolic blood pressure greater than or equal to 160 mm Hg and/or diastolic blood pressure greater than or equal to 95 mm Hg, and/or taking antihypertensive medication) is 1.5 times higher among blacks (25.7%) than among whites (16.8%) (1). Although hypertension-related mortality appears to be declining among blacks, this problem continues to be disproportionately higher among blacks than among whites, particularly in younger age groups (2). Poor compliance with prescribed treatment is cited as the major reason for inadequate control of hypertension in blacks and whites (3). Improved understanding of patients' beliefs about hypertension could aid the development of public health strategies to reduce or control the disease. This report summarizes a study of the relationship between beliefs about hypertension and compliance with antihypertensive treatment among black women who received health care at a public hospital clinic in New Orleans.

From May 1985 through July 1986, 54 (72%) of 75 black women aged 45-70 years receiving treatment for essential hypertension and possibly one other chronic disease unrelated to hypertension were included in the study. Each patient participated for 2 months. To elicit beliefs and attitudes about hypertension and general health, investigators interviewed each patient twice using a standardized questionnaire. Patients were visited in their homes at 2-week intervals to monitor blood pressure and compliance with prescribed medication. The 15 resident physicians who treated these patients at the clinic were interviewed about their awareness of patient health beliefs.

Based on medication diaries, field notes, and pill counts (at the initial visit and at 1 and 2 months after the initial visit), patient compliance was categorized as "poor" (pill use less than 60%) or "good" (use greater than 80%). For women with pill use 60%-79% (n=14) or for whom complete pill-use records were not available, diaries and field notes were used to determine whether compliance was "good" or "poor." The likelihood of poor compliance among women who professed folk beliefs* was compared with the likelihood of poor compliance among women who believed in a biomedical model of hypertension.

The 54 patients conceptualized their disease as "pressure trouble" or simply "pressure." One group (n=22) believed in the existence of the biomedical disease, hypertension; the other group (n=32) believed instead in the existence of two diseases, "high blood" and "high-pertension," distinguished by folk etiology, symptomatology, and treatment.

Patients characterized "high blood" as a physical disease of the blood and heart in which the blood was too "hot," "rich," or "thick"; the level of the blood rose slowly in the body and remained high for extended periods. These participants considered "high blood" to be caused by heredity, poor diet, and "heat" (from either the body or the environment); to be predictable and controllable; and to be capable of resulting in illness or death. "High blood" was thought to be appropriately treated by dietary control (i.e., abstention from pork, hot or spicy foods, and "grease") and by various folk remedies such as ingestion of lemon juice, vinegar, or garlic water. Patients believed these treatments cooled and thinned the blood, causing its level in the body to drop.

Patients considered "high-pertension" to be a disease "of the nerves" caused by stress, worry, and an anxious personality. Unlike "high blood," "high-pertension" was believed to be volatile and episodic. These patients believed that at times of emotional excitement, the blood would "shoot up" rapidly toward the head, then "fall back" or "drop back" quickly. Rather than medication and dietary control, these patients considered the appropriate treatment for "high-pertension" to be mitigation of stress and emotional excitement through control of emotions and the social environment.

Of the 32 women who believed in either of the two folk illnesses, 20 (63%) complied poorly with antihypertensive treatment, compared with six (27%) of 22 who believed in biomedical hypertension (relative risk=2.3; 95% confidence interval (CI)=1.2-4.4). Differences in compliance were also related to self-diagnosis: women who believed they had "high-pertension" were 3.3 times as likely to comply poorly as women who believed they had biomedical hypertension (95% CI=1.7-6.8). Those with "high blood" were 0.5 times as likely to be poor compliers (95% CI=0.1-3.1). Patients who believed they had both folk illnesses were 2.4 times as likely to be poor compliers as those who believed they had biomedical hypertension (95% CI=1.1-5.2).

The 15 resident physicians had limited knowledge of the existence among their patients of folk beliefs about hypertension. Only two physicians knew of their patients' beliefs about the role of blood and emotional states in hypertension. Although 12 of the 15 physicians were aware of folk terms for hypertension, eight believed such terms were simply folk expressions for the biomedical illness. Reported by: S Heurtin-Roberts, PhD, Dept of Epidemiology and Biostatistics, Univ of California, San Francisco. E Reisin, MD, Dept of Medicine, Louisiana State Univ Medical Center, New Orleans. Div of Technical Support, International Health Program Office; Div of Surveillance and Epidemiology, Epidemiology Program Office, CDC.

Editorial Note

Editorial Note: Compliance with drug therapy has been a major focus of research on the control of hypertension since 1979, when the Hypertension Detection and Follow-Up Program Cooperative Group (1) reported lower mortality in persons with moderate hypertension who received therapy. Although the benefits of drug therapy are well established, excess mortality associated with essential hypertension persists among black persons in the United States. The findings in this report suggest that physicians might decrease the excess mortality associated with hypertension through health education efforts and by taking into consideration their patients' beliefs.

This study 1) documented hypertension-related beliefs of a high-risk population under treatment, 2) demonstrated a measurable relationship between patients' perceptions of illness and compliance behavior, 3) determined that physicians treating these patients were unaware of their patients' perceptions of their illness, and 4) suggested the importance of training physicians to elicit patients' conceptions of the illness (4) before selecting a therapeutic regimen.

Limitations of the study sample are that it was small and facility-based and included only black women. Nonetheless, the findings about these patients' perceptions of hypertension are consistent with other studies that used larger, community-based samples of blacks (5,6) and facility-based samples of whites (7). These studies advocate educating physicians about the importance of patient beliefs about hypertension.

The practice of clinical preventive medicine is critical to achieving the public health goal of risk reduction. Ensuring that patients understand what is prescribed and that physicians understand the patients' views of the illness requires dialogue; however, minority patients are less likely than whites to receive adequate time in primary-care settings (8). This study demonstrates the role physicians might have in influencing mortality in a high-risk group by eliciting the patient's conception of the illness (9,10). Further evaluation and more consistent use of approaches that improve physician-patient relationships will be necessary if compliance with hypertension drug regimens is to improve and if morbidity and mortality associated with hypertension are to be reduced.

References

1. Drizd T, Dannenberg AL, Engel A, NCHS. Blood pressure levels

in persons 18-74 years of age in 1976-80, and trends in blood pressure from 1960 to 1980 in the United States. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1986; DHHS publication no. (PHS)86-1684. (Vital and health statistics; series 11, no. 234).

2. National Heart, Lung, and Blood Institute. The 1988 report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. Arch Intern Med 1988;148:1023-38.

3. National Heart, Lung, and Blood Institute. The 1984 report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. Arch Intern Med 1984;144:1045-57.

4. Kleinman A. Patients and healers in the context of culture: an exploration of the borderland between anthropology, medicine, and psychiatry. Berkeley, California: University of California Press, 1980:105-6.

5. Snow L. Traditional health beliefs and practices among lower class black Americans. Western J Med 1983;139:820-8.

6. Wilson RP. An ethnomedical analysis of health beliefs about hypertension among low income black Americans (Dissertation). Stanford, California: Stanford University, 1985.

7. Blumhagen D. The meaning of hyper-tension. In: Chrisman NJ, Maretzki TW, eds. Clinically applied anthropology. Boston: Reidel Publishing, 1982.

8. Gemson DH, Elinson J, Messeri P. Differences in physician prevention practice patterns for white and minority patients. J Community Health 1988;13:53-64.

9. Kleinman A, Eisenberg L, Good B. Culture, illness and care: clinical lessons from anthropologic and cross-cultural research. Ann Intern Med 1978;88:251-8. 10. Harwood A. Introduction. In: Harwood A, ed. Ethnicity and medical care. Cambridge: Harvard University Press, 1981.

*Belief in two distinct illnesses, "high blood" and "high-pertension," instead of a biomedical model of hypertension as recognized by physicians.

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