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LIBRARY
Michigan State
University -

 

 

 

This is to certify that the

thesis entitled
NDDIFICATION OF THE STUDY: THE
REIA’I‘IONSHIP BEIWEEN PERCEIVED BARRIERS
TO TREA‘D’IENT AND C(IVIPLIANCE WITH THE
HYPERTENSIVE THERAPEUTIC REGIMEN:
'URBAN AMERICAN PLAINS INDIANS
presented by

LYNDA L. KENDALL

has been accepted towards fulfillment
of the requirements for

Master Qf._S£:ienae_ degree in MEL

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MODIFICATION OF THE STUDY:

THE RELATIONSHIP BETWEEN PERCEIVED BARRIERS
TO TREATMENT AND COMPLIANCE WITH THE
HYPERTENSIVE THERAPEUTIC REGIMEN:
URBAN AMERICAN PLAINS INDIANS

BY

Lynda L. Kendall

A THESIS

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE

College of Nursing

1988

ABSTRACT
MODIFICATION OF THE STUDY:
THE RELATIONSHIP BETWEEN PERCEIVED BARRIERS
TO TREATMENT AND COMPLIANCE WITH THE

HYPERTENSIVE THERAPEUTIC REGIMEN:
URBAN AMERICAN PLAINS INDIANS

BY
Lynda L. Kendall

A cross sectional survey of 24 hypertensive urban American
Plains Indians was undertaken to determine the relationship
between perceived treatment barriers and stated compliance with
therapy. Interviews, questionnaires and medical record audits
based on the original instruments by Given and Given: Patient
Contributions to Care: Link to Process and Outcome: 1983 were
used to collect data from a convenience sample of adults. The
Health Belief Model and 1. King‘s theory of goal-attainment were
the organizing frameworks for the study.

Univariate and correlational statistics were used to
describe the sample and analyze the relationships between
perceived barriers to treatment and stated compliance with
prescribed diet, exercise and medication. The sample was
composed of middle to older-aged adults whose blood pressure was
in control. 'The majority was obese; twenty percent treated their
illness with folk or traditional medicines. One subject stated
non compliance to the medication regimen. There was a low
negative relationship found between perception of barriers to
diet and stated compliance with a dietary regimen. Twenty

percent of the sample stated an exercise regimen was followed.

Lynda L. Kendall

No correlation between.variables was computed for exercise due to
small sample size. A low negative relationship was found between
age and compliance with deit. Reliability of the instruments for
internal consistency were not reported due to limitations

imposed by the sample size.

DEDICATION

The present study is dedicated to Mr. Edward M. LaMere, past
Director of the Great Falls Native American Center. The
Indian Health Clinic was started and continued with.Edfs
support and direction. He was committed.to improving the
health and cultural integrity of Great Falls Indians. His
untimely death from cardiovascular disease at age 53 will
cause a great loss to his family, his tribe and his
community. Ed was an enthusiastic supporter of my research,
which helped me to appreciate the unique needs and strengths

of the Native American.

ii

ACKNOWLEDGMENTS

I wish to extend appreciation for the preparation and
completion of this thesis.to:my Committee members: Barbara
Given, Bill Given, Elaine Harmon and Brigid Warren. Special
recognition goes to Larry Davis, ITLD. for his expert assistance
in running and analyzing the data. Carol Ferro has proved to be
a skilled and concerned professional in the typing of the
manuscript. My employer and workmates deserve congratulations
for tolerating my absences, as well as, emotional reactions
during the preparation of this study.

Lastly, I wish to thank my husband, Russ, and daughter,

Dana, for their patience and support.

iii

TABLE OF CONTENTS

Chapter I Introduction

Background

Summary

Definition of Hypertension
Definition of Compliance
Definition of Health Belief Model
Research Question

Concepts Defined
Hypotheses

Sample

Assumptions

Limitations

Chapter II Conceptual Framework

Overview

PathOphysiOIOgy of Hypertension

Health Belief Model

Summary

Nursing Theory

Integration of the Health Belief Model
with King's Theory for Nursing

Nursing Process of Care

Summary

Chapter III Review of the Literature

Overview

The Nature of Hypertension in the
Native American

Treatment of Hypertension

Summary

The Health Belief Model: Barriers to
Treatment and Compliance Behavior

Summary

Nursing Intervention for the Hypertensive
Native American

Summary

Chapter IV Methodology and Procedures

Overview
Research Question
Research Hypotheses
Instruments
Validity and Reliability
Operationalization of Study Variables
Population and Sample
Data Collection Procedures
Statistical Analysis
Summary

iv

78
82

84
84
84
84
85
87
88
92
93
94
95

Chapter V Data Presentation and Analysis
of Results
Overview
Study Sample: Descriptive Findings
Summary of Descriptive Findings
Reliability
Hypotheses Testing Results
Summary of Descriptive Data by Hypotheses
Extraneous Variables
Summary of Results
Limitations of Findings

Summary

Chapter VI Summary and Conclusions

Overview

Summary of the Findings

Sociodemographic Characteristics

Summary of Statistical Procedures
Recommendations for Future Research
Implications for Advanced Nursing Practice
Recommendations for Nursing Education
Conclusions and Discussion

Suggestions for Future Research

Summary

Appendix A:

Appendix B:

Appendix
Appendix
Appendix
Appendix

Appendix

E:

F:

G:

Consent Form

Hypertension Intake Information
Medical Record Audit

Hypertension Patient Interview
Sociodemographic

Perceived Barriers to Therapy
UCRIHS Approval

Native American Center Board Approval

96

96

96
104
105
105
109
110
111
112
114

115
115
115
118
125
128
133
137
139
140
141

LIST OF TABLES

Table 1. Distribution and Percentage of Subjects
by Age

Table 2. Distribution and Percentage of Income
Annually

Table 3. Distribution and Percentage of Education

Table 4. Distribution and Percentage for Years of
Diagnosed Hypertension

Table 5. Average Systolic Blood Pressures During
the Past Six Months

Table 6. Average Diastolic Blood Pressures During
the Past Six Months

Table 7. Dietary Habits: Estimates of Percentages
of Food Consumption

Table 8. Length of Residence in Great Falls in Years
and Percentage of Distribution

Table 9. Length of Residence at Same Residence in
Years and Percentage of Distribution

Table 10. Compliance with Medications
Table 11. Barriers to Medication
Table 12. Compliance with Diet

Table 13. Barriers to Diet

Table 14. Relationship between Diet Compliance and
Barriers to Diet

Table 15. Barriers to Exercise

Table 16. Extraneous Variables to Compliance with
Diet

Table 17. Additional Variables to Compliance with
Diet

vi

97

97

98

98

99

99

101

103

104

106
107
107
108
108

109
110

111

LIST OF FIGURES

Figure 1. Primary Hypotheses 14

Figure 2. Health Belief Model adapted from 32
Becker, 1974 and Kasl, 1974

Figure 3. Variables used in Present Study: Modified 33
from Original Model Figure 2, Becker, 1974
and Kasl, 1974

Figure 4. King's Conceputal Framework for Nursing: 39
Dynamic interacting systems

Figure 5. King's Model: Process of Human Interactions 42
Figure 6. King's Model with H.B.M. Components: 45
Modifying factors, perceived barriers to

treatment, and compliance with the therapeutic
regimen

vii

MODIFICATION OF THE STUDY:
THE RELATIONSHIP BETWEEN PERCEIVED BARRIERS
TO TREATMENT AND COMPLIANCE WITH THE
HYPERTENSIVE THERAPEUTIC REGIMEN:

URBAN AMERICAN PLAINS INDIANS

CHAPTER I
Introduction

Hypertension has been established as a major contributor to
.morbidity and mortality from heart disease, stroke and renal
failure in the white and black American pOpulations. Heart
disease ranks second as the leading cause of death among the
North American Indian population in 1973-75 (D. HJLW.
Publication). The two leading causes of diseases of the heart
among Indians in 1975 were acute myocardial infarction and
chronic ischemic heart disease, 43% and 32% respectively (IJLS.
Publication No. 78-12009). In 1981-83 diseases of the heart were
the leading cause of death for Native Americans (Rhoades, 1987).

Alterations in rates of these serious illnesses may be
achieved by reduction in blood pressure in all races. Adherence
to a therapeutic regimen to manage hypertension may alter
morbidity and mortality due to heart disease (American Heart
Association, 1987).

Harmon’s study dealt with.the relationship between
perceived barriers to treatment and compliance with the

1

hypertensive therapeutic regimen done in Michigan with
caucasians (Harmon, 1983). The present study will focus on the
relationship between perceived barriers to treatment and
compliance with the hypertensive therapeutic regimen using a
culturally-diverse group of North American Plains Indians.
Native Americans from the Chippewa—Cree, Gros—Ventres, Blackfeet
and Northern Cheyenne tribes who live in an urban environment
will be included. (Approximately 51% of all Native American
Indians live off the reservation at this time) (LaMere, 1985).
The purpose is to explore the influence certain variables exert
upon the hypertensive client altering his compliance with a
therapeutic regimen. .Additionally, data will be utilized from
the study done by B. Given and C.W. Given (1982).

The health belief model (Becker, 1985) will provide the
framewcmk.for exploration of perceived barriers to treatment and
the relationship to compliance with the hypertension control
regimen. .Application of the health belief model to a culturally-
diverse group will be explored in the literature review.

Background

Cardiovascular disease was the cause of death for 987,000
persons or 49% of all causes of death in 1983 (Fact Book, 1984).
Over 63 million Americans suffer with some form of heart or blood
vessel disease (1986 Heart Facts, A.H.A.). Hypertensive disease
had the greatest prevalence rate (57,710,000) of all the major

cardiovascular diseases (1986 Heart Facts, A.H.A.). The risk for

cardiovascular events: coronary heart disease, stroke and
congestive failure, is related to the height of the blood
pressure. Based on 1983 projections, the increased risk of
morbidity and mortality associated with hypertension necessitates
the use of specific therapies and systematic monitoring (Final
Report of Subcommittee on Definition and Prevalence, 1984).

A review of medical and nursing literature for the last five
years demonstrates a paucity of information available regarding
the Native American populations experience with cardiovascular
disease (Gillum, 1984: Alfred, 1970: Torrey, 1979, DeStefano,
1979: Sievers, 1977: Hollow, 1978: Rhoades, 1987L.

The prevalence of hypertension has been increasing in
certain tribal populations. Hollow (1978) reports a prevalence
rate of 12.6% for urban Indians seen in Seattle, Washington in
1977. This prevalence rate compares to the general population
prevalence rate of 14:7% for whites and 27.6% for blacks in that
same year (Hollow, 1978). "Cardiovascular disease is the leading
cause of death among Minnesota Indians, both urban and rural“
(Gillum, 1984, p. 724). Heart disease and stroke combined
account for 26% of the 1,100 deaths in 1968-73 among Indians
(age-adjusted rate 448:7/100,000 compared to 455.2 for all
races). A survey of residents 18-84 years of age in a
Minneapolis Indian-operated public housing project occupied
almost exclusively by American Indian families demonstrated.a
prevalence of systolic BP 1140mm Hg of 15%. and a prevalence of

diastolic BP 390mm.Hg of 14% (Gillum, 1984).

“The leading cause of death for Navajo men in 1974 was
:motor vehicle accident followed by diseases of the heart,
respiratory diseases, cirrhosis of the liver, and cerebrovascular
diseases. The leading cause of death for the American population
in general in the same year was diseases of the heart, followed
by malignant neoplasms, cerebrovascular diseases, accidents and
respiratory diseases.“ (Markides, 1983).

DeStefano (1979) studied 640 Navajo men and*women in New
Mexico and Arizona. He reported prevalence rates of elevated DBP
390 per decade of life: the ranges included: 27% in 20-29 year
old males to 4% in 60 years and older. For females the lowest
prevalence was in the 20-29 year olds: 3%: 10% in 30-39 year
olds: and, 5% in 60 years and older (DeStefano, 1979).

DeStefancfls survey conducted on the Navajo reservation
demonstrated that over the last twenty years "diastolic blood
pressure and the prevalence of elevated pressures have remained
essentially the same for women, but for men there has been a
slight rise in both parameters“ (p. 340). DeStefanoHs study
further substantiated that hypertension occurred more frequently
among off-reservation Indians " with fewer traditional customs
than Indians who have remained on the reservation“ “L 343).

A survey of Aleuts on St. Paul Island, Alaska in 1976,
yielded a hypertension prevalence rate of 51%. Conversely
Alaskan Eskimos have systolic and diastolic blood pressures

“below the mean for the United States population as a whole, and

thus much lower than the Aleut blood pressuresJ'(Torrey, 1979.
P. 11).

In the studies available, major differences exist among
various Indian tribes in regard to cardiovascular disease.
Sievers (1977) believes it is meaningless to consider the general
“frequency of hypertension among Indianst" ZHe states that “no
comprehensive prevalence data exists for hypertension among the
Native Americans" (p. 607). Additionally, specific data
regarding the prevalence of hypertension, heart disease, stroke
and renal failure for the North American Plains Indian residing
in Great Falls, Montana is not available at this time. An

estimate of prevalence of hypertension for Indians seen at the

 

Native American Center was given at 30% by the Director of the
Center (LaMere, 1986). The 30% is estimated on clients seen, not
necessarily the population of urban Indians.

Alfred (1970) studied the effects of migration from a rural
to an urban environment on male Navajos and found a significant
rise in blood pressure in those who lived in the urban
environment. Few studies are available at this time which deal
with migration of the Plains Indians. The effects of urban
lifestyle changes on blood pressure of these tribes has not been
studied. Specific demographic information will be sought using a
modification of Harmon's tool (Harmon, 1983).

No‘direct effort will be made in this study to relate
migration, city-dwelling vs. reservation lifestyle. Prevalence

rate for the current population of Plains Indians using the

Native American Center will be estimated. Based on the latest
United States Census for Cascade County, prevalence rates will be
estimated for whites, blacks and Native Americans residing in
this area.

The magnitude of hypertension is well documented for the
United States population (Final Report of Subcommittee on
Definition and Prevalence, 1984, National Heart, Lung and Blood
Institute Fiscal Year 1984, Fact Book). In the report from the
Subcomndttee on Definition and Prevalence of the.Joint National
Committee on Detection, Evaluating and Treatment of High Blood
Pressure, 1984, the prevalence estimate is 57.7 million
hypertensive adults (Final Report of Subcommittee on Definition
and Prevalence, 1984).

Personal and public costs in terms of chronic illness,
disability and death from hypertension and associated
cardiovascular disease and target organ damage has also been well
established (National Heart, Lung and Blood Institute, 1984:
Framingham, 1978: Levy, 1982: Grundy, 1987). In the expanded
survey conducted to update the 1973 study, “The Public and High
Blood Pressure“, issues of knowledge, control, treatment,
awareness and compliance are presented for ”other minoritiesfl'
”Other minorities" include those persons who do not identify
themselves racially as white or black. The composition of the
group is 68% Hispanic, 20% Asian, and 11% American Indian. It
is, therefore, difficult to determine the application of this

information to the Plains Indian.

Rhoades (1987) published a survey which described the impact
of mortality and morbidity for Indians served by the Indian
Health Service (IHS). Cardiovascular disease accounted for 1,362
deaths annually, or 192 deaths per 100,000 pOpulation (age-
adjusted death rate) (Rhoades, 1987). Rates of potential life
lost before age 65 was reported by each IHS service area.

The Montana/Wyoming service area reported 12 years of productive
life lost before age 65 due to death from cardiovascular disease
(Rhoades. 1987).

Summary

Cultural and genetic heritages of the 507 Federally-
recognized Indian entities differ widely (Rhoades, 1987). The
prevalence rates of hypertension and related cardio-vascular
disease varies among tribes. Although the magnitude, as well as,
personal and public costs are well known for the general UNA
population, less is known about the Native American minority.

Definition of Hypertension

Since this is an expansion of Harnmxvs study, the definition
of hypertension will be used as outlined by Harmon.(1983) and
Given and Given (1982): “hypertension not under control is
Operationalized as a systolic pressure above 140mm Hg and/or a

diastolic pressure above 95mm Hg on two occasions at least two

 

months apart“ (p. 61).
The World Health Organization in the past identified
hypertension as a blood pressure of 160/952mmng. In 1984 the

Joint Committee on Detection, Evaluation and Treatment of High

Blood Pressure issued a new classification of blood pressure.
Diastolic blood pressure 90 - 104mm.Hg is considered mild
hypertension and follow up confirmation is necessary within two
months (Archives of Internal Medicine, 1984).

Definition of Compliance

The health-illness values, beliefs and patterns of behavior
of the Native American with hypertension will have an impact on
the long term care of hypertension, which is based on compliance
with a therapeutic management regimen. Compliance is defined as
"the extent to which cIients follow recommendations of health
providers“ (Harmon, 1983, p. 7).

Linden offered several definitions of compliance related to
the client's performance, attitude and habits. The most often
used is "standard compliance," which is defined as the client's
”performance in relation to general medical expectations which
defines optinuun performance“ (Linden, 1981, p. 87). Levy states
that ”compliance“ is essential to reduce the risk of heart
disease, stroke and renal failure (1982).

Non-compliance with the hypertensive therapy is high in the
population studied by Webb (1980). and seen as a significant
threat to health due to cardiovascular consequences. Neither
compliance nor non-compliance behavior in regard to hypertension
has been studied in the Native American population.

It is reasonable to assume, based on studies with different
cultural groups, that chronic illness, treatment, and or care may

be perceived differently (Ludell Snow, 1983). For example, Snow

(1983) found that the blacks she studied believed all illnesses
have a cure and one must search to find it. Historically,
Blackfeet Indians believed disease was caused by an evil spirit
entering into a person's body and it could be cured by a doctor
who possessed the power to expel the spirit (Eivers, 1958, p.
184).
Definition of Health Belief Model

The Health Belief Model (H.B.M.) was developed to analyze an
individual's beliefs about health conditions or illness, and his
decision-making to take action weighed against perceptions of
"costs“ or barriers of the prOposed action (Maiman, 1974). The
conceptual model devised by Rosenstock, Hochbaum, Leventhal, and
Kegeles defines client perception factors as: perception of
illness threat, susceptibility and seriousness, and perceptions
of treatment benefits or barriers (Maiman, 1974). Rosenstock
(1974) described the potential use of the model as a way of
testing what action an individual would undertake to prevent
illness, respond to symptoms in specified ways, and/or would
follow professional recommendations. Compliance is the extent to
which.an individual will carry out therapeutic recommendations
from health care providers (Linden, 1981). Therefore, the model
can be used as a predictor of compliance. Although the “set of
beliefs" possessed by an American Indian may differ culturally
from other populations, the decision to act or not act in regard
to health-related situations will still be dependent upon the

"set.“ Perceptual factors may also be culturally influenced.

10

Perception of barriers to treatment may vary from other cultural
groups since medical services, medications, and educational
resources are provided through the Indian Health Service.
Compliance may be positively or negatively influenced by the
dominant social group, which may disagree with certain elements
of the therapeutic regimen, iJL, Indian-folk medicines to
control hypertension. Janz (1984) states that the assumption is
made that diverse demographic, sociopsychological and structural
barriers might affect the individual's perception, and thus
indirectly influences health-related behavior.

The component of the health belief model duplicated in this
study is perceived barriers to treatment: and perceived barriers
effect on compliance behavior. Becker's model offers a
multiplicity of possible interrelationships which will not be
explored in this study. No research is currently available to
support the use of the H.B.M. with a culturally diverse
population. Therefore, an additional purpose of this study will
be to use the components of the H.B.M., barriers to treatment and
compliance with the hypertensive regimen to determine if the
findings from this group are similar to groups previously
explored.

Research_guestion

This study is a modification of Harmon's study in which the
question studied was: “How do clients' perceptions of barriers
to treatment relate to their stated compliance with the

hypertension therapeutic regimen?“ (Harmon, 1983. p» 9). The

11

problem is germane for nurses, in that, health—related behavior
is based on unique beliefs and perceptions which must be
comprehended by the care-giver. Sociocultural factors are
inherent in the client's perception. No other study is currently
available that deals with the Plains Indians of Montana.
Furthermore, cultural factors have not previously been explored
as an integral component of client perception.

Harmon further states that the health belief model approach
"implies that attempts to influence the behavior of clients must
be based on knowledge of client's health beliefs and
perceptions” (p. 9). For optimal health outcomes, issues of
compliance behavior must be appropriately managed.

Concepts Defined

The definition of concepts are replicated from Harmon

(1983), and Given and Given (1982) with the addition of cultural

concepts. The variables to be included are:

INDEPENDENT
1. Perceived barriers to treatment:
DEPENDENT
2. Stated compliance with the therapeutic regimen.

Perceived Barriers are those potentially negative aspects of
taking health action. Individuals generally perform a cost-
benefit analysis before taking action. ‘The potential impediments
may be perceived as expensive, dangerous, unpleasant,

inconvenient, time-consuming, painful or other (Janz, 1984).

12

Perception is the individual's*world view based on his

 

interface with his environment. Reality awareness of persons,
objects and events is influenced by self concept, biological
inheritance, past experience, educational background, and
socioeconomic (and cultural) group (King, 1981). Each personfs
encounters with his world are personal and selective based on his
unique characteristics: growth and deveIOpment, context,
integrity of his biological organism, concept of spatial-temporal
relationships (King, 1981).

King defines perception as a process of organizing,
interpreting and transforming information from sense data and
memory. It is a process of human transactions with environment.
It gives meaning to one's experience by reporting one’s image of
reality and influences one's behavior (King, 1981).

King does not specifically include cultural variables in her
definition. Leininger, however, points out that each cultural
group can and does “classify their universe" according to their
perceptions (Leininger, 1978).

Given defined "client perceptions of barriers to treatment
as the expressed beliefs and attitudes of the client concerning
the barriers to undertaking aspects of the therapeutic regimen"
(Given, pn 27). Harmon further delineated separate “dimensions of
barriers to implementation of therapy“ that are taken from the
study by Given and Given. The dimension relevant to exercise was
added for this study. The separate dimensions are defined as

follows:

13

Beliefs about difficulties with medications refer to the
confusion of taking a number of medications, the habit changes
required, the concern over medication dependence, the disruption
of daily activities to take medications, and the necessity of
continued medication.

Specific beliefs about difficulties with changes required
£95 gigt include interference with normal activities and personal
life, feelings of hunger, dislike of the taste of allowed foods,
the time required to follow a diet, and the need for family
support.

Specific beliefs about difficulties with chagges required for

exercise including: interference with normal activities and

 

personal life, feelings of fatigue, dislike of the specific
exercises recommended, the time necessary to follow an exercise
plan, physical discomfort associated with exercise and the need
for supportive others.

Compliance with therapy to control hypertension prevents
target organ damage and complications. Therefore, it is
necessary to include compliance behavior as a study variable.
Given and Givenfs definition, combined with.Harmonfs, of ”stated
compliance with the therapeutic regimen as the extent to‘which
the client carries out the therapeutic recommendations of health
care providers concerning prescribed medications, diet, and
exercise" will be used for this study (Given and Given, 1982).

Compliance will be accessed during the research interview by

questioning whether ”medication was takenfi: whether “the

14

prescribed dosage was taken“, and the recommended schedule for
dosage was followed. Similar questions regarding "stated
compliance“ with diet and exercise will be asked. The same five
point scale as originally used will be employed.

Hypotheses

 

In this study, the primary hypotheses with subsets will be
patterned similar to Harmon's:

Primary hypothesis. 1. There is a relationship between
client perception of barriers to treatment and stated compliance
with the therapeutic regimen.

Secondary hypotheses:

a. There is a relationship between perception of barriers

concerning medications and stated compliance with.a medication

 

regimen.

b. There is a relationship between perception of barriers
to gigs and stated compliance with a diet regimen.

C. There is a relationship between perception of barriers
to exercise and stated compliance with an exercise regimen.

INDEPENDENT DEPENDENT
VARIABLES HYPOTHESBS VARIABLES

 

 

 

PERCEIVED BARRIERS —-j)» STATED
COMPLIANCE
with
MEDICATION
DIET
EXERCISE

 

 

 

 

 

 

Figure 1. Primary Hypotheses

15

Extraneous variables examined for possible relationships to
stated compliance are: age, sex, income, marital status, blood
pressure, percentage overweight, and duration of hypertension.

Sample

The voluntary sample for study will be obtained from
accessible hypertensive clients under the care of local
physicians and Indian Health Service physicians at the Native
American Center in Great Falls, Montana. The sample subjects
will parallel the Characteristics in Harnmxfls study with the
exception of unique demographic characteristics. The sample will
include Plains Indians of several tribes residing in Great Falls
City limits: able to speak and comprehend the English language:
have an established medical diagnosis of essential hypertension;
18-85 years of age: no evidence of stroke, end-stage renal
disease, blindness, cancer, psychiatric problems, pregnancy or
lactation, and on a prescribed medication and/or a dietary
regimen (Given & Given, p. 61). subjects screened into the study
will have had two elevated blood pressure readings 1140/95 mmlflg
within six months prior to the interview. The results of the
study will not be generalizable due to convenience sampling.

Assumptions

The following assumptions are replicated from Harmon, with
alterations specific to the sample. The seventh assumption was
added.

1. Compliance with a therapeutic regimen is a health

behavior that will improve present and future health states.

16

2. Health-related perceptions affect compliance and other
health—related behavior in the Indian culture.

3. The concepts of perceived barriers to treatment,
and compliance as defined in this study are real and measurable
phenomena.

4. Measurement of stated compliance is a reliable method of
measuring compliance in Indian hypertensive Clients.

5. The testing instruments are sensitive to the concepts of
perceived barriers to treatment and stated compliance of the
Indians.

6. The sample is unique and represents a portion of North
American Plains Indians of the Chippewa-Cree, Gros-Ventres,
Blackfeet and Northern Cheyenne tribes residing in an urban
environment in the northwest.

7. Sociocultural variables will affect health-related
perceptions.

Limitations

1. A convenience sample of available hypertensive adults
will be participating in this study, therefore, bias may be
introduced by inclusion of only those accessible and willing to
participate.

2. The findings of the study will not be generalized to
other populations since the cultural group to be studied does not
represent all Plains Indians, nor is the group necessarily
representative of all North American Indians living in an urban

environment.

17

3. The type of compliance assessed is limited to stated
compliance to medication, diet and exercise. Compliance with
culturally-specific modalities may interfere with prescribed

therapies.

4. The one point in time in the chronic-illness trajectory
at which data was collected may not be representative of the
usual perceptions and behavior of this sample. Other points in
time may be more typical.

5. Different, individual perceptions of the meanings of
answer choices may have affected individual responses.

6. The need to express a socially desirable response may
have affected the responses of participants.

7. All possible factors affecting compliance are not
addressed in this study. Findings may be due, in actuality, to
an inter-relatedness of other factors with the ones identified.
Examples of factors which are not included are: other aspects of
the health belief mode, provider-patient relationships,
developmental stages, and social support.

Overview of Chapters

In Chapter I the present study was described as a
modification of E. Harnmxfls (1983) ,‘WhiCh used data from the
original study by B. Given and C. W. Given (1982). The rationale
and purpose of the study has been outlined. The problem
statement, definition of terms, hypotheses, assumptions and

limitations consistent with replication have been presented.

18

The specific characteristics of the population sample were
described as unique and not included in previous research.

A conceptual framework designed to integrate the health
belief model, I. King's theory of nursing, and concepts from
Leininger's theory of transcultural nursing will be presented in
Chapter II. There will be a brief review of essential
hypertension.

In Chapter III the review of literature will focus on

ppdated materials available since Harmonfs study in 1983. There

 

will be an exploration of literature relevant to the nature of
hypertension in the Native American, as well as, an expansion of
nursing theory into the transcultural dimensions. The purpose of
the review is to expand on the findings of others concerned with
hypertension, compliance and application of the information to a
culturally diverse group.

In Chapter IV the methods of research design,
instrumentation, procedures and human rights protection, as used
in Harmon's study, will be outlined.

A description and presentation of data including analysis
will be presented in Chapter V.

The final chapter, VI, will include a summation and
discussion to include: research findings, implications, and

recommendations.

CHAPTER II
CONCEPTUAL FRAMEWORK
Overview
In Chapter II there will be a discussion of the

pathophysiology of hypertension, the HJIFL, nursing theory by
King (1981) with supportive concepts from Leininger (1978), and
the integration of the concepts for the nursing care of the
hypertensive Native American client. Perceived barriers to
treatment and compliance behavior as described by the H.B.M. are
organized within King‘s theoretical framework. Social variables
are included as influencing perceptions.

The purpose of this study is to examine the relationships
of the variables within the framework to determine which
significantly influence the hypertensive clientis compliance with
the therapeutic regimen. The conceptual framework is consistent
with.Harnmnvs study with the addition of social and cultural
parameters.

Pathophysiology of Hypertension
Blood pressure is a function of cardiac output and
peripheral resistance represented by the formula: blood pressure
= cardiac output x peripheral resistance (Kochar, 1981:
Plunkatt, 1984: Kaplan, 1978: Marcinek, 1980: Somermeyer, 1986).
Blood pressure is regulated by several interacting body systems:
cardiovascular, renal, neurologic and endocrine (Guyton, 1984:

Price, 1982: Kochar, 1981: Kaplan, 1978: Somermeyer, 1986).

19

20

Alterations in cardiac output or peripheral resistance will
affect systemic arterial blood pressure (Marcinek, 1980).

To further define the formula for blood pressure, cardiac
output is the volume of blood ejected into the pulmonic and
systemic circulation by each ventricle per minute. The average
output is five liters per minute (Price, 1982). Cardiac output
is the product of heart rate and stroke volume which is dependent
upon cardiac contractility and the intravascular fluid volume
(Marcinek, 1980: Somermeyer, 1986). “Heart rate is largely under
the control of the autonomic nervous system" (Price, p. 315).
"Control of stroke volume is a function of the interaction of
three variables: preload, contractivity (of myocardial muscle)
and after load“ (Price, p. 317). Further refinement of
definitions will not be done since this is not the focus of the
study.

Peripheral blood flow is dependent upon properties of the
vascular bed and the volume and viscosity of circulating blood.
Metabolic needs and functional demands of tissues determine the
distribution of blood flow. Both extrinsic and intrinsic neural
and humoral regulatory mechanisms exert control in the
distribution of blood (Price, 1983: Kaplan, 1978).

Kochar (1981) states that cardiac output (heartrate x stroke
volume) is the major determinate of the systolic blood pressure.
Systolic blood pressure is the measure of peak cardiac ejection:

wherein, diastolic blood pressure is the low point at the end of

21

cardiac relaxation (Somermeyer, 1986). Diastolic blood pressure
is primarily determined by resistance in the arteriole (Kochar,
1981).

Long-term arterial pressure control may be achieved by the
renal—body fluid control system aided by the renin-angiotensin
system, the nervous system and the aldosterone system (Guyton,
1984). The kidneys will retain fluid when arterial pressure
falls, and will cause diuresis when arterial pressure rises.
Increases in renal artery pressure Changes the blood pressure
flowing through the afferent arteriole into the glomerulus.
Juxtaglomular cells in the walls of the arteriole are activated
by stretch receptors near the JG cells and secrete the enzyme
renin (Price, 1983). Renin catalyzes the conversion of
angiotensinogen from the liver to angiotensin I (Chobanian,
1982). Angiotensin I is converted to angiotensin II by an enzyme
found in lung and other capillary beds. Angiotensin II
stimulates the production of aldosterone by the adrenal cortex
(Chobanian, 1983). Aldosterone promotes renal tubular
reabsorption of sodium, volume expansion, and a rise in arterial
pressure. .Afferent arteriolar pressure rises which shuts down
the production of renin (Price, 1983). The renin-angiotensin
system also may cause marked total peripheral resistance.

Nervous control of cardiac output and the peripheral
vascular system is achieved by sympathetic innervation.

Sympathetic stimulation increases heart rate and contractility,

22

thereby, cardiac output. Further, arterioles will be stimulated
by the sympathetic adrenergic fibers to either dialate or
constrict to redistribute blood flow to capillary beds according
to need (Price, 1983).

In addition, Price (1983) states that "the adrenal medulla
secrets catecholeamines, epinephrine and norepinephrine in
response to sympathetic activity“ (p. 319). “These hormones
elicit sympathetic responses in the peripheral vasculature” UL
319).

The chronic elevation of systolic and/or diastolic blood
pressure is classified as hypertension. The two main
Classifications of hypertension are: primary, idiopathic or
essential indicating no known cause: and secondary in which the
etiology is known. At this point in time, 90-95% of all persons
with hypertension are classified as essential (Chobanian, 1982:
Kaplan, 1978: Kochar, 1981: Harrison, 1983: Guyton, 1984). The
category of essential hypertension is heterogenous, in that, the
population differs in probable mechanisms of action, underlying
factors, i.e. aging, and genetic predisposition, i.e. blacks and
Native Americans (Somermeyer, 1986). The focus of this study
will be essential hypertension in the Native American population
seen in a primary care setting.

Multiple changes in the aforementioned physiologic
mechanisms that control blood pressure take place in the

hypertensive individual. Guyton (1984) describes two

23

determinants of arterial pressure: 1) The pressure range of the
renal output curve and 2) the net rate of fluid intake. Changes
in one or both of these determinants will change arterial
pressure levels. In the person with essential hypertension, the
renal output curve is shifted to a higher level. Urinary output
remains normal as long as the arterial pressure remains high.

The cause of the shift is unknown; however, changes in the
afferent arteriole or the glomerulus of the kidney is suspected.
Renal retention of sodium with a concomitant rise in blood volume
and an increase in cardiac function are two mechanisms causing
pressure elevation (Kaplan, 1978: Chobanian, 1982). High volume
and retention of sodium and water may reflect a failure of the
kidneys (Kaplan, 1978). The "renal perfusion pressure-sodium
excretion control mechanism" may have an inherited defect which
may respond to high salt intake over years resulting in
hypertension (Kaplan, 1978).

Kaplan (1978) also indicates there may be an imbalance
between vasopressor hormones: renin + angiotensin II and
vasodepressors: prostaglandins and kalliken. The role of each
of these is not completely understood, but is currently being
researched (Kaplan, Hollenberg, 1984: Taimarco, 1985: Chobanian,
1982: Tuck 1985).

Cardiac output and peripheral resistance are elevated in
some hypertensives. Increased peripheral resistance may be due
to an increase in vascular wall thickness or vascular smooth

muscle sensitivity (Kaplan, 1978).

24

Sympathetic nervous activity may be enhanced by emotional
stress causing Changes in heart rate, cardiac output, stroke
volume and decreased plasma volume. Renin release is stimulated
by the sympathetic system (Kaplan, 1978: Chobanian, 1982).

Kaplan (1978) states this possible sequence of events: "stress

---9 a genetically determined autonomic hyperactivity ---9'
intermittent rise in blood pressure —--9»structural Changes in
resistance vessel ---$'permanent tension“ (p. 59).

Additional factors which may influence the develOpment of
hypertension include increasing age, race, obesity, physical
activity, smoking, medications, genetics (Chobanian, 1982:
Kochar, 1981: Harrison, 1983). A multifactoral approach to
describe essential hypertension is necessary. No single theory
adequately represents all the known facts about essential
hypertension (Mendlowitz, 1979).

Hypertension may be very damaging by causing an increased
'workload on the heart and destruction of the arteries by
excessive pressure (Guyton, 1984). High pressure in the arteries
causes sclerotic Changes. Target organs most prone to vascular
Changes and resultant damage are the heart, brain and kidney
(Marcinek, 1980: Guyton, 1984).

Destruction of brain tissue results from cerebral blood
vessel changes. .Atherosclerosis and microaneurysms cause
strokes. The early symptom of occipital early morning headaches

progress to fatigue, forgetfulness and irritability consistent

25

with extending damage (Marcinek, 1980). Hypertension causes 50%
of all strokes (Labunetz, 1986).

Renal blood vessels are also affected, which in turn cause
destruction of the nephron. Inability of the kidney to
concentrate and form urine is evidenced by changes in the BJLN.
and serum creatinine. Protein in urinemay also occur in some
patients (Marcinek, 1982). “Cardiac disease is the leading cause
of death among persons with high blood pressure“ (Marcinek,
1982). Coronary atherosclerosis causing reduced perfusion may
lead to myocardial infarction, left ventricular strain and
congestive heart failure (Marcinek, 1982).

An index to the severity and prognosis for vessel damage in
body organs is the retina. Hypertension causes focal spasms and
progressive narrowing of the arterioles. Hemorrhages, exudates
and papilledema are apparent. Significant positive changes can
occur with reduction in blood pressure (Harrison, 1983).

To summarize, multiple factors and body systems are involved
in the regulation of blood pressure. No single defect can be
implicated in the cause of essential hypertension. The
complications of hypertension are related to target organ damage:
myocardial infarction and congestive heart failure: strokes,
renal failure, blurred vision and blindness.

Treatment for the patient with hypertension includes a
program tailored.to controlling arterial pressure with a minimum
of side effects (Harrison, 1983). General measures employed

could include diet, regular exercise, control of risk factors and

26

medication (Harrison, 1983). Diet, exercise and medication are
the usual treatments for hypertension (Chobanian, 1982: Kaplan &
Liebeiman, 1987: Harrison, 1983). Medication, diet and exercise
are the therapeutic recommendations selected as compliance
variables for this study. Non pharmacologic approaches for the
control of hypertension are weight control, alcohol restriction
and sodium restriction, (AJLA. Report, 1984).

Medication therapy includes five classes of drugs:
diuretics, adrenergic inhibitors, vasodialators, angiotensin
converting enzyme (AJLIL) inhibitors, and calcium channel
blockers (Chobanian, 1982: Kaplan, 1978: Harrison, 1983:
Somermeyer, 1986). Diuretics are the first step of therapy and
provide a normal BP in 50 to 60% of hypertensives (Chobanian,
1982). The second Class of drugs are adrenergic inhibitors which
may be used initially or added to diuretic therapy. Adrenergic
inhibitors may produce sexual dysfunction and exercise
intolerance influencing patient compliance (Somermeyer, 1986).
Often the drug of choice is an.AJLEL inhibitor which has limited
side effects and provides Optimal BP control. Calcium channel
blockers and vasodialators were grouped together for this study.
Both drugs lower peripheral vascular resistance. The fifth
category was used for combined drugs, such as tenoretic, which is
a diuretic and beta-blocking agent combined . Combined drugs
simplify regimens for patients who may be noncompliant, however,
flexibility in prescribing and dosage is limited (Becker,

1985).

27

Dietary management has three aspects: 1) sodium reduction
(AJLA. Report, 1984: Harrison, 1983: Langford, 1981: Reisen, et
al., 1978: Stamler, et al., 1978): 2) caloric restriction for
weight loss/control: and, 3) restriction in Cholesterol and
saturated fats which decreases the incidence of athlerosclerotic
complications (AJLA. Guidelines, 1984: Harrison, 1983).
”Exercise may be an adjunct prescribed for its usefulness in
weight control, cardiovascular disease risk control, and stress
reduction, as well as, for normalizing the blood pressure through
physical conditioning of the body (Horton, 1981: American Heart
Association, 1984: Harmon, 1983: Harrison, 1984).

Psychosocial, as well as, physiological factors would need
to be included when individualizing nursing care for the
hypertensive client. The health belief model provides a way to
assess the psychosocial needs of the hypertensive Client. The
present study uses the process outlined in the H.B.M. to describe
the interaction of psychosocial variables which influence the
individual's behavior.

Health Belief Model

The health belief model is a psychosocial model which
describes the subjective world of the acting individual in
decision-making about health—related concerns (Maiman, Becker,
1974: Rosenstock, 1974) (Figure 2). The foundation of the model
is phenomenological (Van Doren) in that ”the world of the
perceiver determines what he will do and not the physical

environment, except as the physical environment comes to be

28

represented in the mind of the behaving individual" (Rosenstock,
In 329). Furthermore, in the model the orientation is on current
or present dynamics acting on the perceiver with past experiences
only important insofar as the impact on current behavior.
(Rosenstock. 1974).

The variables of the health belief model (H.B.M.) are
translated from original work by Kurt Lewin. Lewinfls theory
postulated that “behavior depends mainly upon two variables:

1) the value placed by an individual on a particular outcome: and
2) the individual's estimate of the likelihood that a given
action will result in that outcome" (Maiman, p. 9). In addition,
Lewin described individuals as existing in life-space regions
composed of positive, negative or neutral valence. Life-space
regions of negative valence, of which disease is a part, would
exert force upon the individual to move away from that region
(Rosenstock, 1974). An individual's daily activities could then
be viewed as a process of movement influenced by positive or
negative forces.

Using Lewin's theory, the original H.B.M. was developed to
include the concepts of susceptibility, severity and barriers to
action. In order for an individual to take a health-related
action he must feel personally susceptible to the disease: the
disease would have at least moderate severity on some component
of his life: and taking a specific action would benefit the
individual by risk reduction in either acquiring the disease or

reducing its severity. Negative aspects of health action, such

29

as cost, inconvenience, unpleasantness, pain or distress serve as
barriers to action. Resolutions of these conflicts are weighed
against the possible benefits of action (Rosenstock, 1974).

Susceptibility and severity combined provide the energy or
force to act, and the perception of benefits less barriers
provide a preferred path of action. An instigating event,
stimulus or cue sets the process in motion (Rosenstock, 1974).
Cues may be internal, perception of bodily states, or external,
interpersonal interaction or impact of media or communication.
The intensity of the cue necessary to obtain action varies with
the levels of susceptibility and severity (Rosenstock, 1974).

Also included in the original model are modifying variables
which served to condition both individual perceptions and the
perceived benefits of actions. These include demographic
variables such as age, sex, race, ethnicity:
sociOpsyCholOgical: personality, social Class, peer and
reference group pressure, and structural variables such as
knowledge about the disease and prior contact with the disease,
complexity and cost and duration of the regimen (Rosenstock,
1974).

The original H.B.M. was formulated to explain preventive
health behavior, but has been expanded to be used with.illness
behavior, and Chronic illness behavior (Rosenstock, 1974:
Kirscht, 1974: Beck, 1974: Kasl, 1974). Cogent to this study are
the studies which have used one or more of the H.B.M. variables

to predict patient compliance with the therapeutic regimen for

30

Chronic illness (Becker, et al., 1977: Cummings, et al., 1982:
Given 5. Given, 1982: Greene, et al., 1982: Hershey, et al., 1980:
Morisky, et al., 1982: Taylor, 1979: Nagy, 1984: Janz, 1984).
Janz (1984) reported that the perceived barriers component of the
model “proved to be the most powerful of the H.B.M. dimensions
across the various study designs and behaviors” (p. 1).

Motivation was added to the original H.B.M. to describe the
necessary condition and action (Maiman, 1974). “Motivation has
been operationalized as a state of readiness to take specific
action: (1) concern about health matters in general, (2)
willingness to seek and accept medical direction, (3) intention
to comply, and (4) positive health activities" (Harmon, 1983, p.
28). Cues for action differ for prevention behavior and illness
behavior. The presence of symptoms provide motivation for
compliance in illness behavior (Kasl, 1974). The motivational
goal for preventive behavior is that of maintaining health
(Rosenstock, 1974). One motivation for compliance in chronic
illness is risk-reduction (Kasl, 1974).

The H.B.M. will be used as a framework to study the
hypertensive clients' perceived barriers as they relate to
compliance with the therapeutic regimen. Figure 2 is the
original H.B.M. for use as a predictor for compliance for
hypertensive clients (Becker, 1974: Kasl, 1974).

Individual perceptions of illness include perceived
susceptibility and perceived severity of illness, Figure 2. The

concept of perceived severipy of illness refers to the personus

31

subjective estimate of how serious the illness may be (Becker,
1974). “The perception of illness severity includes the overall
consequences of having hypertension and the extent of
interference with social roles (Becker, 1974: Kasl, 1974)"
(Harmon, 1983). Nelson, et al., (1978) found that patients who
believed their BP would.be substantially higher and would more
likely have a stroke or heart trouble if treatment was ignored
tended to be compliant with therapeutic regimens. Glanz (1980)
stated in her review of studies of severity of nutritional
problems that greater cooperation was found among patients with
inore serious disorders. The concept of perceived severity of
illness will not be used in the present study.

Three components of the H.B.M. will be used in the present
study: modifying factors: demographic and sociOpsychological
variables: perceived barriers to treatment: and, compliance with
a therapeutic regimen (Figure 3).

Rosenstock defines demographic and sociopsychological
variables as conditioners of individual perceptions (1974). Age,
sex, race and ethnicity are included as demographic variables.
Social class, peer and reference group are grouped under
sociopsychological variables. Studies done in the early 1960's
and 1970's provided by Rosenstock indicated differences in
patterns of utilization of medical services (1974). Services
were used most by younger or middle-aged, white females, who were
relatively better educated and had higher incomes (p. 28). In

1984 Janz reviewed current studies of H.B.M. variables. In the

32

 

 

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33

review of the Randall and Wheeler study, Janz indicated the
sociodemographic variables had statistically significant "direct”
affect on utilization of medical services, and significant
“indirect“ affect on barriers (Janz, 1984). No specific studies

on ethnic variables are available at this time (NARIS, 1987).

 

 

 

 

 

MDDIFYIMS FACIORS: INDIVIDUAL PERCEPTIONS LIKELIHQD OF
D OF 'I‘REA'JMENI‘ ACTION
DEMJGRAPHICB Perceived Barriers to D Oarpliance with
PSYCHOSOCIAL Treatment (negative Reccmnended
(CULTURAL) impact) Therapeutic
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Figure 3. Variables used in Present Study:
Modified from Original Model Figure 2
Becker, 1974 and Kasl 1974.

Perceived barriers to treatment, under individual treatment
perceptions, were selected for study to address beliefs related
to the need for new patterns of behavior required for treatment.
Studies have dealt with the concept of barriers to treatment in
regard to the tangible, cost, side effects, and accessibility
(Brand, et al., 1977: LOgan, et al., 1979: Nelson, et al., 1980)
and to the intangible and effective barriers to measurements of
compliance (Cummings, et al., 1982: Hershey, et al., 1978). In

Janz' decade review of the H.B.M., studies of hypertension were

grouped under sick-role behaviors. "Cost of following advice”

34

was identified as a barrier to compliance in the Kirscht and
Rosenstock (1977) study. In the Nelson (1980) study "perceived
side effects from taking hypertension medications" were
significantly associated with medication—taking (p. 25). Taylor
(1979) and associates studied Canadian steelworkers' beliefs
about drug safety as a barrier to compliance. Sociodemographic
variables could have had a major impact on this study, but were
not reported (Janz, 1984).

The present study is directed to beliefs about intangible
barriers to treatment: difficulties incorporating required
changes into life style and problems with diet, medication or
exercise. Potential barriers to compliance for Native Americans
may be specific ethnic food preferences. Medication as
recommended.by health care providers may not be in concert with
traditional folk medicine beliefs. ZDaily habits may preclude
adherence to a drug regimen, iJL, being away from home when its
time to take medications. Exercise may not be perceived as a
legitimate component of the therapeutic regimen. Two additional
barriers: job/regimen conflicts and doubt concerning treatment
efficacy dealt with in Harmonfs study will not be included in
this research.

In Figure 3 the section "Likelihood of Action: Compliance
with recommended therapeutic regimen" is defined as the extent to
which the client carries out the therapeutic recommendations of
health care providers concerning prescribed medications, diet,

behavior modifications and follow-up care (Given and Given, 1983:

35

Harmon, 1983). As in Harmonfs research, "measures of client
compliance are based on client report of compliance with
medication, diet and exercise recommendations” “A 30).
Compliance implies either a positive or negative
connotation: follow-through, adherence, participation or
conversely resistance, drOp out, or deviation (Linden, 1981).
Adherence and compliance are often used interchangeably with no
difference in their intended meaning (Glanz, 1980). Several
definitions related to patient and provider performance have been
outlined by Linden. Performance is the observed and actual
behavior whereas the evaluative judgment using a frame of
reference is compliance. One frame of reference may be the
patientfs. Aspirational compliance is the extent to which the
patient or client performs in regard to his own expectations.
Standard compliance is the medical frame of reference which
defines performance or behavior by present medical knowledge.
Standard compliance or the patient performance evaluated in terms
of general [therapeutic] medical expectations or standards will
be the accepted definition for this study (Linden, 1981). This
is the most common and often used definition. When standard
compliance cannot be used because of insufficient knowledge for
medical standards, therapeutic compliance can be utilized.
Therapeutic compliance is defined as the relationship between
patient performance and the therapeutic expectations established

by the provider (Linden, 1981).

36

Patient compliance performance will be accepted as stated by
the patient. There is no perfect method of measuring compliance,
however, Rudd (1979) stated that “patient interview supplies the
most useful, practical information“ “L 627). Inui (1981) and
Sackett (1979) found that clinician verbal inquiry/patient self-
report is highly predictive for non-compliance. Compared with
self-report, measurements of blood pressure, urine or blood tests
for metabolites of medication or unobtrusive pill counts, were
more variable and less accurate (Haynes, 1980: Becker, 1980:
Craig, 1985: Caldwell, 1984).

Summary

The chronic, asymptomatic and complex nature of hypertension
presents management problems for the Client (Braithwaite, 1981).
Often clients are not prepared for the part they must play in
their own care. Control of hypertension is imperative to
decrease the risk of complications: stroke, myocardial
infarction and kidney failure. Blood pressure is controlled by
pharmacologic and non pharmaCOIOQiC modalities.

The H.B.M. could be used to identify client behaviors that
indicate compliance or non compliance. Specific interventions
could be designed to support or alter Client behaviors. Further,
the nurse needs to take responsibility for educating and
assisting the Client in active management of a regimen designed
to meet the individual's unique lifestyle, priorities and beliefs

(Foster and Kousch, 1978).

37

Facilitation of the nursing process in concert with the
ELB.M. may be achieved by use of King‘s theory of goal
attainment. Several concepts and definitions will be used from
Leininger to more fully explain King‘s description of social
systems. Social systems will be incorporated as a modifying
factor which impinges upon perception. Further, modifying
factors impinge upon both the client and the nurse.

Nursing_Theo;y

An overview of King‘s theory with specific descriptions of
personal, interpersonal and social systems will be presented.
Leininger‘s definitions consistent with social structure and
culture will be used to expand King‘s theory of social systems.
The H.B.M. will be integrated into the personal system. The
impact of the social system upon the personal and interpersonal
system, as well as, the H.B.M. will be indicated. King's theory
of goal attainment which is an elaboration and refinement of the
nursing process will be used to describe the process of care of a
hypertensive client.

King‘s theory is an Open-systems approach based on the
premise that human beings are open systems interacting with their
environment (King, 1981). She stated that there is a "dynamic
state of a human being which involves an exchange of energy and
information between the person and the environment for
regulation and control of stressors“ (p. 98).

The focus of nursing is care of the human being. Care is

defined by Leininger (1978) as those “assistive, supportive or

38

facilitative acts toward or for another individual or group with
evident or anticipated needs to ameliorate or improve a human
condition“ (p. 9). Therefore, the domain of nursing includes the
"promotion of health, maintenance and restoration of health, care
of the sick and injured, and care of the dying" (King, p. 4,
1981).

King (1981) identifies health as the “way individuals deal
with the stresses Of growth and deveIOpment while functioning
within the cultural pattern in which they were born and to which
they attempt to conform" (p. 4). Obtaining a "level of health"
that allows the person to lead a ”useful, satisfying, productive
and happy life“ is dependent upon “harmony" and balance in each
personfs environment (p. 4). Conversely, illness is defined as a
"deviation from normal” or "imbalance in a person's biological
structure or in his psycholOgical make-up, or a conflict in a
person's social relationships" (p. 5).

King identities three interacting dynamic systems: personal,
interpersonal and social. Individuals are identified as personal
systems: whereas, individuals forming groups are called
interpersonal systems. Social systems are created when groups
with common interests and goals come together within a community
or society (P. 10). (Figure 4).

Personal systems are elaborated by six concepts:
perception, self, growth and develOpment, body image, time and
space. The concept of perception is critically important to

explain in relation to the model (Figure 4). "Perception is each

39

human being‘s representation of realityu.awareness of persons,
objects, and wants" (p. 20). King describes perception as a
personfs transaction with the environment in which sensory data
and memory organize, interpret and transform information (p. 24).

Perception is an individual's representation of reality which

influences his behavior (p. 24).

' SOCIAL SYSTEMS °
’ (SOCIETY) °
' IN'I'ERPERSONAL SYSTEMS ' °
' (GROUPS) '

PERSONAL SYSTEMS
( INDIVIDUALS)

   

Figure 4. King's conceptual framework for nursing:
dynamic interacting systems. * indicates the interface of
personal with interpersonal systems, which is specifically

outlined in Figure 5. Process of Human Interactions

40

Two or more persons interacting in a situation comprise the
interpersonal system (King, 1981). (Figure 5.) This system is
the major focus of the theory and the basis for derivation of the
theory of goal attainment (Gonot, 1983). "Perceptions,
communication, and transactions are the major concepts presented
as fundamental for understanding human interactions as
interpersonal systems" (Gonot, p. 232). Communication is the
transfer of information between two or more persons and
transaction is the transfer of value. Transactions are
considered to be goal—directed behaviors (Gonot, 1983).

Social systems are the suprasystem within which the
interpersonal systems are experienced (Gonot, 1983). King
defines social systems as an "organized boundary system of social
roles, behaviors, and practices developed to maintain values and
the mechanisms to regulate practices and rules” (King, p. 115k.
Leininger describes the structure of social systems as
"interrelated and interdependent systems which determine how it
functions with respect to major elements: political (legal),
economic, social (kinship), educational, technical, religious and
cultural systems" (Leininger, 1978, p. 61). Commonalities in
structure and function are found in all social systems. .A few
include: values, behavior patterns, prescribed roles, status and
authority.

A social system is a configuration of relationships within a
culture (King, p. 115). Culture refers to patterns of learned

behaviors and values which are shared among members of a

41

designated group which are usually transmitted to others over
time (Leininger, 1978). This pattern of behaving, thinking,
believing, valuing and feeling changes in the process of cross-
cultural contact (King, 1981).

Critical variables that enter into perception and
interaction are social class, role, status, and ethnic values
(King, 1981). Furthermore, at the personal level, King
emphasizes that behavior is influenced by not only biological
inheritance but the social system into which a person is born,
grows and develops. "Beliefs, attitudes, values and
customs are learned within social systems“ (King, 1981. p. 114).
Psychosocial variables are identified as modifiers of perception
in the H.B.M. Psychosocial variables are identified as
modifiers of perception in the H.B.M. Both models are consistent
in identifying social factors as influencing perception which
impinges upon interaction. jKing believes that personal systems
and social systems influence the quality of care (1981).

The theory of goal attainment is derived from interpersonal
systems and offers a systematic approach to problem—solving for
both client and nurse. King (1981) described the nature of
Client-nurse interaction as one which leads to goal achievement.
Concepts from the theory are perception, judgment, action,
reaction, interaction, and transaction. “These concepts are
congruent within the nursing process whereby human interaction

between nurse and client take place, goals are set, ways to

42

achieve them are explored, and interventions are implemented and

evaluated" (Harmon, 1983, p. 34).

FEEDBACK

PERCEPTION

 

W

 

4' lfi'
E
O
2

CLI ENT REACTION INTERACTION TRANSACTION

ll

NURSE

5939.13
JUDGMENT

» PERCEPTION

 

 

FEEDBACK
Figure 5. King's Model: Process of Human Interactions
Integration of the H.B.M. with King's
Theory for Nursing (Figure 6)
The H.B.M. and King's theory of goal attainment are

psychosocial models which attempt to describe behaviors. The

H.B.M. has been used extensively to provide evidence for the

43

importance of health beliefs in understanding patient compliance.
King's (Becker, 1985) model is not limited to specific personal
beliefs, but describes the individual, the interfaces between and
(among individuals and further outlines the impact of the larger
social system.

The interface between the personal system and interpersonal
system has been further refined by King as the process of human
interaction. The personal system is defined as the self, body
image, and others. The H.B.M. identifies these attributes as
:modifying factors or demographic and psychosocial variables.
These personal attributes influence perception, or the personws
interpretation of his reality. Conditioners of the individual's
perception are cues. Cues are the stimulus to act.

Judgment according to King (1981) means to “evaluate a
situation and the person in it and to make decisions based on.
conclusions drawn from that evaluation” “A 88). Essentially the
ILB.M. is a decision-making model, wherein the individual
determines which actions he will take regarding health. Actions
to be taken are weighed in a cost—benefit analysis determining
preferred behaviors.

Reaction, interaction, and transaction represent the
communication phase of the human interaction process. During the
reaction and interaction phases, knowledge and skills are taught
and learned, relationships are developed, and socialization
occurs. Transaction is the final phase and is defined as goal

attainment. An assumption of the H.B.M. is that health is a

44

highly valued goal for most individuals. .Both models are focused
on similar goals.

Compliance by the individual could be assumed in attitudinal
or behavioral contexts. Measurement of compliance can be done
using behavioral parameters. Both the nurse and the Client are
considered compliant when moving toward mutually determined
health-care goals. The closed-loop diagram indicates that the
interaction process is continuous and self-correcting.
Transactions will impact modifying factors: psychosocial and
cultural introducing Change to the system. Personal systems are
depicted as interaction with interpersonal and social systems in
King‘s conceptual framewcmk, therefore, Changes at each level

W111 affect all others.

 

45

 

 

 

 

 

 

FEEDBACK
E EVALUATION :
: E
\_ PERCEPTION - BARRIERS To TREATMENT :
'7 |
MODIFYING O l
‘FACTORS: JUDGMENT :
DEMOGRAPHICS u
PSYCHOSOCIAL O :
ACTION - BASED ON CUES g
Q :
I
I
l
HYPERTENSIVE REACTION INTERACTION TRANSACTION :
CLIENT ASSESSMENT PLANNING IMPLEMENTATION'
(LIKELIHOOD MUTUAL COMPLIANCE

 

OF ACTION) WITH THE :
THERAPEUTIC REGIMEN

4)

 

 

I
NURSE ACTION :
I
O l
MODIFYING JUDGMENT — RESEARCH BASED l
FACTORS: '
I
DEMOGRAPHICS O I
PSYCHOSOCIAL PERCEPTION - BARRIERS To TREATMENT :
g l
\ I I
/ I I
| l
. l
: EVALUATION :
FEEDBACK
Figure 6. King's Model with H.B.M. Components:
Modifying factors, perceived barriers to treatment, and

compliance with the therapeutic regimen.

Nursipg Process of Care

Compliance with a therapeutic regimen for management of

hypertension

issues. Use

by a Native American presents several complex

of the H.B.M., King's theory for nursing with

46

support from transcultural care concepts affords the nurse a
myriad of interrelated variables to assist in problem recognition
and resolution.

Both the nurse and client bring to the relationship
perceptions based on personal, interpersonal and social
interactions. Each is a part of the other's experiential
milieu. Both are considered equal partners in working toward
goal attainment.

Goal attainment is considered mutual compliance. Compliance
for the Client means following through.with recommendations for
lifestyle adjustments, diet, exercise, and medications.

Compl. iance for the nurse is following through with
recouxmendations based on standards of care for hypertension
management. Furthermore, compliance also indicates a
consistently supportive care role in long-term behavior Change.

Assessment includes ascertaining the Client's perceptions of
illness severity and susceptibility. The following questions
might be asked:' What kinds of problems have you had recently?

Do other members of your family have high.blood pressure? Has
anyone in your family had a heart attack? a stroke? What will
high blood pressure do to you? To assess barriers to therapy
several specific questions might be asked: Where do you obtain
Your medications? How do you feel when you take your
medications? Who prepares your food? What kinds of food do you
Prefer? What foods are you able to eat? Are you able to walk

in your neighborhood? How do you feel when you exercise?

47

Critical to the Native American, the nurse would need to know how
the therapeutic regimen has been accepted by family members
(GoinS, 1985). The nurse also needs to assess which behaviors
are most resistant to Change versus those the individual is
willing to add or delete. It is also helpful to know which
family members provide support and will help the individual
sustain Change.

Planning, negotiating and mutually identifying goals with
the family/Client are important. Planning interventions will be
based on the client's perception of barriers. For example,
simplification of the medication regimen and changing drugs to
minimize side effects may improve compliance. Integrating
ethnic food preferences in meal planning is evidence of mutual
goal setting. .Adding components of an exercise program to an
existing activity may encourage the individual to make minor
changes toward fitness. As conditioning improves, aerobic
exercise consistent with preference, could be added.

Intervention at each phase of learning supports behavior change,
thereby, reducing barriers which impact compliance. Transaction
occurs when both the client and the nurse have mutual values
regarding the maintenance of the hypertension regimen.

Evaluation of the prOgreSSion toward control of hypertension
'would be on-going. Compliance on the nursefls part is focusing on
acceptable standards of blood pressure control with consideration
of the demographic variables and possible alleviation of

intangible barriers.

48

Summary

King's theory for nursing was described as the overall
framework into which Leininger's cultural concepts and the H.B.M.
were integrated. The nursing process is outlined through
the interpersonal system, which describes the client's and
nurse's interaction. The interaction process proceeds from
assessment of the client's perceptions of illness severity,
susceptibility and perceptions of barriers to treatment so there
is mutual establishment of goals (transaction) and compliance

with the therapeutic regimen.

CHAPTER III
REVIEW OF THE LITERATURE
Overview

The review of literature will include relevant studies from
Harmon's study, updated materials concerning the H.B.M., the
nature of hypertension in the Native American population, and
nursing theory as applied to a culturally diverse group.
Literature specific to the study variables of perceived barriers
and compliance with the therapeutic regimen will be reviewed.
Both expert opinion and research findings will be presented to
support these concepts. No studies are available demonstrating
the use of the H.B.M., or any of its components with Native
Americans (Computer Searches: Med-line 1987, Psych-Soc 1986,
NARIS, 1987).

The discussion will be divided into the following sections:
the nature of hypertension in the Native American, treatment of
hypertension: including diet, exercise and medication: the
health belief model, including treatment barriers and compliance
behavior: and lastly, nursing care of the Native American client
with hypertension.

The Nature of Hypertension in the Native American

Several studies available are surveys of Indian communities
in large cities. Gillum (1984) conducted a survey of "Little
Earth of United Tribes, Inc.“iwhich is an Indian-operated public
housing project in Minneapolis, Minnesota. Adults 16-24 years of

age were included: 242 completed a 30 minute interview and 173

49

50

had blood pressure measurements taken in their homes. Several
other parameters were included: blood drawn for serum lipids and
glucose; height, weight and triceps skinfold measures: and a
brief medical history was done. The prevalence rate for SBP _>_
140 mm Hg was 15%, DBP Z 90 mm Hg was 14%. Among those residents
reporting previously diagnosed hypertension 33% had DBP Z 90 mm
Hg and 26% had SBP Z 140 mm Hg. Only ten persons reported taking
medication for hypertension. Blood pressures tended to increase
with age and were Slightly higher among men.

Of the 242 persons interviewed, 84% added salt to their
food: 43% added salt before tasting the food. Weight reduction
diets had been tried by 47%: only 9% had ever enrolled in a
formal weight reduction program. All age groups and both sexes
demonstrated greater weight than the white population of Similar
age. In regard to activity, 33% engaged in strenuous exercise in
leisure and 21% at work. The assumption was made by the author
that “Indian adults probably have low physical activity levels--
unemployment is high and participation in recreational sports is
low" (Gillum, 1984, p. 773).

Cigarette smoking was found to be more prevalent among
Indians than whites (Twin Cities' whites) in both men and women.
Of the persons interviewed 60% responded to questions regarding
alcohol consumption: 48% claimed to be non-drinkers: the
remainder consumed alcohol at least two days per week (neither

the amount of alcohol consumed nor the number of Cigarettes

51

smoked was included). The author commented that heavy alcohol
usage was a major problem in this community (Gillum, 1984).

Several questions in the survey were included to ascertain
the knowledge of cardiovascular symptoms and risk factors.
Interestingly, of those diagnosed with hypertension 46% said
medicines could cure high blood pressure: 93% of those with no
history of hypertension felt medicines could cure hypertension.
Both groups listed over weight, smoking and stress as major
factors causing heart attack and stroke (64% of hypertensives,
66% of non-hypertensives listed stress as the most important
cause of heart attack and stroke) (Gillum, 1984).

Gillum concluded by stating that the risk factors for
cardiovascular disease are undesirably high among Minneapolis
Indians. He recommended that “various cardiovascular risk factors
and chronic disease control programs, as well as, mortality,
morbidity, and risk factor surveillance are urgently needed among
urban American Indians“ (Gillum, p» 775).

In 1980, Gillum et al., surveyed children in Minneapolis
schools in grades 1, 2 and 3, comparing whites, blacks and Native
Americans. He measured blood pressures, height, weight, pulse
rates and triceps skinfold thickness. Native American Children
were found to have had consistently higher systolic blood
pressures, but lower diastolic blood pressures. The Native
American children had lower pulse rates, greater pulse pressures,

similar height, and greater weight than either black or white

52

Children. Gillum concluded that the higher SBP could be
explained statistically "almost entirely by greater ponderosity“
(p. 748).

Obesity has been a consistent finding in studies of Native
American populations (Gillum, 1984: DeStefano, 1979: DePrez,
1985: Torrey, 1979). Borhani (1981) reported that the prevalence
of hypertension is positively associated with excess body weight.
In the discussion of risk factors, Borhani also pointed out that
the probability of a major complication of hypertension depended
upon age, sex, race, level of serum cholesterol, cigarette
smoking habit, and an abnormal electrocardiogram (Borhani, 1981).

The Joint National Committee (1984) reviewed recommendations
for young hypertensive clients stating that weight control and
reduction of dietary sodium "are strongly encouraged in children
with marginal or higher BP elevations and a high risk for
development of hypertension, eqm, children with hypertensive
parents (1984, p. 1055). In the Framingham study, Kannel pointed
out that families experiencing a Cluster of cardiovascular
diseases share inherited, as well as, environment factors.
“Spouses tended to Share obesity, hypercholesterolemia and blood
pressure as well as the Cigarette habit“ (1978, p. 101).
Offspring of the original cohort studied in Framingham had higher
levels of some risk factors, but tended to have lower blood
pressure and cholesterol levels which had been influenced by

environment (Kannel, 1978).

53

One additional study done in Minneapolis compared
anthrOpometric measurements of Children between those living on a
reservation and those within the city. Compared to United States
standards, as well as to a reservation sample, the urban sample
was found to be slightly shorter and consistently heavier.
Johnston, et al., (1978) stated that his study supported the
existing data that environmental factors attribute to physiologic
changes. Higher caloric intakes result in a much higher
incidence of obesity with its concomitant problems (Johnston,
1978).

Hollow (1978) reported a prevalence of 12.65% of
hypertension.(3 140/90) in urban Indians seen at the Seattle
Indian Health Board. He noted that females have a greater
prevalence rate in younger ages when compared to white and black
females. Females also have almost twice the prevalence of Indian
males. The rate for both peaks at middle age and declines,
unlike the black and white populations.

In Hollow's study, charts of patients with confirmed
hypertension were audited for risk factors and complications.
Those cardiovascular—related risks and complications included:
diabetes 21%, anxiety-psychological problems 45%, obesity 58%.
smoking history 37%, alcoholism 22%, hyperlipidemia 6%, CHD 20%.
MI's 8%, CVA's 4.9%. TIA 2.6%, CHF 11%. ventricular hypertrophy
11%, and retinopathy 7%.

Hollow also reported changes in BP control from 1977 to

1979: for confirmed hypertensives, 56% were in control < 90 DBP

54

in 1977: 63:7% were in control in 1979. He made no reference to
therapies used for maintaining control Further, he indicated
that a computer service was used to “track“ those patients with
elevated BP and those with confirmed hypertension. It is unclear
from his study what “tracking“ implies.

Three studies of Southwestern Indians were published in the
1970's. Alfred (1970) conducted BP surveys of male Navajos
before and after migration to “investigate the effects of
migration on a particular Characteristic, blood pressure“ (1970,
p. 190). The assumption was made by Alfred that “general
tensions“ exist when people leave a rural agrarian culture for an
"urban industrial culture dominated by"foreignersd" (p. 190).
This entire study is fraught with inconsistencies. Blood
pressures were gathered on two groups: a reservation sample of
“healthy“ males and the second group who applied for and received
relocation (the migrantsL. The two groups were not randomly
selected nor were they matched for any specific characteristics.
Blood pressure readings were taken from B.I.A. (Bureau of Indian
Affairs) charts for pre-migration physicals and post migration
readings were taken by six trained observers. Blood pressure
readings were compared.before and after migration and with the
reservation group. Since the reservation group tended to be
older, their readings were consistently higher. The
migrants “after“ blood pressure readings were significantly
higher. No correlation was found regarding length of urban

residence compared with blood pressure elevation. In the

55

discussion Alfred reviewed possible causes: dietary changes in
fat and sodium intake, calcium carbonate in drinking water,
altitude changes, diurnal variations and environmental changes.
No where else are these factors entered into the study variables.
Factors Alfred related to the act of migration included cultural
rest patterns, urban pollution, and separation from kin. His
conclusion was that “urban migration is a possible cause of
stress for Navajos which is independent of at least some of the
differences in the physical environment“ (p. 200).

Considering Alfredis sampling procedure, testing of only BP
at various times with a variety of observers, no relationships
could be measured. .Another implicit assumption is that
elevations in blood pressure are caused by stress. Evidence has
been gathered since 1970 which implicates a myriad of factors
involved within the pathophysiology of hypertension, none of
which is stress, per se (Harrison, 1984: Kochar, 1981: Kaplan,
1978: Chobanian, 1983).

Prevalence data from DeStefanofls study was reviewed in
Chapter I in order to substantiate hypertension as a problem in
the Native American population. The survey was conducted on the
Navajo reservation at several sites wherein 640 Navajos over 19
years of age were screened. Contrary to the findings in Hollow's
study in Seattle, blood pressure elevations are more prevalent in
Navajo men than women (24% and 11% respectively).

Comparisons were made between height, weight and blood

pressure. Consistent with other surveys, there was a significant

56

association between blood pressure elevation and body weight
(Gillum, 1984: Gillum, 1980: Johnston, 1978: Torrey, 1979). One
unique finding was that no subjects‘werezmore than 20% above the
optional weight for height (DeStefano, 1979).

Alcohol use was also found to be associated with high blood
pressure. However, Cigarette smoking among Navajos is minimal:
13% smoke: 94% of the smokers smoke less than one pack per day
(DeStefano, 1979).

DeStefano used an acculturation index based on five
categories: residence, language spoken at home, employment,
alcohol use and smoking, to determine the similarity of lifestyle
between the Navajo and “modern, white Americans“ (DeStefano, p.
345). The index calculated for each subject found that males
‘were:more acculturated than females. Further, no consistent
pattern of change in blood pressure was found with the
acculturated group, except that SBP in women decreases with
increasing acculturation. One could argue that the acculturation
index categories are not indicators of modern white Americans'
however, Alfredfs (1970) study of migrant Navajo Indians used no
tool to determine cross cultural interface and the effects on
blood pressure changes. There are no studies available regarding
Native Americans in which reliable and valid tools are described
to measure the impact of acculturation on Specific physiologic
parameters. In the present study there will be a survey of urban
Native Americans, but only length of residence within the urban

setting will be reported. No attempt will be made to correlate

57

exposure to the majority population group and the study
variables.

Strotz (1973) reported prevalence and associated target
organ disease for hypertensives in the Papago tribe studied from
1969 to 1972. In a population of 11,411. 19:75% were
hypertensive, using 1 95 DBP or 3 160 SBP as the definition of
hypertension. According to Borhani (1981), the "actual“
prevalence of hypertension depends upon the arbitrary cut-off
point used for the purpose of screening. In the Hypertension
Detection and Follow-up Program (HDFP) conducted in 1973-74 in
several communities across the United States, the prevalence of
hypertension was found to be 25.3% when the cut-off point was DBP
l 90 mm Hg: it was 14.5% with DBP 3 95 mm Hg: and only 5.0% when
the cut-off point was 3 110:mm.Hg (Borhani, 1981). Therefore,
the prevalence of hypertension in Papago Indians would be higher
if the cut-off point for DBP was lowered to 3 90 mm Hg, thereby
approximating the national level reported in 1973-74. According
to Strotz (1973) twenty years earlier the prevalence rate was
approximately 2%, a dramatic change in two decades.

Changes in the dietary and cultural habits were implicated
as factors which have increased the rate of hypertension.
Dietary studies during the same period Show the diet to be
primarily cooked carbohydrates, 20% of the diet composed of
animal protein, and liberal use of salt and lard in cooking

(Strotz,1973).

58

Physical labor decreased when farming was abandoned. Food
was made available through governmental sources. Strotz
described the Changes as parallel to those in West Africa where
rapid Change in lifestyle has occurred (1973).

Prevalence of associated diseases was also presented.by
Strotz (1973). Significant increases were noted for congestive
heart failure, cerebrovascular and renal disease. Prevalence was
markedly increased when hypertension and diabetes were rated
together.

In a recent study done in Maine (DePrez, 1985), Penobscot
Indians were noted to have a prevalence rate of 26% compared to
24% for the statewide population (hypertension defined as DBP 3
90 mm Hg or on hypertensive medication). Body weight was not a
significant factor in this tribe. Further, no description of
daily habits was included.

Awareness of disease was studied and found to be lower in
the Penobscot Indians than in the statewide sample. The low
awareness rate was ascribed to “lack of detection opportunities
in medical and community settings“ (DePrez, 1985, p. 654). The
control rate (DBP _<_ 90 mm Hg) for hypertension was 56% compared
to 80% in the statewide sample. DePrez speculated that “poor
physician relationships can be a factor in poor control among
some treated Indian hypertensives and are a critical factor in

the maintenance of long-term Chronic disease therapy“ (DePrez,

1985, p. 654).

59

One of the comments with import to the study of compliance
behavior was made by DePrez with unsubstantiated references
or Study data: “ethnic differences can compromise the
communication between.the physician and Indian patients and
ultimately affect patient compliance with medical regimens"
(DePrez, p. 654).

A geographically remote group of Indians, Aleuts, were
surveyed in 1966 and 1976. These island dwellers had the highest
rate of hypertension in the entire United States, 61% in 1966 (3
140/90) and 51% in 1976 (Torrey, et al., 1979). There was a
demonstrated correlation between hypertension and obesity in the
1966 study. Salt intake was not quantified, but Torrey estimated
the intake to be high due to consumption of food preserved in
brine. Hypertension was found to be present in both Children and
parents of the same family indicating a possible association with
genetic factors.

A unique finding in this survey was that the Aleuts have an
exceedingly high.level of cadmium intake since seal liver is a
dietary staple. A possible causal relationship between cadmiun:
and hypertension has been confirmed in animal studies (Torrey,
1979).

To summarize, several surveys of Native Americans have been
done since 1970. The review discussed Native American groups
from the Southwest, Midwest, Northeast, Northwest and Alaskan
islands of the United States. All of the studies are descriptive

surveys. Prevalence rates range from 12.6% in urban Seattle

60

Native Americans to 51% in Aleuts of Alaska. Various factors
have been described as contributors for the development of
hypertension in Native Americans: genetic predisposition, diet
high in sodium, obesity, substance abuse (alcohol and tobacco),
reduced physical activity and acculturation.

Only one author, DePrez, mentioned the negative impact
health care providers may have on compliance behavior. 1%)
studies are available at this time which deal with health.beliefs
and compliance behavior in Native Americans. Therefore, the
health beliefs held by Native Americans need to be explored. The
present research seeks to elucidate cultural beliefs which may
have an impact positively or negatively in following therapeutic
recommendations. Non compliance by Native Americans is assumed
by some providers, but valid evidence is lacking (LaMere, 1986).

Treatment of Hypertension

Nonpharmacologic and pharmacologic therapies are used to
treat hypertension. Nonpharmacologic approaches are generally
used first and as an adjunct to drug therapy (Chobanian, 1982:
Joint National Committee, 1984: Kaplan, 1978). Dietary
management, exercise and habit modification are consider
nonpharmacologic treatments (Harrison, 1983: Chobanian, 1982:
Joint National Committee, 1984).

Dietary management has three agents: weight reduction by
calorie restriction, moderate sodium restriction, and reduction
in saturated fats (Harrison, 1983: Joint National Committee,

1984). Weight reduction results in a substantial decrease in BP

61

even if ideal body weight is not achieved (Chobanian, 1982: Joint
National Committee, 1984). Chobanian (1982) equates a 25 pound
weight loss in an obese hypertensive to a 10 mm HG drOp in
systolic blood pressure. Riesin (1978) had also found a
significant correlation between reduction in blood pressure and
'weight loss. The Joint National Committee (1984) recommends that
weight reduction be an integral part of therapy for all obese
persons (> 115% of ideal weight) with hypertension.

The Joint National Committee (1984) has also recommended
that alcohol consumption Should be moderate. Alcohol consumption
is not a study variable but may be considered a confounder, in
that, heavy consumption (> 56.8 g/day or > 2 oz. of ethanol/day)
may elevate arterial blood pressure (Joint National Committee,
1984). Some Native American populations are heavy consumers of
alcohol: however, the urban group in Great Falls has not been
studied for alcohol consumption.

In the review of literature regarding sodium restriction,
there was evidence that the ingestion of 2 gm or less of sodium
daily may reduce or prevent hypertension (Fries, 1976: Joint
National Committee. 1984). The recommendation from the Joint
Committee (1984) is that all those persons with essential
hypertension receive proper counseling for moderate restriction
of sodium. Information regarding food labeling, as well as,
blood pressure monitoring should be done.

Luft (1984) conducted a randomized cross-over trial Of 32

patients to study the usefulness of a qualitative Chloride

62

titrator strip in facilitating compliance with a reduced sodium
intake diet. Most of the subjects (N=28) were hypertensive:
however, patients with other illnesses were also included.

During the initial three weeks, the subjects received instruction
in use of the titrator strip and dietary instructions regarding a
85 mEg/day or less sodium intake. Practice sessions and access
to the dietitian were provided. .An eight week study period began
following instruction, which included daily early morning urine
testing with the titrator strip: biweekly visits with a research
nurse: and blood pressure measurements. A lab technician also
performed independent chloride titrator strip determinations to
permit comparison with the measurements by the subjects. There
‘was significant correlation between the technician and all but
three subjects. During the course of the study the subjects had
significantly lower values while using the titrator. Nine
subjects reduced their sodium excretion to 28 mEq (95% confidence
interval for those with < 85 mEq/day ingestion) without the
strips. One~third of the population was compliant with or
without the strips. One-third of the non-compliers showed
improvement with use of the strips. No change was noted in the
remaining one-third. There was a moderate reduction in blood
pressure related to the dietary intervention. Luft concluded

. that the use of the titrator strip may not serve to “motivate the
unconcerned, but rather to facilitate and sustain behavior

changes of those committed to it'I (Luft, 1984, p. 1965).

63

No specific recommendations have been made regarding the
reduction of dietary saturated fats. However, the Joint National
Committee (1984) does state that abnormal levels of blood
cholesterol should.be reduced when feasible to minimize the risk
of cardiovascular disease. Similar guidelines were given for
avoidance of cigarette smoking. There is no “definitive“
evidence that identifies the prolonged use of tobacco with
increased risk of hypertension.

A regular program of isotonic exercise as an aid to weight
control may be helpful in reducing blood pressure for the patient
with uncomplicated essential hypertension. “Professionals should
advise hypertensive patients initiating an exercise prOgram to do
so gradually and after appropriate evaluation” (Joint National
Committee, 1984, p. 1048).

McMahon and Palmer (1985) reviewed clinical trials that
utilized exercise as antihypertensive therapy. The trials
included untreated borderline essential hypertensives and those
on consistent therapeutic management. All of the trials were of
short duration from 10 weeks to one year: all included limited
numbers of 5 — 37 persons. Consistently, lowering of systolic
and diastolic blood pressure occurred both in normotensives and
hypertensive persons. In one of the trials, (Kukonen, 1982) a
reduction in blood pressure was found at rest and during exercise
after four months of dynamic (isotonic) training.

Cade, et a1. (1984), studied 105 persons with established

diastolic hypertension 3 90 mm Hg after three months of running

64

for two miles per day. There was a significant decline in
arterial blood pressure for all but four subjects. Four male
patients had decreases of less than 5 mm Hg in the calculated
mean blood pressure. (A decrease of 5 mm Hg or greater was
considered a positive response to the exercise program).

Twenty four patients discontinued medications and of the 23
patients who were still taking medications after three months of
exercise, four were receiving diuretics alone, and 14 had either
decreased or discontinued one major antihypertensive drug (Cade,
1984). Weight loss was not the focus of this study,
nevertheless, 60% of the patients lost weight, no change was seen
in 10%, and 30% gained weight. The author commented that “the
decrease in blood pressure was as great in those patients who
gained weight as in those whose weight decreased” (Cade, 1984, p.
788).

To summarize, Cade found that in.young patients with short
duration of illness, control with exercise alone could be
achieved. The dosage of major antihypertensive drugs could also
be decreased.

A point of interest was Cade's estimate of cost savings for
those 24 patients who were able to discontinue all medications.
The daily expenditure average of $3436 for medication was
(compared to the cost of one pair of running shoes per year: for
those 23 persons still receiving medications after three months
of exercise, the average cost dropped from $4.12 per day to $2.52

per day, plus the cost of running shoes (Cade, 1984).

65

McMahon and Palmer (1985) reviewed diuretics, sympathetic-
inhibiting drugs and vasodialators interactions with the
Jhemodynamic responses to exercise. Some diuretics have
,potentially adverse effects associated with hypokalemia, or
depletion of extra cellular volume that may impair the function
of cardiac and skeletal muscle. Potassium depletion is further
jpromoted through exercise in hot weather which causes increased
sweating; KAdequate potassium levels are necessary for
intracellular enzyme activity, electrical membrane potential,
:nuscle cell contraction, structural integrity, and increased
blood flow during exercise“ (McMahon, et al., 1985, p. 63).

Beta-adrenergic blocking agents reduce blood pressure by
decreasing heart rate and cardiac output with slight increases in
total peripheral resistance. Strenuous exercise stimulates a
beta-adrenergic response which is blunted by the beta-blockage
agents. The aerobic conditioning effect of intensive dynamic
training has been shown to be decreased in some subjects
(McMahon, 1985).

Specific drugs which reduce total peripheral resistance may
not interfere with the physiologic response to exercise.
Pragosin, as reported by Lund-Johansen, is a post-synaptic alpha-
adrenergic blocking drug, which reduces total peripheral
resistance without concomitant Changes in cardiac output or heart
rate. In the subjects studied, systolic and diastolic blood
pressure dropped during rest and during dynamic exercise

(McMahon, 1985). “The ideal drug would reduce peripheral

66

vascular resistance without adversely affecting cardiac output,
muscle blood flow, or exercise capacity‘ (p. 67).

McMahon, et al., recommended that patients with moderate or
severe hypertension receive antihypertensive drug therapy in
order to reduce blood pressure before participating in an
exercise training program. Although currently available
antihypertensive drugs can produce side effects, none are
contraindicated during exercise. Maximum.target pulse rates will
be decreased by beta blockers. “Perceived“ exertion, as well as,
heart rate can be used as an index of training intensity
(McMahon, 1985).

The remaining nonpharmacologic therapy is considered
modification.in behavior through various relaxation and
biofeedback techniques. The Joint National Committee states that
behavioral therapy be considered ”in the context of a
comprehensive treatment prOgram" that may include both
pharmacolOgiC and nonpharmacologic therapies (Joint National
Comndttee, 1984). Clinical trials to demonstrate the efficacy of
behavioral therapies are not available.

In 1984, the Joint National Committee indicated that the
benefits of drug therapy outweighed the known.risks from therapy
in those persons whose DBP was persistently elevated above 95 mo:
Hg. In persons with 90-94 mm Hg BP range, drug therapy was
recommended when high risk factors were present: target organ
damage, Diabetes Mellitus, and other risks for coronary heart

disease. ‘When risk factors were not apparent, aggressive use of

67

nonpharmacolOgic therapy was recommended while BP's were
carefully monitored.

“Stepped care is suggested as a guide for treating
hypertensive patients when drug therapy is indicated“ (Joint
National Committee, 1984, p. 1051). The intent of a stepped care
approach is initiation of a small dose of an antihypertensive
drug, increasing the dose of the drug, and then adding or
substituting one drug after another in gradually increasing doses
as needed until 1) the goal BP is reached: 2) side effects become
intolerable: or, 3) the maximum dose of each drug has been
reached (Joint National Committee, 1984).

Recent reports advocate therapy be based on different
pathOphysiologic abnormalities (Laragh, 1985: Somermeyer, 1986).
Combinations of drugs at low dosage may achieve blood pressure
control by matching the pharmacologic properties of the drugs
with the physiologic needs and lifestyle preferences of the
patient (Somermeyer, 1986). Both approaches will be described.

Pharmacologic management of hypertension may be achieved by
a “stepped care“ approach as recommended by the Joint National
Committee (1984), or by an individualized approach based on
pathOphysiologiC abnormalities (Laragh, 1985: Somermeyer, 1986).
There are five classes of drugs which may be used. They are
diuretics, adrenergic inhibitors, vasodialators, A.C.E.
inhibitors and calcium channel blockers (C.C.B.). Diuretics are
considered the initial step in pharmacologic management.

Diuretics may be combined with adrenergic inhibiting drugs, or

68

AJLE. inhibitors to attain maximal control (Somermeyer, 1986).
Adrenergic inhibiting agents, or AJLE. inhibitors, may be added
in a step-wise progression to attain control, or may be
individually matched to the patientis plasma.renin and sodium
excretion level. The fifth class of drugs, calcium channel
blockers, may be used with patients who have athlerosclerotic
heart disease and hypertension.

Therapeutic modalities for Native Americans include prOQrams
for the control of obesity and cessation of tobacco use. Rhoades
(1987) reports that the Zuni Diabetes Project in New Mexico has
involved Native Americans in aerobic exercise and minor changes
in eating habits, which have encouraged fitness and weight
loss. The Indian Health Service (I.H.S.) should initiate
aggressive interventions to prevent the upsurge of Diabetes,
hypertension and cancer according to Rhoades (1987).

No studies are currently available which describe the use of
pharmacologic therapies with Native Americans. Tobacco use is
unique to certain tribes, however, nearly all IJLS. facilities
are smoke-free. The IJLS. "encourages'I smokers to stop
(Rhoades, 1987).

Summagy

In summary, management of essential hypertension is achieved
by non.pharmacologic and pharmacologic modalities. Dietary
management entails weight control, sodium restriction and
reduction in saturated fats. Exercise is used as an adjunct to

weight control, as well as, a method to reduce blood pressure.

69

In two studies subjects were able to reduce or discontinue
medications after participating in isotonic exercise programs.

The use of pharmacologic and non pharmacologic modalities
entail behavior Change. Psychosocial variables which influence
behavior may be explored through the H.B.M. Many studies using
components of the H.B.M. have been done: however, a review of
only barriers to compliance follows.

The Health Belief Model: Barriers
to Treatment and Compliance Behavior

As described in Chapter II, the health belief model (H.B.M.)
is a psychosocial framewcuk.developed to explain health—related
behavior at the level of individual decision making. The model
variable included in this study is perceived barriers to
treatment which influences the likelihood of action or
compdiance. Modifying factors: demographic characteristics and
psychosocial variables will be included as extraneous variables.

Perceived barriers to treatment have been shown to be the
“most powerful“ of the H.B.M. variables in studies reviewed from
1974 to 1984 by Janz and Becker (1984). In the decade review,
studies were grouped under preventive health behaviors, sick-role
behaviors and clinic visits. Significant to this study are those
studies dealing with sick-role behaviors. (Janz reviewed.four
studies which dealt with hypertension and components of the
H.B.M.

In three of the studies the variable of barriers to

compliance was included. Kirscht and Rosenstock (1977) conducted

70

interviews with 132 patients to ascertain compliance with
medication regimens and dietary recommendations. The levels of
adherence or compliance were explained by the following belief
measures: perceived severity, perceived susceptibility, efficacy
of intervention and “perceived cost of following advice“ (Janz,
p. 25). “Cost“ is a tangible barrier .to compliance. Statistical
significance was not reported for perceived cost of following
advice, thereby limiting the interpretation of barriers impact on
compliance.

In the Nelson study relationships between H.B.M. variables
and compliance with medication and appointment—keeping were
studied. One hundred forty-two (142) interviews were conducted
to assess medication adherence. “Perceived severity of own
hypertension" and "perceived side effects from own hypertension
medications“ were significantly associated with medication-taking
(Janz, 1984). Nelsbn viewed side effects as “modifying factors“
instead of barriers, which is the traditional conceptualization
(Janz, 1984). Janz stated the study was fraught with “serious
measurement/analytic difficulties,“ which made measurement of
compliance difficult. A subject was listed as _n__on compliant if a
single dose of medication was missed during a 28 day period.
Nelson also altered the H.B.M. by adding variables, i.e.,
“priority of health in life" and Changing the definition of
barriers.

Janz also reviewed the Taylor (1979) study of 230 Canadian

steelworkers. Medication compliance was determined at Six and

71

twelve months post treatment. Barriers were listed as beliefs
about drug safety. At six months “drug safety“ was significantly
related to adherence (Janz, 1984). Taylor included no
sociodemographic data which could have been of potential benefit
to the present study. Since education booklets were provided to
the steelworkers in English, Italian and Croatian, ethnic-group
beliefs could have had significant impact on the findings.

Janz (1984) stated that research Since 1974 demonstrated
that “barriers“ had the highest significance ratios (91%) in
studies of preventive health behaviors and sick-role behaviors.
.Moreover, Janz' intent was to provide evidence supporting the
H.B.M. dimensions as “important contributors to the explanation
and prediction of individual's health-related behaviors“ (Janz,
p. 41). This posture supports the use of the H.B.M. dimension,
barriers, in the present study.

Studies from 1983 to the present will be included in the
review of compliance behavior. Direct measures of compliance in
patients taking antihypertensives have been studied. Craig
(1985) reported a Study of 40 patients with essential
hypertension who were treated exclusively with hydro-
chlorothiazide for at least six months. A quantitative
urinalysis was done three times at monthly intervals to detect
the presence of hydrochlorothiazide. Blood pressure readings,
pill counts and patient interviews were also done to compare
accuracy of the techniques. The urine assay indicated a non-

compliance rate of 25%. No one measure was found to have both

72

high sensitivity and Specificity. Patient interviews asking
“directly and in a non-threatening manner about medication
consumptionfl correctly Classified the largest number of
individuals as compliant and non-compliant (Craig, 1985. p. 65).

Caldwell (1984) measured plasma propranolol levels in 50
ambulatory hypertensives to determine the plasma level
relationship to the dose prescribed. There is a predictable
relationship between the dose and plasma levels and therefore,
measures represent a “reasonable” indication of compliance with
prescribed medication (Caldwedl, Eh 689). In addition, patients
‘were interviewed using a standardized questionnaire: the
Compliance Index, and a medical record review was done.

As with Craig‘s study, Caldwell found patient interviews
the best means to determine compliance with medication. Poor
blood pressure control was associated with a low correlation
between dose and propranolol levels, which was felt to be an
indicator of poor compliance. However, physiologic mechanisms
(alteration in hepatic metabolism of the drug) could offer an
alternate explanation. Caldwell measured plasma propranolol
levels in patients receiving the same dosage which demonstrated
twenty—fold differences in concentration. This finding
prohibited showing a relationship between the plasma level/dose
ratio and the compliance index.

Both Craig and Caldwell used.biochemica1 methods to estimate
compliance within specific antihypertensive medications.

However, the most reliable indicator for compliance was patient

73

interview. Craig stated 85% of the patients in her study were
correctly Classified as either compliant or non compliant by the
patient interview.

Nagy (1984) conducted a study to analyze psychosocial
'variables in predicting compliance behavior in chronically ill
patients: Type II Diabetes Mellitus, hypertensives, and those
with pulmonary disease. The locus of control construct and the
H.B.M. were used as the structural frameworks for the study.
Forty—nine hypertensive patients were interviewed to assess
demographic information, value of health to the patient,
subjective perception of the medical problem (perceived severity,
experienced symptoms and long-term outlook), satisfaction with
clinic treatment, social support for treatment, and health locus
of control beliefs. A second interview was done Six months after
the initial interview to ascertain from the patient the
.medication and self-management procedures prescribed for him.
The patient was asked to indicate his own degree of compliance
‘with.the prescribed regimen. A.health.care provider was also
asked to describe the patient183prescribed regimen and level of
compliance.

Nagy administered several scales to the patients to measure
the following study variables: three scales measuring locus of
control, severity of medical problem, four scales from Warefls
Patient Satisfaction Questionnaire, two»concerning patient's

evaluation of medical care services, and two measures of social

74

support. Three indexes of compliance were used: self-report,
provider-report and on-time pharmacy refills.

Stepwise multiple regression analyses were conducted to
determine the degree of relationship between predictor variables
an indexes of compliance. Satisfaction with the medical care
services, as measured by the Warefls Patient Satisfaction
Questionnaire, was the only variable significantly related to
all three indexes of medication compliance.

Compliance with self management was most strongly associated
with symptoms. Fewer reported symptoms were associated with
greater compliance. Compliance with medication was high‘when
patients were satisfied with the medical care they received.

No relationship was found between health locus of control
scales and compliance measures. In conclusion, Nagy stated that
“evidence suggests that cognitive variables in general and health
locus of control beliefs specifically play a limited role in
determining compliance in chronic disease patients" (NagY. P.
920).

Nagy recommended further research focus on "perceived custom
barriers” rather than beliefs or intentions. The author's intent
was to re-emphasize the “multidimensional nature of compliance“,
which was achieved. (Nagy, p. 920).

Due to the inclusion of many variables based on two separate
behavioral constructs, the study is difficult to follow. Patient

satisfaction and lack of symptoms were indicated as predictors of

75

compliance: however, the statistics only indicated a “very modest
proportion of the variance“ was explained (Nagy, 1984). Variance
may be further explained by additional factors, such as, the
seriousness of the illness, the long-term Chronicity of
hypertension, and cognitive deficits, 14%. loss of memory or
interpretive error by the patient.

DeVon and Powers (1984) studied the effects of modifying
factors in compliance, health.beliefs and psychosocial adjustment
to illness. This study included 15 hypertensives in control and
15 matched hypertensives who were not in control. Compliance was
evaluated with the Standardized Compliance Questionnaire by
Sackett, et al. (1976): and psychosocial adjustment was assessed
by the Psychosocial Adjustment to Illness Scale (PAIS)

(Derogatis, 1976). No significant correlations were found
between compliance scores and demographic variables (age, sex,
marital status) or duration of hypertension. Regarding
psychosocial adjustment scores, uncontrolled hypertensives had
higher mean scores indicating that overall the group experienced
:more psychosocial maladjustment to illness. Devon (1984)
reported a significant negative relationship between the total
conmfliance score and the total PAS score in the uncontrolled
group (I = .60 p< .02): the correlation indicated less compliance
vvith less adjustment. No differences in health beliefs affecting
compliance were found between the groups, suggesting that control

of hypertension is not necessarily synonymous with compliance.

76

DeVon (1984) concluded that psychosocial distress may be a
significant moderating variable to consider in the development of
the H.B.M. Further refinement would support recognition of
adjustment problems which may assist providers in promoting more
effective treatment modalities. Thus far, this was the only
study located which dealt with modifying factors as a study
variable.

One hundred sixteen (116) hypertensives were involved in a
study by Kerr (1985) to determine whether education, monitoring
or a combination of both without supervision or support from
providers would promote compliance to antihypertensive regimens
(Kerr, 1985). The volunteers were randomly assigned to one of
four groups 1) control group: 2) education and self-monitoring:
3) self-monitoring only: and, 4) the education only group. After
instruction and demonstration for the appropriate groups, no
further contact occurred with the subjects for three months. At
the end of this time interval, final blood pressure readings were
taken: BP cuffs and tally sheets upon which the number of pills
taken and blood pressure readings were recorded were collected.
There were no significant differences in compliance rates among
the four groups three months after the initiation of the
interventions. In addition, there were no Significant
differences in age, sex, number of pills prescribed, or mean DBP
at the end of three months. The number of subjects who were <

80% compliant were evenly divided between the self-monitoring

77

only and education only groups. The study had a high attrition

rate (68%) possibly related to no contact or follow-up until the

final BP readings and collection of tally sheets. Kerr (1985)

indicated that follow—up or special attention may be a principal

factor in promotion of compliance to hypertension regimens.
Summagy

The H.B.M. has been extensively studied to explain health-
related behavior. Janz' decade review (1974-84) provided support
for the study of barriers to compliance. “Barriers“ has been
shown to be the most powerful of the H.B.M. dimensions.

Studies of compliance have been reviewed from 1983 to the
present. Studies of direct and indirect measures of compliance
have been included. Plasma propranolol levels and urinalysis for
hydrochlorothiazide were done in two studies to verify patients'
reports of medication adherence.

Nagy and DeVon studied psychosocial variables in predicting
compliance. A variety of measurement tools was used. Nagy
found that patient satisfaction with medical services was a
significant predictor of compliance.

The final study reviewed discussed education and provider
support as promoting compliance behavior. Kerr (1985) indicated
that “special“ attention from the provider of care may be a
principal factor in promoting compliance.

Becker (1985) reported that in a review of literature

approximately one-third of patients follow physicians'

78

directions. Significant to the nurse is the identification of
“determinants“ of patient non compliance. The barriers to
compliance dimension of the H.B.M. helps to identify the
impediments to compliance with the hypertension regimen.
Regimens which.are complex, of long duration, dependent on an
alteration in lifestyle, and are inconvenient, or expensive
encourage non compliance (Becker, 1985). Methods for monitoring
regimen compliance offer inconclusive evidence. Patient report
is the most reliable measure of compliance. The provider of care
has a pivotal position in interpreting health beliefs and
influencing compliance behavior.

Nursipg Intervention for the Hypertensive Native American

Early attempts to control hypertension through education

were instituted in 1972 by the National High Blood Pressure
Education Program. In 1982, the National Institute of Health
published a review of the same education program activities in
minority populations. Formal channels of communication between
the NHBPEP and minorities occurred through the 1975 Forum on
Hypertension in Minority Populations. A committee was then
established to oversee implementation of the Forumfs
recommendations. A series of conferences were held between 1975
- 1980 to help develop prevalence data and to “facilitate
information sharing between minority health professionals and

organizations“ (N.I.H. Pub. No. 82-2188. p. 4).

79

Two national conferences on high blood pressure control in
Native Americans have been convened. 1977 and 1980. Specific
recommendations issued in 1977 that have relevance to this study
include:

Epidemiologic studies on the prevalence of high blood
pressure and its impact on.mortality and morbidity in
Native American populations be implemented.in

order to provide a data base for future planning.
Increased research be instituted in the area of non—
pharmacological treatment of hypertension and that
special consideration be given to traditional

Native American health beliefs.

The Association of American Indian Physicians review
the Joint National Committee report on Detection,
Evaluation and Treatment of High Blood Pressure and
determine its applicability to Native American
pOpulations. (Accepted, 1980) (N.I.H. Pub. No. 82-
2188.1982). ‘ ‘ ’

There have been no additional national conferences held in
COOperation with the National Institute of Health (National
Office, N.I.H., Phone Communication, Sept.. 1987).

General guidelines pdblished by the Department of Health,
Education and Welfare in 1978 define the activities of the
community health nursing staff of the Indian Health Service,
which, in part, include: ”strengthening of health teaching in
homes, hospitals, Clinics, schools, and the community with the
goal of preventing disease or reducing the ill effects of
unavoidable disease: teaching a member of the family to give

nursing care to the non-hospitalized sick and handicapped:

deveIOpment of habits conducive to health, and increasing the

Cd

he

re:
Thi
the
wit

pap]

Orde;

Care

80

capabilities of families, groups, and communities to cope with
health.problems that arise and.with.problems of daily living.“
(I.H.S. Publication No. 78-12009. 1978).

The practice area of the community health nurse includes
responsibility for providing "primary health carefl'(p. 25).

This definition of practice could, therefore, be used to indicate
the nurse's role in “delivering health care services to those
with hypertension" (Harmon, p. 5) in the Native American
population.

The advanced practice role of the nurse complimented with
transcultural nursing education would provide well qualified
primary care of the hypertensive American Indian. Transcultural
nursing focuses on an analysis of different cultures with
“respect to their caring behavior, nursing care, health-illness
values, beliefs and patterns of behavior“ (Leininger, 1978. p.
8). The goal of transcultural nursing as defined by Leininger is
to develop a “scientific and humanistic body of knowledge in
order to provide culture-specific and culture-universal nursing
care practices“ (p. 8).

The objectives for professionals caring for hypertensives
may be based on the recommendations from the National High Blood
Pressure Education Program. The Committee states that emphasis
must be on 1) identification of at-risk persons, early detection
and prompt treatment: 2) lifestyle modification: 3)ldietary

management and counseling: 4) effective, tolerable, affordable

81

treatment: 5) achievement of goal blood pressure: and, 6) long-
term, periodic monitoring (Coordinating Committee, National High
Blood Pressure Education Program, 1984).

An interdisciplinary team approach which includes the
patient and family as active participants provides an organizing
framework to achieve blood pressure control. "Inter-professional
collaboration offers benefits to patient care because it can
bring all of the perspectives and skills of different disciplines
to bear on a common goal“ (NHBPEP, 1984, p. 394). The unique
contributions of the nurse can be organized into four categories:
Clinical service, research, education, and community activities
(Grimm, 1981).

The advanced nurse practitioner may adopt a person-centered
approach to the Client. A person-centered orientation allows the
care-giver to consider the client in both institutionalized and
individualized ways, and consider how each patientis attitudes,
beliefs and values are likely to influence health behavior
(Kausch, 1985). Strategies for enhancing adherence to regimens
for hypertension would be based on persuasion rather than control
by the care-giver. Reason, logic and rationale for treatment
‘would be a necessary component of the treatment regimen (Kausch,
1985). “The defining characteristic of person-centered
communication is that it focuses direct and explicit attention on
the needs, feelings, and psychological Character of the patient

or others involved in the situation“ (Kausch, 1985, p. 56).

82

Coins (1985) states that Native Americans seek group
approval before committing to follow-through with therapy. They
tend not to follow protocols if treatments do not coincide with
those treatments other members of the group are receiving, or if
they do not sound reasonable. Further, there is a strong family
orientation. Designing therapies that coincide with their
lifestyle is more effective (Goins, 1985).

Culture affects health care practices. Beliefs about causes
of illness and ways to care for the illness, family dynamics and
interactions, and patient expectations of the provider and the
health care system may influence the course of an illness
(Kristal. 1983). The advanced nurse practitioner needs to
incorporate specific knowledge and Skills of ethnic variations
into the process of care. ‘Utilization of family assessment and
intervention skills, as well as, consideration of health beliefs
and traditional practices will assist the nurse and Client in
planning individualized interventions.

Summagy

In this chapter literature has been reviewed regarding the
nature of hypertension in the Native American population.
Prevalence data was discussed. Factors contributing to the
development of hypertension was also included. Non pharmacologic
and pharmacologic therapies for the treatment of hypertension

have been described.

83

Studies of barriers to treatment and compliance with

therapeutic regimens were reviewed. Janz' decade review dealt

with studies from 1974-1984. Compliance studies were reviewed

from 1983 to the present.

In the final section there was a discussion of the nursing

care of the Native American client with hypertension.

CHAPTER IV
METHODOLOGY AND PROCEDURES
Overview

A cross—sectional survey will be employed for this study to
examine the relationship between perceived barriers to treatment
and stated compliance with the hypertensive therapeutic regimen.
The foundation for the hypotheses and concepts are based on the
studies by Given and Given (1982) and Harmon (1983).

Modification of the variables will be delineated and the unique
population sample will be described. One ambulatory care Site in
Montana will be used to gather data.

In the following chapter are the research question,
descriptions of hypotheses, instruments, Operationalization of
the variables, sample selection, data collection procedures,
human rights protection, and statistical analysis techniques.

Researchpguestion

As previously described in Chapter I, the present study is a
modification of Harmon's study in which the research question
was: “How do clients' perceptions of barriers to treatment
relate to their stated compliance with the hypertension
therapeutic regimen?“ (Harmon, 1983. In 9). Information will be
sought from urban Plains Indians who have not been involved in
prior studies.

Research Hypotheses

Primary hypothesis. The client's perception of barriers to

therapy will be negatively related to stated compliance with the

therapeutic regimen.
84

85

Secondary hypotheses:

a) There is a negative relationship between perception of
barriers concerning medications and stated compliance.

b) There is a negative relationship between perception of
barriers to diet and stated compliance with a dietary regimen.

c) There is a negative relationship between perception of
barriers concerning an exercise program and stated compliance.

d) The percent overweight will be negatively related to
compliance with diet and/or exercise regimens.

e) The duration of hypertension will be negatively related
to compliance with medications and/or diet.

f) Age, sex and alcohol consumption will be related to a
higher level of blood pressure hag. young adult males who
consume more than 1 to 2 ounces of ethanol per day will have
higher blood pressures) and will be negatively related to
compliance with medications.

9) Consumption of predominantly high carbohydrate or high
fat foods will be positively related to percent overweight and
negatively related to compliance with diet.

h) Lower education level will be negatively related to
compliance with medication, diet and exercise.

Instruments

The instruments used in this study were designed for
Patient Contributions to Care: Link to Process and Outcome
(Given and Given, 1982). Additional questions have been

developed to assess barriers and compliance with an exercise

86

program. The questions are 20 - 28 on the Perceived Barriers to
Therapy Questionnaire (Appendix E). Questions have been added to
the patient interview scale which seek Specific ethnic
preferences regarding diet, food choices, and folk or “Indian“
.medicines. All questions related to job and impact on work have
been deleted due to the age of the population and the high rate
of unemployment. Severity and efficacy of treatment were also
deleted in order to focus the study on the dimension of barriers
to compliance. Additional questions have been added to the
sociodemographic questionnaire in order to better describe the
sample subjects. Question #3 was added to explore ethnic
background by identifying Native American tribal affiliation.
Lower classifications of income status (5) were added based on
preliminary interviews with the nurse clinician at the Native
.American Center. Four lower categories of income from $2,000 —
$8.999 annually were added to the questionnaire. The nurse
clinician indicated that a significant number of clients would
have less than an income of $8,900 annually. Education
Classifications (6) were also lowered based on preliminary
interviews with the Director of the Center and the nurse
Clinician. Household composition and length of residence were
added to ascertain.available composition of family members and
the stability of residence. Smoking and alcohol consumption were
added to estimate the extent addictive behaviors influence

compliance to therapy.

87

Validity Reliability

Validity and reliability of the original instruments have
been established. Validity, a measure of quality of an
instrument, refers to the extent to which a testing instrument
measures what it purports to measure. Several methods may be
used to establish validity for the replicated instruments.
Content validity was Chosen. Content validity is based on expert
analysis of the items to determine the adequacy of coverage and
proportion of inclusion of the “hypothetical content universe“
(Polit and Hungler, 1983, p. 396). For the scales replicated in
this study content validity was established by literature review,
interviewing of hypertensive Clients, pretesting with two samples
of hypertensive Clients, and knowledge and judgment of the
principal investigators (Given and Given, 1982).

Specific questions have been added to the patient interview
scale in order to expand the information available regarding
Native Americans. ‘Validity is supported by review of the
literature: salt ingestion (Gillum, 1984, Torrey, 1979), alcohol
consumption (Gillum. 1984. DeStefano, 1979). activity level
(Gillum, 1984. Johnston, 1978. Hollow, 1978) and obesity (Gillum,
1984, DeStefano, 1979. DePrez, 1985. Torrey, 1979).

The instruments were also evaluated for reliability.
Reliability refers to the accuracy, consistency, dependability
and precision of the measuring instrument. Cronbachfls alpha is a
statistical method for interpreting the internal consistency of

an instrument. The higher the coefficient, the more stable the

88

measure (Polit and Hungler, 1983). A satisfactory coefficient is
0:70 or higher (Borg, Gall, 1979). The reliability coefficient
for the perceived barriers to treatment scale was .91 in the
Given study, whereas the reliability for the total stated
compliance score was {76.

Polit and Hungler state that “reliability of an instrument
is not a property of the instrument, but rather of the instrument
when administered to a certain sample under certain conditions“
(1983, Pu 386). Therefore, the alpha coefficients will be
computed for the instruments completed by the Native American
sample. Comparisons will be made between the original and Native
American samples.

Qperationalization of Study Variables

Perception of barriers to treatment is defined as the
expressed beliefs and attitudes of the client concerning the
barriers to undertaking aspects of the therapeutic regimen"
(Given and Given, 1982). Three dimensions of barriers to
implementation of therapy will be measured: 1) beliefs about
difficulties with medication: 2) beliefs about difficulties with
changes required for diet: and, 3) beliefs about difficulties
with changes required for exercise.

Dimension 1, beliefs about difficulties with medications,
refers to habit change required, concern with dependency,
disruption of daily activities, and duration of therapy.
Barriers to medication therapy are proposed to be measured.by

items 1-9 (Appendix E). Dimension 2, beliefs about difficulties

89

with changes required for diet, will include interference with
normal activities, personal life, feelings of hunger, dislike of
allowed foods, time required to follow a diet, and need for
family support. Diet barriers are proposed to be measured by
items 10-17. Dimension 3, beliefs about difficulties with
changes required for exercise, will include interference with
normal activities and personal life, feelings of fatigue, dislike
of the specific exercises recommended, the time necessary to
follow an exercise plan, physical discomfort associated with
exercise, and the need for supportive others. Exercise barriers
will be measured by items 19-27‘(Appendix E).

The scoring will be done similar to the original instrument.
A Likert-type reSponse scoring method will be used for the
Perceived Barriers to Therapy Questionnaire. Strongly agree will
be assigned a ;, ranging to a 3 for strongly disagree. A low
numerical score will be indicative of a high degree of perceived
barriers for questions 2 - 6 regarding medications: 12, 13. 15
regarding diet: 21. 22, 24, 28 regarding exercise questions.
Reversed scoring for a high degree of perceived barriers will be
done for questions 7, 8, 9 regarding medications: 11, 14. 16, 17,
18 regarding diet: 20, 23. 25, 26 and 27 regarding exercise. The
three dimensions of barriers to treatment will be scored
separately, iJL, difficulties with medications, difficulties
with diet, and difficulties with.exercise: and, may be

combined for a total score for barriers.

90

Stated compliance with the thergpeutic regimen is defined as
the extent to which the Client carries out the therapeutic
recommendations of health care providers concerning prescribed
medication, diet, behavior modifications, and follow-up care
(Given and Given, 1982, p. 28). The interview will be a verbal
report by clients regarding their frequency of compliance with
prescribed medications (questions 1, 2, 3), diet (questions 6 and
7), and exercise prOgram (questions 15 and 16) (Appendix C). A
high degree of stated compliance will be indicated by a low
numerical score on the Patient Interview Scale. 4A Likert—type
response scoring for perceived barriers to therapy will also be
used for the stated compliance response. “All the time“ will be
assigned a _1_, ranging to a g for “none of the time.“ The
compliance scores will be totaled separately for medication, diet
and exercise: and will be combined for a total compliance score.

Short-answer and open-ended questions have been added to the
patient interview to access unique cultural beliefs regarding
diet, exercise, and medications. Question 4 will be stated: “Do
you use any traditional 'Indian' or 'folk' medicines to treat
your high blood pressure?“ “If yes, please describe what it is
and how it worksJ‘ Question 4 will be content analyzed. .A
description and rationale as provided by the participant will be
included. Direct quotations will be used for Clarity.
Similarities in responses will be grouped, classified, if
feasible, and described. Inquiries about diet will be

descriptive of what is usually eaten and how often. Specific

91

questions focus on sodium ingestion and types of beverages
consumed (questions 8 through 13). Questions 8 and 9 are
evaluations of dietary composition: predominantly carbohydrate,
protein or fats. Questions 10, 11 and 12 indicate frequency and
amount of nutrients consumed. Sodium consumption will be
reported on a scale from “always“ to “neverJ' "Always, often, or
seldom“ will be further defined by indicating when sodium is
added: ‘while cooking, at the table, or both. ”Always" is ranked
as a 3 ranging to a 3 for “never.“ The higher the number, the
higher the intake of sodium. When g_(always) or 3 (often) is
combined with adding while cooking (1), at the table (2), or both
(3), the addition will elevate the sodium past the recommended 2
gm. of sodium per day. Estimated ranges and percent of over
consumption of sodium will be reported.

Three questions to elicit information on type, duration and
frequency of physical activity (17. 18, 19) are included.

Frequency is written in as number of times per week engaged in a

 

recommended physical activity. Duration is indicated by number
of minutes per week expended doing the recommended activities.
Ranges will be reported. Type of exercise is indicated by light
(1), moderate (2), or vigorous (3). Type refers to activity that
uses large muscle groups that can be maintained for a prolonged
period, and is rhythmical and aerobic in nature (American College

of Sports-Medicine, 1986). Light, moderate, or vigorous are

92

indicators of work determined by heart rate during exercise.
Estimates of work were made by the researcher: data on HR was not
collected.

Extraneous variables are defined as independent variables
that may influence the results of the study (Polit and Hungler,
1983). Sociodemographic data of age, sex, marital status, race
and tribal affiliation, yearly income, educational background,
residence, members of household. and personal habits: smoking,
food consumption, physical activities and alcohol ingestion are
included on the sociodemographic questionnaire; The medical
record audit which identifies the duration of hypertension, the
level of blood pressure and the weight of the client will also be
included as an extraneous variable. Possible correlations among
selected extraneous variables and the major study variables will
be examined.

Population and Samplg

The sample for the study will be volunteers from among
hypertensive clients seen at the Native American Center in Great
Falls, Montana. Fifty adults with the following characteristics
will be included: 1) ages 18-85: 2) male or female: 3) ability
to read and write in the English language: 4) an established
diagnosis of essential hypertension: 5) a prescribed diet and/or
medication regimen: and, 6) no evidence of the following:
stroke, end-stage renal disease, blindness, cancer, psychiatric

problems, pregnancy or lactation.

93

Recruitment of subjects will be done with the assistance of
the nurse Clinician at the Native American Center. The initial
contact with the client will be made by the nurse clinician at
the Native American Center to ascertain permission for inclusion
in the study. .A follow-up phone call by the researcher will be
done to further describe the study. The purpose of the study
will be described, as well as, the potential benefit to the
client, the length of time necessary to complete the instruments,
and requirements for participation will be explained. The Client
will be requested to come to the Native American Center at an
arranged time to Sign a written consent. After written consent
to participate is obtained from the Client by the researcher, a
medical record audit will be done by the nurse clinician at the
Native American Center. Appropriateness for inclusion of the
client will be determined.

Data Collection Procedures

Subjects meeting the requirements for eligibility and
willing to participate will be interviewed at the Native American
Center. Confidentiality of subjects will be protected through
the use of pre-coded instruments. Interviews will be held in
privacy with strict confidence maintained. The instruments will
be completed during the interview.

Data will be collected from two sources: 1) a structured
interview with questionnaires administered by the researcher to
the client: and 2) the client!s.medical record. Subjects will be

interviewed in a private office provided at the Native American

94

Center. The interview will be conducted by the researcher alone
with the subject. A quiet room, without interruptions, will be
maintained during the interview. Each subject will be thanked
for his/her participation, and will be offered a summary of
findings upon completion of the study. .All questions will be
checked for completion by the researcher before coding for
computer analysis.

Reports of the findings will be in group form only. Consent
forms from the subjects will be used only for verification of
consent or withdrawal of a participant from the study. The
protection of the rights of the participants will be assured
using the standards of M.S.U. Committee on Research Involving
Human Subjects.

Statistical Analysis

Univariate and correlational statistics will be used to
describe the sample and test the hypotheses of the research.
Univariate distributions will be used to describe the
sociodemOgraphic and medical audit variables and responses to
certain patient interview questions: range, distribution,
percentages and means. Correlations (Pearson r) will be used to
describe the relationship between selected extraneous variables
and the major study variables, eML, alcohol consumption related
to stated compliance, educational level related to stated
complianceu The Pearson r is a correlation coefficient which
expresses in numerical terms the direction (+ or -) and magnitude

of a relationship between variables (Polit and Hungler, 1983).

95

The hypotheses will be tested by correlation techniques.
Scores for the subscales of perceived barriers and stated
compliance will be completed. (Frequencies, means and standard
deviations will be calculatedJ The correlation of perceived
barriers and stated compliance with each of the components of the
therapeutic regimen will be computed using the Pearson r
statistic. The Pearson r expresses the direction and magnitude
of a relationship from -1.00 to 1.00. Negative relationships are
those values falling between -1.00 and 0.00: whereas, positive
relationships are those correlations falling between 0.00 and
1.00. The strength of correlations for this study will be set
the same as those for Harmon's, which were taken from Borg and
Gall. No relationship is indicated by 0.00 to 0.20, a low
relationship as 0.20 to 0.35. a moderate relationship as 0.35 to
0.85, and a high to perfect relationship as 0.85 to 1.00 (Borg
and Gall, 1979. p. 513-514).

Summagy

Research methodology was described in Chapter IV. The
specific areas discussed were: the research question, the
hypotheses, instruments, Operationalization of variables,
extraneous variables, sample, human rights protection, data

collection procedures, and statistical analysis techniques.

CHAPTER V
DATA PRESENTATION AND ANALYSIS OF RESULTS
Overview

Chapter V is structured to include five components. A
description and analysis of the study sample will be presented
initially. There will be a discussion of the reliability
measures for each of the scales. The relationships between
perceived barriers to treatment and stated compliance with the
hypertensive therapeutic regimen will be described using the
sample data. Extraneous variables and sociodemographic findings
will be included. Lastly, there will be a summary of the results
of the statistical procedures.

Study Sample: Descriptive Findingg

The sample for the study was composed of 24 volunteers. The
extraneous variables addressed were: age, sex, marital status,
income, educatiOn, duration of hypertension, blood pressure and
percentage overweight. .Additional variables were included to
further describe the subjects: smoking, drinking alcohol,
dietary habits, exercise, household composition and residence,
and tribal affiliation.

A_A_g_e3 The age of the sample subjects ranged from 37 to 83
years. The mean age was 60.8 years, standard deviation 11.25.
The average age of men ranged from 42 to 74 years, mean age 60.2
years, standard deviation 8.7. The age of the women ranged from

37 to 83 years, mean 61l3 years, standard deviation 12.4.

96

97

Table 1. Distribution 5 Percentage of Subjects by Age

 

 

Number of
Ag; Participants Percentagg
30-40 1 4.17
41-50 3 12.50
51-60 6 25.00
61-70 10 41.67
71-80 3 12.50
81-90 _1 4.17
Totals 24 100.00%*

*Totals may be slightly above or below 100% due to rounding.
Sex. There were more females (N=14, 58.3%) than males
(N=10. 41.7%) in this sample.

Marital Status. Half of the sample was married (N=12. 50%).

 

No single persons participated: N=3 or 12.5% were divorced, and
N=9, or 37.5% were widowed.

Income. Five persons (20.8%) did not respond to the
question regarding income. Of the nineteen reporting, 58.3%
reported less than $11,000 annually: N=3 (12.5%) earned $2.000-
$2,999 annually: N=5 (20.8%) earned $3,000 - $4.999: N=4 (16.6%)
earned $5.000 - $6.999, one person earned $7,000 - $8.999, and
one person earned $9,000 - $10,999 annually. None earned over

$17,000 annually.
Table 2. Distribution & Percentage of Income Annually

 

 

Income Participants Percentagg

$ 2.000 - $ 2.999 3 12.50
$ 3.000 - $ 4.999 5 20.83
$ 50000 ’ S 61999 4 16.67
$ 71000 - $ 80999 1 4.17
$ 9.000 - $10,999 1 4.17
511.000 - $12.999 2 8.33
$130000 - $140999 1 4617
$15.000 - $16.999 2 8.33
No Response _§ 20:83

Totals 24 100.00%

98

Education. Most of the sample subjects attended

 

only grammar school (< 7th grade) N=10 (41.7%): N=6 (25%)
graduated from high school: N=2 (8.3%) attended some college but
did not graduate: and, 1 (4.2%) attended a technical, business or
trade school.

Table 3. Distribution & Percentage of Education

 

 

Education N=24 Percentagg

None or Some Grammar School 10 41.7
Junior High School 3 12.5
Some High School 2 8:3
Graduated High School 6 25.0
Techn., Bus. or Trade School 1 4.2
Some College _3 8.3

Totals 24 100.0%

Duration 9; Hypertension. The duration of hypertension was
determined.for 23 subjects. The range of years of duration was 1
to 19 years. The mean was 7.3 years, standard deviation 5.2.

The highest percent 47.8% (N=11) had been diagnosed 1 - 5 years
ago: N=3 (13%) had been diagnosed 15 - 20 years.

Table 4. Distribution 8 Percent for Years
of Diagnosed Hypertension

 

Years N=23 Percentagg
1 - 5 11 47.3

5 - 10 5 21:7

10 - 15 4 17.4

15 - 20. _3 13.0
Totals 23 100.0%

Blood Pressure. Blood pressure readings during
the past Six months were obtained for 22 subjects. Two blood
pressure readings from each subject were averaged for the six

:months time interval. The grand average systolic blood pressures

99

ranged from 110-168 mm Hg: mean of 137.5. standard deviation
16.1. Diastolic blood pressures ranged from 70 - 96 mmng.. mean
of 81, standard deviation 7.6.

Table 5. Average Systolic Blood Pressures
'During the Past Six Months

 

mm Hg; N=22 Percentagg
110-116 2 9.1
117-122 3 13.6
123-128 3 13.6
129-134 2 9:1
135-140 3 13:6
141-146 1 4.6
147-152 4 18:2
153-158 2 9.1
159-164 1 4.6
165-168 _3 4.6
Totals 22 100.0%

Table 6. Average Diastolic Blood Pressures
During the Past Six Months

 

ET Hg; N=22 Percentagg
69-75 5 22.7
76-81 5 22:7
82-87 5 22.7
88-93 6 27:3
94-99 _3 4.5
Totals 2 100.0%

Percenpgge Overweigpt. The sample subjects' current weight
and height were recorded and compared.to the ideal body weight
for men and*women. The percentage overweight was calculated
using the Metropolitan Life tables for men and women (1983L. The
tables are not structured for use in culturally-diverse groups,
therefore, percentage overweight may be over estimated. Five

subjects (20.8%) of the sample were at ideal body weight: N=2

100

(8.3%) were overweight, but less than 20% overweight: N=17
(70.8%) were 20% or greater than ideal body weight.

The following formulae were used to calculate ideal body
weight: women, 100 pounds for the first five feet plus 5 pounds
for each additional inch of‘height: men, 106 pounds for the first
five feet plus 6 pounds for each additional inch of height. The
ideal weight was divided into the actual weight to determine
percent overweight.

Dietary Habits: Food Consumption. Sample subjects
indicated that foods “liked best“ and “eaten most often“ are
carbohydrates (79.2% and 66.7% respectively). Proteins are
“eaten most often” by 20.8% of the subjects. Eating patterns
‘varied: N=3. 12.5% eat only once a day, N=12 (50%) eat twice
daily, N=7 (29.2%) eat three times a day, N=2 (8.3%) eat five or
more times per day. Three subjects (12.5%) get up to eat at
night. N=17 (70.8%) of the subjects consume over the daily
requirements of certain nutrients: N=6 (25%) include all
nutrients in recommended.quantities: only one consumed less than
the recommended quantities.

Consumption of nutrients was estimated from a twenty-four
hour diet recall. The participant was asked to state “typical“
or “usual“ daily intake. The information was used to calculate
the number and types of exchanges consumed in a day: nutrients

were estimated from the total exchanges.

101

Table 7. Dietary Habits:
Estimates of Percentages of Food Consumption
Dietary Habits N=24 Percentagg

Foods Liked Best:

 

 

 

Predominantly Carbohydrates 19 79.17
Proteins 5 20:83
Fats _Q 0
Totals 24 100.00%
Foods Eaten Most Often:
Predominantly Carbohydrates 16 66.67
Proteins 6 25.00
Fats _3 8.33
Totals 24 100.00%
Foods Eaten in a Typical Day;
All nutrients included in
recommended amounts 6 25.00
Over consumption of certain
nutrients 17 70.83
Under consumption of certain
nutrients 1 4.16
Over a under consumption of '
certain nutrients _Q 0
Totals 24 100.00%

Salt Intake. Fifty percent, N=12. indicated they seldom
added salt to their food: N=4 (16.7%) often added salt: N=2
(8.3%) always added salt. Six (25%) subjects indicated they
never added salt. Of those 18 persons adding salt to their food:
9 (37.5%) added while cooking: 7 (29.2%) added while at the
table: and 8 (33.3%) added both while cooking and at the table.
Over consumption of salt may be assumed by those (25%) always and

often adding salt to their food.

102

Liquid Intake. Of the 24 sample subjects surveyed only 3
(12%) consume liquids in recommended quantities. Five (34%)
subjects consume recommended “kinds“ of fluids, i.e., water,
fruit juices, etc.: 24% or 6 subjects consume in excess of
recommended quantities of fluids (i.e.. coffee, tea): 16% or 4
subjects consume less than recommended quantities: six or 24%
consume excesses of some fluids and too little of other fluids.

Alcohol Consumption. Twenty-three subjects responded
to the question about alcohol consumption. Fourteen or 58.33%
indicated they did drink alcoholic beverages: 9 (37.50%)
indicated they did not drink: 1 subject did not respond. Of
those drinking alcohol 9 consumed less than 1 ounce ethanol per
day: 4 consumed 1 - 2 ounces ethanol per day: only 1 consumed
more than 2 ounces ethanol per day.

Smoking. N=11 (45.83%) of the sample subjects did not
smoke. Five (20.8%) smoked 10 - 19 cigarettes per day: 7 (29.1%)
smoked 20-29 cigarettes per day: and 1 (4.1%) smoked 30 or more
cigarettes per day. Two non smokers had indicated they quit
smoking in the past year.

Exercise. The majority of the sample subjects indicated no

 

participation in exercise (N=18. 75%). Of the remaining 6, one
exercised twice weekly, one exercised three times weekly, two
(8%) exercised four times weekly, one exercised five times
weekly: and, one subject exercised daily. All subjects performed

light exercise from 10 to 30 minutes per session.

103

Residence/Household Composition. The length of residence
within Great Falls ranged from 4 to 66 years. The mean range was
30-40 years: N=11 (45.8%) of subjects resided in Great Falls for
this interval: N=6 (20.8%) of subjects had lived in Great Falls
for 50-60 years. Length of residence at the same house is: N=12
(50%) lived in the same house 0-5 years: Ns3 (12.5%) lived in the
same house 5-10 years: N=3 (12.5%) resided in the same house 20-
25 years.

A description of household composition demonstrated: N=8
(33.33%) of subjects lived alone: N=12 (50%) lived with a spouse,
no Children still live at home: however, N=2 (8.3%) have other
relatives living with them: and N=2 (8.3%) have non-related
persons residing in their homes.

Table 8. Length of Residence in Great Falls in Years &
Percentage of Distribution

Residence in Great Falls

 

Years N=24 Percentagg
0 - 10 2 8.3

11 - 20 2 8.3

21 - 30 2 8:3

31 - 40 11 45:8

41 - 50 1 4.2

51 - 60 5 20.8

61 - 70 _g_ 4.2
Totals 24 100.0%

104

Table 9. Length of Residence at Same Residence in Years 5
Percentage of Distribution

Residence at the Same Address

Years N=24 Percentage
0 - 5 12 50.0

6 - 10 3 12.5

11 - 15 2 8.3

16 - 20 2 8.3

21 - 25 3 12.5

36 - 40 1 4.2

41+ _l 4.2
Totals 24 100.0%

Traditional or Folk Medicine. Of the 24 subjects
interviewed, Abs (20.8%) indicated they took “Indian" or folk
medicine to treat their hypertension. The most frequently
indicated medicines were garlic and unidentified herbs.

Tribal Affiliation. Twenty-two of the Native Americans who
participated were Chippewa-Cree, two were Sioux, and one was
Assiniboin. Tribal registry is required for care at the Native
American Center. Blood quantum was not asked.since it is not
significant to this study.

Summary of Descriptive Findingg

To summarize the descriptive statistics, the sample is
composed of middle to older-aged adults, with Slightly more
females than males. The majority of the sample are married, have
low incomes, and have a grade or high school education. The
average duration of hypertension is about seven years. The mean
Systolic pressure is 138 munihn, and the mean Diastolic pressure
is 81 mm Hg. Seventy percent (70%) of the sample are overweight

and consume a diet high in carbohydrates. Twenty-five percent

105

(25%) of the sample consume more salt than recommended. Only one
subject consUmes more than two ounces ethanol per day. The
majority of the sample smokes Cigarettes. Only six (25%) of the
subjects participate in light exercise. The majority of subjects
have lived in Great Falls for 30-60 years. However, the subjects
are mobile within the city, remaining at the same house: 0-5
years for 50%: 5-10 years for 12.5%: and, 20-25 years for 12.5%.
Half of the sample live with a spouse and 33% live alone.
Approximately 20% of the sample indicated they took traditional
medicines to treat hypertension.
Reliability

Statistical procedures to establish internal consistency of
the instruments were not done due to the limited sample size.
Internal consistency is an indication that the subparts of the
instruments measure the same Characteristic (Polit and Hungler,
1983). Correlation between the subparts could not be done
within the exercise and medication subscales. Correlational
statistics could be done between the barriers to diet subparts,
however, the sample size precludes accuracy. A Cronnbachfs alpha
can be computed for the barriers to diet subscale but may also be
considered to be inaccurate.

Hypotheses Testipg Results

The primary hypothesis as presented in Chapter IV, the
client's perception of barriers to therapy will be negatively
related to stated compliance with the therapeutic regimen, cannot

be tested as explained by the following results. Specific

106

secondary hypotheses will be discussed. Nineteen individuals
stated they were taking medications. One subject taking
diuretics (med #1) stated he took the medication more than half
the time: the remainder stated the medication was taken all the
time. One subject taking a betablocker stated She took her
medication less than half the time: the remainder took the
medications all the time. One subject took an AJLE. inhibitor
more than half the time: the remainder took this medication all

the time. Therefore, only one subject could be defined as non

 

 

compliant.
Table 10. Compliance with Medications
' N=19
Standard

Medication Mean Deviation Range Median
Diuretic 1.07 .27 1 - 2 1
Betablocker 1.75 1.50 1 - 4 1
ACE Inhibitor 1.25 .50 l - 2 1
Vasodialator 1 ' 0 1 - 1 1
Others 1 0 1 - 1 1

Descriptive statistics for the barrier to medication
variables were calculated. The questions follow with mean,
standard deviation, range and median. A Likert response Option:
Strongly agree, agree, undecided, disagree, strongly disagree (1-
5) was used. No correlations can be computed due to lack of

variance in compliance with medication.

107

Table 11. Barriers to Medication

 

 

N=19
Standard
Barriers to Meds Mean Deviation Range Median
Confused 3.63 .76 2 - 4 4
Change Habits 4 0 4 4
Become Dependent 2.89 1.10 2 - 5 2
Not Interested 3.94 .62 2 - 5 4
Interferes 3.89 .46 2 - 4 4
Must Take Meds 3.78 .73 2 - 5 4
Believe Control 3.84 .76 2 - 5 4
Meds How Hard 3.89 .74 2 - 5 4

All respondents disagreed that "I would have to change too

 

many habits to take my medicatituh” Conversely, the greatest
variability in response was to the question: “If I take my
medications, I may become dependent upon thenu“ Responses ranged
from agree to strongly disagree. Scores for compliance with diet
were calculated for: "would you say you follow the diet as
suggested" (at home) (31). and "when you are away from home, have
you followed the diet as prescribed“ (32).

Table 12. COmpliance with Diet

 

 

N=18
Standard
Compliance Mean Deviation Range Median
Diet at home 2.67 1.15 1 - 5 2
Diet away fr. home 3.14 1.35 1 - 5 3

Scores for compliance with diet variables were correlated
Obtaining a correlation coefficient (r) = 0.66. Since the
correlation is moderate, the variables were combined.
Descriptive statistics were calculated: meanl5.5. standard

deviation 2.14, range 8. N=18.

108

Descriptive statistics were calculated for each of the

barriers to diet questions and scored the same as barriers to

medications.

undecided, disagree,

Table 13.

Barriers 59 Diet

Does Not Interfere
Always Hungry
Dislike Foods
Personal Life
Difficult to Diet
Time to Diet
Family Help

Spouse Helps

Mean

3.67
3.33
3.25
3.68
3.16
3.67
3.21
3.28

A Likert response Option:

Barriers to Diet

N=20

Standard
Deviation Raqgg

.84
.94
.97
.75
1.06
.66
1.13
1.09

strongly agree,

I—‘I-‘NI-‘NNNH

(flUlrbbbrblblhlb

strongly disagree (1-5) was used.

m

louse-owsrsouh

agree,

A correlation matrix was designed to evaluate whether diet

compliance (combined variables 31 and 32) was a function of diet

barriers.

The dependent variable:

diet compliance was

correlated initially with each barrier to diet (independent

variable).

Table 14.

and Barriers to Diet

Barriers to Diet

Does Not Interfere

Always Hungry
Dislike Foods
Personal Life

Difficult to Diet

Time to Diet
Family Help

N=18

Diet Compliance

The correlation coefficient (r)

-.29
-.44
-.12
-.38
-:43
-.50
-.13

Relationship Between Diet Compliance

0:70 explained a moderate

correlation between compliance with diet and the total barriers

109

to diet variables: r2 = 0.48, which is the proportion Of
variance accounted for by the combined influence of the
independent variables.

Twenty-five percent (25%) or six subjects indicated they
followed an exercise or activity progranh Descriptive statistics
have been calculated for the barriers to exercise questions. A
Likert response Option: strongly agree, agree, undecided,
disagree, strongly disagree (1-5) was used. NO correlations
could be computed due to the small number of subjects who

exercise.

Table 15. Barriers to Exercise

 

' N=6
Standard
Barriers 59 Exercise Mean Deviation Range Median
Does'nt Interfere 4 0 4 4
Always Tired 3 1.09 2 - 4 3
Dislike 2.66 1.03 2 - 4 2
Personal Life 4 0 4 4
Difficult 2.66 1.03 2 - 4 2
Time to Follow 4 0 4 4
Family Helps 3.66 .82 2 - 4 4
Spouse Helps 4 0 4 4
Body Aches 2.83 1.33 1 - 4 3

NO variability was found for four of the nine barriers to
exercise questions: whereas, the remaining five questions were
widely varied.

Summary of Descriptive Data by Hypotheses

a) There is a negative relationship between perception Of

barriers concerning medications and stated compliance. Only one

subject was classified as non-compliant. Therefore, nO

110

relationship between barriers to medication and stated compliance
could be calculated.

b) There is a negative relationship between perception Of
barriers to diet and stated compliance with a dietary regimen.
There are low inverse relationships between each Of the barriers
to diet variables and the combined stated compliance with diet
variables. The combined barriers to diet variables have a
moderate correlation (r = J70)‘with the combined compliance with
diet variables.

c) There is a negative relationship between perception of
barriers concerning an exercise program and stated compliance.
The relationship could not be computed due to small sample size.

Extraneous Variables

Bivariate correlations were performed on the extraneous
variables, percent overweight, age, and duration Of hypertension
with compliance with diet.

Table 16. Extraneous variables to Compliance with Diet

 

 

Percent Duration of

Compliance Overweight Age Hypertension
Diet (at home) .29 -.02 -.18
N=17 N=17 N=20

A low relationship exists between percent Overweight and
following the diet when at home (r = .29). A low inverse
relationship exists between age and following the diet at or away
from home. Duration Of hypertension has a low inverse

relationship to each diet compliance variable.

111

Bivariate correlations were performed for diet preferences,
“foods liked best" and “eaten most Often“ with diet compliance.
Education level was also correlated with diet compliance. Very
low relationships exist between diet compliance and foods liked
or eaten Often. There is a weak inverse relationship between
education and diet compliance.

Table 17. Additional Variables to Compliance

 

 

 

with Diet
N=21
Foods Eaten
Compliance with Diet Liked Best Often Education
Diet (at home) .17 -.23 -.13
Diet (away) .02 .09 -.05

The extraneous variables of Overweight and age cannot be
correlated with exercise due to the small sample size. The
effect of alcohol consumption related to medication compliance
cannot be computed since only one subject drank greater than two
ounces of ethanol per day. Age, sex, and medication compliance
correlations could not be computed due to small sample size.

Summary of Results

Since the primary hypothesis could not be tested,
descriptive statistics were used to evaluate each subscale for
barriers and compliance to the therapeutic regimen. Only one
subject indicated non compliance for taking medications. Seven
subjects (39%) indicated non compliance to diet recommendations.

Exercise was performed by six of the twenty-four subjects.

112

Compliance with diet variables were correlated with the
extraneous variables Of percent Overweight, age, duration of
hypertension, and food preferences, finding low relationships.

Limitations of the Findipgs

Interpretation of the results of the data needs to be done
with recognition of several limitations. .A non-probability
approach to sampling was done. The subjects were volunteers who
represented the most readily available persons. A.“sample Of
convenience“ is not necessarily representative of the population
with regard to the variables being measured (Polit and Hungler,
1983). Twenty-four subjects were included, constituting a small
sample size. Generalization of the findings from the sample to
the population cannot be done with these conditions.

Several problems with the instruments occurred. Negatively
worded questions were confusing, for example: “I am pg;
interested in taking my medications regularly.“*with a response
Of strongly agree, agree, undecided, disagree, or stronly
disagree, gives the subject a double negative response if he does
take medication. Language in the instruments needed to be simple
enough for the least educated (Polit and Hungler, 1983). Forty-
One percent of the sample had less than a seventh grade
education, wherein the instrument was constructed to test at
approximately eighth grade level.

Response set factors may have biased the measures on several
variables. The social desirability response set refers to giving

answers that are consistent with prevailing social mores (Polit

113

and Hungler, 1983). Finding only one person reporting over
consumption of alcohol may be an example of this type of bias.
Additionally, questions which used words associated with
authority, i.e., “prescribed," "as recommended,“ may have
elicited socially desirable responses.

The acquiescence response set may have also been operational
due to cultural differences. Native Americans represent a
minority population (which is 1% of the U.S. population), which
may influence agreement with statements independent of the actual
content of the question.

Data was collected.by an interview method, which.has both
strengths and weaknesses. Anonymity is not possible which may
limit socially unacceptable answers. The presence of an
interviewer of a different cultural background may introduce bias
which may affect the subjectfs response. Interaction between the
interviewer and the respondent may also affect the subject's
reSponse.

Strengths of the interview method for this study included:
Obtaining additional data by Observation, exposure to a different
cultural context, clarifying ambiguous and/or confusing questions
and Obtaining a greater response rate than with questionnaires.
Based on the education level, the interview method facilitated
accuracy and completion of the instruments.

Cognizant of the limitations of the data the writer makes
the following interpretations: sociodemographic data provides a

description of subjects not previously studied. Compliance with

114

the medication regimen is unexplained for this sample. Barriers
to compliance with medications could not be correlated with
compliance due to lack Of variability. Correlational techniques
used to describe relationships between compliance with diet and
barriers to diet explained 70% of the variability. The low
number of responses to the exercise questions indicated few
subjects participated in an exercise regimen. Exercise may not
be viewed as a therapeutic modality for blood pressure control by
this sample.

Extraneous variables, percent overweight, age and duration
Of hypertension correlated weakly, although in the expected
direction with diet compliance. Education also had a low inverse
relationship with diet compliance. The expectation Of the
relationships, as strongly correlated, was not found.

Summary

In Chapter V is the presentation Of statistical analyses
relative to the sociodemographic data, extraneous variables and
hypotheses. No attempt was made to test the hypotheses based on
limitations Of the data. The reliability of the instruments was
not done due to limited sample size. Correlations were
calculated to determine relationships between compliance with
medication and diet and specific extraneous variables.

A discussion and interpretation Of findings will be in
Chapter VI. Specific implications for nursing practice,
education and research will also be included in the final

chapter.

CHAPTER VI
SUMMARY AND CONCLUSIONS
Overview

In Chapter VI there will be a summary of the research
findings, recommendations for future research. and conclusions
based on description statistics. A discussion of nursing
implications for practice, education and research will be
presented. The chapter is organized in the following manner:
initially there will be a summary of the findings, which will
include a description Of the problem, sociodemographic
Characteristics, and an analysis of the hypothesis testing
results. In the “Recommendations” section there will be a
discussion of potential future research and the contributions Of
the present study. Finally, there will be a presentation Of the
conclusions and a discussion of implications for nursing
practice, education and theory.

Summary of the Findingg

Summary Of the problenu A descriptive study of 24 Native
Americans was undertaken to determine the relationship between
perceived barriers and stated compliance with the hypertension
control regimen. Interviews were conducted using the instruments
originally designed by Given and Given (1983). The purposes for
conducting this study were:

1) A great deal Of information is known about Caucasians'

experience with hypertension, whereas, little research

115

116

has been published regarding the Native Americans'
health problem Of hypertension .

2) NO known.studies are available using the Health Belief
Model (H.B.M.) with Native Americans.

3) Barriers to compliance in following a control regimen
for Native Americans with hypertension may or may not
be similar to the majority population.

4) Sociocultural factors impact the clientis perception
and therefore will influence perception of barriers and
stated compliance.

The nursing conceptual framework for this study is Kingws
theory Of goal attainment. King offers a definition of
perception as the individual's world view based on his interface
with his environment. This broad view compliments the components
Of the Health Belief Model: perceived barriers and stated
compliance utilized in this study. The major focus Of Kingws
theory is the interpersonal system which forms the foundation Of
the theory of goal attainment. “Perceptions, communication, and
transactions are the major concepts presented as fundamental for
understanding human interactionsmu" (Gonot, p. 232). The theory
Of goal attainment is an elaboration of nursing process which
provides assistance to the nurse and Client in recognizing and
resolving health problems.

King's theory and the H.B.M. were used to define the

research question “How do clients' perceptions of barriers to

117

treatment relate to their state compliance with the hypertension
therapeutic regimen?" Information from the sample subjects,
relative tO this question, was sought using the Hypertension
Patient Interview, barriers to therapy, and sociodemographic
instruments.

The 24 subjects between the ages of 37 and 83 were seen at
the Native American Center in Great Falls, Montana. All
participants met the characteristics for inclusion, which were,
in part, established diagnosis Of hypertension and a prescribed
diet or medication regimen. Confidentiality was assured and
procedures for Obtaining consent were followed. A medical record
audit was performed to designate those persons meeting the
characteristics for inclusion. .An interview was conducted to
obtain the information sought.

Unexpectedly, the hypotheses could not be tested. Only one
subject indicated non compliance to the medication regimen,
therefore, no variability in response was evident. Six (25%)
subjects indicated participation in exercise. The limited
response prevented statistical analysis Of barriers to
compliance. IDietary variables were evaluated: 11 complied with
recommendations while 7 did not comply. Regression analysis was
done with the barriers to diet and diet compliance subscales to
detect any relationships. NO significant relationships were
found. Specific extraneous variables: percent overweight,

duration of hypertension, and level of blood pressure were

118

correlated with compliance with diet variables, finding no

significant relationships. IDescriptive statistics were performed

on each of the barriers and compliance subscales.
Sociodemographic Characteristics

Sociodemographic information for the study subjects included
age, sex, marital status, income, education, household
composition and residence, tribal affiliation, dietary habits,
smoking, and alcohol consumption. .Additional clinical
characteristics of duration Of hypertension, blood pressure, and
percentage over ideal body weight were included as extraneous
variables.

3ge and Sex. The sample indicated 14 females (58.3%) and 10
males (41.7%): the group was distributed over a wide age range
from 37 to 83: the greatest number being 61 years Of age (58.3%).
Gillunvs (1983) survey included 16 through 84 year Olds with the
majority below the age of 64. In Torrey's survey of Aleuts the
mean age was 40. with individuals 18 years and Older included.

NO pattern for more males vs. females is demonstrated in the
studies Of Native Americans.

.More females (58.3%) were included in the present study than
were in Harmon's (50.6%). However, The Public and High Blood
Pressure (1981) sample had almost the same percentage Of females
(58.0%) as the present study.

Age, sex, and medication compliance could not be computed

for this sample. In Harmonfs study, low, significant

119

relationships were found between age and medication compliance,
and age and dietary barriers (Harmon, 1983).

Marital Status. In the present study, half of the sample
was married. Gillum found 41% Of his population unmarried:
possibly related to the inclusion of 16 to 24 year olds in the
study. Sixteen percent in the Gillum study were divorced, while
15% were listed as “separated.“ .No category for "separated” is
included in the present study: however, 12.5% were divorced.
Marital status was not included in the remaining studies of
Native Americans. No relationships were calculated between
marital status and the study variables. Harmon (1983) and
Cummings (1982) found that no relationships could be demonstrated
between marital status and compliance. Conversely, Nelsonks
(1980) study showed living alone to be positively related to non
compliance.

gpggm33 Consistent with Gillumfs study, in this research
the majority of the sample earned less than $11,000 annually
(58.3%). Twelve percent earned less than $3,000 annually, while
no one earned over $17,000 a year. Gillum reported 45% of his
sample earned less than $5.000 annually: 72% earned less than
$10,000 a year. Harmon (1983) reported a mean income range of
$17,000 to $19,000, which is higher than the PHBP sample, which
reported 61.6% below $10,000 annually and 19.0% above $15,000.
Studies of Native Americans demonstrate considerably lower levels

of income when compared to the majority population. OLE.

120

Services, supplies, and alternative sources Of revenue were not
specifically sought in this study: therefore, a standard of
living cannot be assumed without further investigation.)

Education. The greatest number Of subjects attended only

 

grammar school (41.6%), while 25% graduated from high school, and
8.3% graduated from college. Gillum (1983) reported that 41%
attended seventh through eleventh grades: 25% graduated from high
school: and, 4% graduated from college. Apparent in these two
studies are the lower levels of formal education attained by the
samples. Gillum reported that Native Americans had.Wmuch lower
levels Of education, income, and employment than whites in 1960.
1970, and 1980“ “L 768). Education level was not reported in
Harmonls or other studies of Native Americans.

Education was negatively correlated to compliance to diet in
this research.

Duration of Hypertension. For the sample subjects the
largest number had.been diagnosed with hypertension between one
and five years (N=11 or 47.3%). Five subjects (21JT%) had been
diagnosed for 5 - 10 years: 17.4% were diagnosed for 10 - 15
years: and 3 or 13% had been diagnosed 15 - 20 years. Harmon
categorized her subjects slightly differently, however, 54.6%
were diagnosed for 1 - 5 years, 27.7% for 6 - 11 years and 14.5%
for 15 or more years. A total of 54% of the subjects in the PHBP
survey had hypertension for 1 - 5 years, 20% for 6 - 10 years,

and 25% for more than ten years. Duration of hypertension was

121

correlated with diet compliance in this research finding no
significant relationship. .A.regression analysis was done with
duration Of hypertension to compliance with diuretics, and no
significant relationship was found. In addition, Harmon found no
relationships between the study variables and duration of
diagnosed hypertension.

Blood Pressure. The range Of blood pressure readings for
the subjects was 110 to 1682mmng systolic (mean 137.5) and
diastolic 70 to 96 mm Hg (mean 86). Correlation with barriers to
medications or compliance with medications was not done in this
study. Harmon (1983) found that diastolic blood pressure (DBP)
readings correlated in the expected direction (although not
significant) with job/therapy barriers: i.e., as barriers
increased, systolic blood pressure (SBP) also increased. In the
Harmon study, 62.9% Of the participants had SBP >141 mm Hg: and
85.40% had DBP >90 mm Hg. By contrast, 41.1% had SBP >140 mm Hg.
and 31.8% had DBP >87 mm Hg in this research. Compliance with
medication may have been over-reported, however, blood pressure
control is significantly greater in this sample. Gillum (1983)
reported the prevalence Of SBP 3140 mm Hg as 15%. and DBP 390 mm
Hg as 14% of his sample in Minneapolis.

Correlation.between level Of blood pressure and medication
barriers or compliance scores was not attempted.

Percentagg Overweight. Estimates of Obesity or percent

overweight are included in almost all studies of Native Americans

122

for both adults and Children. For this study 70.8% of the
subjects were 20% or greater than ideal body weight. Two-thirds
of Harnmnfls participants were also 20% overweight. Torrey (1979)
studied one island of Aleuts stating that the subjects were 10 -
15 pounds heavier than their neighbors (Aleuts and Eskimos) of
similar heights. There was a significant correlation in Torrey's
study between SBP and triceps skinfold (p (.05) and DBP
correlated with both triceps skinfold and weight (p (.01 for
both). DeStefano (1979) reported a significant relationship
between overweight and DBP 390 mm Hg in his study Of 640 Navajos.
Harmon (1983) found in her study that overweight significantly
correlated with less stated dietary compliance. increased
perceptions of dietary barriers, and increased perceptions of
doubt Of therapy efficacy (p. 142). Percent overweight was the

flprevailing: problem for Harmonfs sample. For this study,

 

compliance with diet did not significantly correlate with percent
overweight. Neither did exercise correlate with percent
Overweight, although the correlations were in the expected
direction (nega t ive) .

Evidence to support the high rate Of Obesity is found in
analysis of dietary habits. This sample consumed.a diet high in
carbohydrates. Foods eaten in a typical day demonstrated that
70.8% Of the sample consumed over the amount of recommended
nutrients per day. There was over consumption of salt by 25% Of

the sample.

123

Alcohol consumption was minimal as reported by this sample.
Only one subject reported drinking more than 2 ounces ethanol per
day. Rhoades (1987) stated that “Indians have the highest
frequency of drinking-associated problems of any ethnic group"
(p. 364). Four of the top ten causes Of death among Indians are
alcohol-related injuries, chronic liver disease and cirrhosis,
suicide and homicide. Gillum (1983) reported that of the 60% of
the subjects responding to the question about alcohol
consumption, 48% Claimed to be non-drinkers, the remainder
consumed alcohol at least two days per week.(amount was not
noted). Considering the nature Of this question, estimates on
consumption for this research are tentative.

Smoking. Fifty-four percent of the sample smoked cigarettes
and 29.1% smoked 20 - 29 cigarettes per day. In Gillumfs study,
70% of the respondents smoked cigarettes, 45% smoked 20 or more
cigarettes per day. However, DeStefanoflS study revealed that few
Navajos smoke (13%). and of those who smoke, 94% smoke less than
one pack per day. The 1984 Joint National Committee Specifically
states that nicotine consumption does not chronically elevate
blood pressure: however, deaths due to hypertension are more
common.among smokers, and.“smokers have a higher frequency Of
malignant hypertension and subarachnoid hemorrhage" (p. 456).

Exercise. Related also to the level Of Obesity is the

 

overall lack of participation in exercise by this sample. Only

six (20.8%) Of the sample participated in light physical

124

activity. The limited response prohibited correlation with other
study variables. Exercise was not included as a study variable
in Harnuxfis research. Gillum (1983) stated in his survey that
33% of the sample engaged in strenuous exercise in leisure and
21% at work.

Residence/Household Composition. The length of residence
within Great Falls had a wide range, 4 - 66 years: however, the
mean range was 30 - 40 years. The most meaningful information
relates to the length Of residence in the same house, which is
extremely short compared to the length Of residence in the city
(50% lived in the same house 0 - 5 years). This mobility leads
to difficulty with tracking for blood pressure management.

Traditional or Folk Medicine. Twenty percent Of the
subjects indicated they took Indian medicine to treat their
hypertension. The mechanisms of actions for the medications were
not explained. Access to the drugs was not disclosed.

Tribal Affiliation. The majority of subjects were Chippewa-
Cree. A possible explanation for this representation is that the
Native American Center Obtains its medications and IJLS.
physician and dental services through the Rocky Boy Health
Clinic. The clinic is located on the Rocky Boy Reservation
designated for the Chippewa-Cree Tribe. Most of the subjects
seen were Of mixed ethnic background, Caucasian and Native

American. Specific details regarding degree of Native American

was not asked, nor of significance to this study.

125

Summary Of Statistical Procedures

Within this section will be the results Of findings related
to the primary and secondary hypotheses. Due to the limitations
imposed by the data, hypothesis testing was not done.
Descriptive statistics were used to describe the instruments.
Correlation and regression analysis was used to describe the
relationships among extraneous variables and specific diet
variables.

Primary Hypothesis 1: There is a negative relationship
between total barriers to treatment and stated compliance with
the hypertensive regimen.

The Null hypothesis was not tested: however, Harmon found a
“moderate statistically significant“ correlation between total
perceived barriers and total stated compliance (Harmon, 1983).
Her findings are consistent with several researchers who have
addressed intangible barriers (Nelson, 1978. Kirscht and
Rosenstock, 1977, and Foster, 1978. Taylor, 1979. Janz, 1984).

Secondary hypothesis a: There is a negative relationship
between perception Of barriers concerning medications and stated
compliance scores.

Of the 19 subjects taking medications, only one was
classified as non compliant. Descriptive statistics were
calculated for this subscale. Mean scores and standard
deviations were similar for all but two questions. All

respondents strongly disagreed they would have to change too many

126

habits to take medications. The variability in response was
greatest for: "If I take my medications, I may become dependent
upon them", standard deviation 1.10.

Secondary hypothesis b: There is a negative relationship
between perception of barriers to diet and stated compliance with
a dietary regimen.

Scores for compliance to diet were calculated for 18
subjects. The variability for these scores was greater than
those for compliance with medications (with the exception of
betablockers). The subscale for perception of barriers to diet
was evaluated with descriptive statistics. The mean, standard
deviation and range were similar for each question. (Greatest
agreement of response was for: "I have time to follow the diet
the doctor ordered for me“, standard deviation .66: greatest
variability for "I can count on my family when I need help
following my diet“, standard deviation 1.13. A subset for
compliant and non compliant responses was calculated for each Of
the compliance with diet questions. ‘Variability in each Of these
scores is very small. A correlation between barriers to diet and
compliance with diet demonstrated a moderate relationship
(I =u73). Harmon also found a moderate (R.= .43) relationship
between perceived barriers to diet and compliance. Since 70% Of
the sample are Overweight, this would be an expected outcome.
Analysis of dietary habits also supports the relationship of

barriers to diet and compliance. Twenty-five percent of the

127

sample also consumed excess amounts Of salt. Several researchers
noted high salt intake in Native American populations (Gillum,
1984, Torrey, 1979. Strotz, 1973).

Secondary hypothesis c: There is a relationship between
perception of barriers concerning an exercise program and stated
compliance.

Twenty-five percent (six subjects) indicated participation
in an exercise or activity program. Descriptive statistics were
calculated for each Of the questions in the exercise subscale.
Respondents were in pgpgl agreement on four of the nine items
included in the subscale. The greatest variability was found in
response to: “my body has aches and pains after I exercise“
(standard deviation 1.33). The small number Of responses
prohibited meaningful correlation with other variables.

Secondary hypothesis d: The percent overweight will be
negatively related to compliance with diet and/or exercise
regimen. No significant relationship was found with compliance
to diet scores and percent overweight. There was a negative, but
not significant relationship, between exercise and percent
overweight, as well as, age and exercise. The correlation is in
the expected direction, iJL, as weight increases, exercise
decreases, and as a person ages, activity drops.

Secondary hypothesis e: The duration of hypertension will
be negatively related to compliance with medications and/or diet.

An analysis to test the relationship of duration of hypertension

128

to compliance with diuretics was done. NO significant
relationship was found. Compliance to diet also does not
correlate with duration of hypertension.

Secondary hypothesis f: Age, sex, and alcohol consumption
will be related to a higher blood pressure. This analysis was
not computed due to small sample size.

Secondary hypothesis 9: Consumption Of predominately high
carbohydrate or high fat foods will be positively related to
percent overweight and negatively related to compliance with
diet. .Analysis was performed for diet preferences and diet
compliance variables. Following the diet is negatively
correlated, not significantly, with foods eaten most Often.
Following the diet when away from home is correlated with diet
preference: foods liked best (.02).

Secondary hypothesis h: Lower education level will be
negatively related to compliance with medication, diet and
exercise. Education level was tested against diet compliance.
There is a negative relationship between education and compliance
‘with diet. .Both compliance variables are negatively correlated
as expected: only “following the diet when away from home“ is
significant, however.

Recommendations for Future Research

Suggestions for future research will be grouped and

discussed under three main areas: the instruments, the

population, and the design.

129

The Instruments. The instruments were originally designed
to extract data from the medical record using the hypertension
information medical record audit: to interview the subject using
the hypertension patient interview: and a self-administered
sociodemographic form and self-administered perceived.barriers to
therapy instrument. The process was altered in the present
research by using all the instruments (except the audit) in a
face-to-face interview. Each instrument will be critiqued and
recommendations for future use stated.

The hypertension patient interview tool specifically asks
for the names of medicines taken. There is no question
structured to Obtain the dosage and timing Of each prescribed
drug which would be important in judging compliance. (Knowledge
of the drug, its action, duration, and interaction with
additional medications would be a significant question to ask
subjectsJ Specific numbers of times of missed medications or
missed dosage or timing would.be a more refined judgment of non
compliance. Considering this is the first question in an initial
encounter with a culturally diverse group, it is not surprising
that compliance is over-reported. Sequencing this question to
the middle or end Of the interview may yield more meaningful
results.

The writer is in agreement with Harmon in that two items are
not “sufficient to tap the complex parameters Of dietary

compliance“ (Harmon, 1983). A generally negative response from

130

the sample was elicited by the use of the‘word “diet.“ Meal

plan is becoming a more generally accepted term (D. Brown. 1987).
Additional items were added to this instrument to evaluate food
content, preferences, patterns of consumption, and addition of
salt. Percent overweight was also included as a measurement
variable of dietary compliance. In future studies skinfold
thickness or impedence testing yielding body composition: lean
body mass to fat mass needs to be added.

The inclusion of compliance to exercise came from Harmon's
recommendations. The questions were structured similarly to
those for diet. Exercise as a therapy modality is not generally
understood in this population. For those subjects with prior
experience with cardiovascular disease this component was
familiar. Specific questions regarding the nature Of exercise
were added. .Another question to determine intensity Of exercise
would have been more helpful: “kinds" of exercise did not
directly identify intensity in this study.

Question 9 of the sociodemographic data could have been
worded to better describe drinking behavior. All three
subsections were combined to give an estimate Of ounces Of
ethanol ingested daily.

The Perceived Barriers to Therapy Questionnaire has several
negatively worded items which.are confusing to answer. For
example: “I am not interested in taking my medications

regUIarly.“ with responses of strongly agree, agree, undecided,

131

disagree, and strongly disagree. Inclusion of negatively worded
items is usually advised in construction of questions to avoid
bias (Polit and Hungler. 1983). Additionally, the educational
level of the majority of the sample may have prohibited the
subjects from responding appropriately.

The diet barrier question: "my husband/wife helps me to
follow my diet" could not be answered by 50% of the sample
because of divorce or widowhood. Therefore, "significant other"
or an appropriate term needs to be used.

Non compliance is frequently reported to be more than 60% in
low-income clinic populations (Becker, 1985). .A high level of
non compliance was not found in this study, indicating several
possible Options: 1) this group differs from all other groups:
2) the instruments do not represent intangible barriers
experienced by this sample: 3) socially-acceptable responses were
given by the subjects based on no prior contact or relationship
of trust with the researcher: 4) cultural barriers exist which
prohibit full expression of compliance or lack of compliance: 5)
tangible barriers may be of greater significance than intangible
barriers.

The next logical step would be to do an exploratory study
using an informal, indepth interview technique to learn what
types of barriers are perceived by the Native American whose
blood pressure is not in control. King‘s concepts of the

interpersonal system would give the structure to exploration of

132

perceptions of the providers as compared to perceptions Of the
Native American. Communication between.the two would need to be
analyzed to determine whether or not transaction could occur.
Communication analysis would include Observation of modes or
styles, techniques, conflicts in verbal or nonverbal behavior,
variations in inter-ethnic or intra-cultural processes and
lastly, the role Of prejudice (Kub, 1986).

Mutuality in planning and mutual compliance would also need
to be studied. An instrument to access compliance behavior would
need to be designed and pilot tested. A study Of follow-through
(tracking) and adherence to standards of care would need to be
done with the providers.

Instruments would need to be designed to define tangible
barriers: idh, access to medical services, resources for
healthy meal planning, available medications, or exercise
programs. Any study would need to be undertaken with the full
support and availability of a Native American researcher. Access
to the sample and the IJLS. system is greatly enhanced by
cooperation of a tribal member.

The Population. In addition to studying the urban Chippewa-

 

Cree, the same tribe could be studied on the reservation.
Differences in exposure to the majority population and
environmental cues may impact compliance with treatment regimens.
An attempt could be made to include more of the younger

population, which was missed in this study. ‘Utilization of the

133

Clinic on the reservation could be contrasted with utilization Of
the urban clinic. Tracking and follow-up would be indicators for
maintaining blood pressure control.

Design. Since no studies have been published on compliance
behavior in Native Americans, exploratory studies are needed to
develop the background information. Folk care practices could be
explored using Leininger's transcultural nursing concepts. The
Native Americanfs perceptions of illness/wellness could be
identified and elaborated. Orientation to goal achievement would
be useful information in understanding compliance behavior. The
process and function of the indigenous health care system could
be explored.

Experimental studies could be designed to test the impact Of
specific treatment modalities in controlling hypertension. For
example, does sodium restriction make a difference in control for
Native Americans: would a community fitness program decrease
Obesity (Heath, 1987).

3mp3ications for Advanced Nursing Practice

Recommendations for advanced nursing practice will be
discussed in relation to King‘s theory of goal attainment, which
is an elaboration and refinement of the nursing process. The
interpersonal system will provide the structural framework for
the discussion.

In order for advanced practitioners to give care to Native

Americans, cultural factors need to be considered. “Differences

134

between cultural values, beliefs and practices Of the client and
those Of health care personnel can lead to some unanticipated
outcomes in health care services“ (M. Leininger, 1984). Initial
interactions are influenced by each.person!s past and present
interaction with the environment. Assessment by the nurse is
influenced by her/his own psychosocial milieu, as well as, the
one presented by the client. Critical variables which enter into
the interaction are perception, social class role, status, and
ethnic values (King, 1981). Appreciation of these variables
allow the nurse the Opportunity to make valid assessments and
proceed from the initial communication.level to the interaction
level.

King (1981) emphasized that communication Skills and
knowledge are necessary to gather accurate information about
behaviors. The development of accurate and meaningful diagnosis
of the health care state Of the client is the outcome of this
communication. Often lacking in the process is the interaction
phase in which the client takes an active role in helping with
diagnosis or problem identification.

A serendipitous finding of this research is that the Native
American has not been an active partner in care. A provider-
dominated system promotes dependence for care and cure upon the
system. Caring behaviors for Native Americans need to be
directed toward social groups. Cultures which value kinship ties

tend to resist individualized caring measures (Leininger, 1978).

135

Transaction as defined by King is the transfer of value
which involves behaviors that are goal-directed. Essential to
this phase is cooperation and reciprocal social exchange. TO
achieve this level Of performance the nurse needs advanced skills
in counseling, education and transcultural nursing theory.
Transaction is the basis from which implementation of care plans
occurs. The strength Of the transaction is Obvious in compliance
behavior by both the nurse and client.

Compliance by the nurse is expressed by adherence to
standards Of care for the hypertensive Native American. Although
the participants' blood pressures were in control, the only
therapeutic modality used was medication. Diet and exercise
offer complex Challenges for Changing behavior, but are
recognized components for hypertension management. Essential to
maintenance of blood pressure control is follow-up. Follow-up or
the evaluation phase of the nursing process is the critical link
in the feedback loop. Without evaluation of outcomes, neither
the client nor the nurse is aware Of the outcomes of transaction.

Compliance by the Native American is expressed by active
participation in the process. Active participation is a learned
skill taught by the nurse. Group-care behaviors need to be
taught and integrated into the overall care Of the hypertensive
client. For example, Native Americans need to know: how to
recognize side effects of medications and when to report them:

how to begin and maintain a safe exercise prOgram: how to select,

136

prepare and store foods: and, how to lose and maintain a healthy
body weight/composition. Self-monitoring of blood pressure
supports the client in taking charge of his own health.
Monitoring is available at the Native American Center several
times each month: however, tracking those who are not in control
is not done.

The scope Of the nurse in advanced practice would also
include "indirect roles" as defined by the AJLA. Council of
Primary Health Care Practitioners (1985). Those roles include
educator, administrator, Clinical supervisor, consultant, and
researcher. Examples Of those roles are partially listed here:

1. Instructing and preceptoring generic students in
community health clinics:

2. Coordinator/administrator of a primary health care
agency responsible for interdisciplinary care Of Native
Americans:

3. PrOgramming continuing education for R.N.'s in the
longitudinal care of families:

4. Consultant for problem resolution of health care
delivery.

Implications for primary care for the Native American are

focused on health promotion activities which may include:

1. Blood pressure screening for all urban Native

Americans, which would include younger age groups:

137

2. Body composition screening for children and young
adults to prevent the problems associated with Obesity:

3. Education programs designed to teach nutrition using a
practical/applicable format:

4. Referral of those individuals with suspected
cardiovascular disease to cardiologists for further
evaluation:

5. Educating the general public about the significant
problems faced by Native Americans in urban
environments:

6. Exercise programs especially designed to meet the needs
of the Older population Of Native Americans, as well
as, one for the younger group:

7. Weight control program with on—going community (Native
American) support.

Recommendations for Nursing_Education

Apparent to the researcher Of this study is the lack of
published information about diverse cultural groups. Within the
past year several articles have been written by allied health
fields regarding the problems experienced by Native Americans
(Rhoades, 1987. Heath. 1987). Leininger, in a personal
communication (1984), stated that studies are being done at
certain universities regarding compliance behavior. She also
emphatically stated that the word compliance carries a negative

connotation to minority groups and is not used in the studies.

138

Leininger gave pg specific references to available studies, but
did indicate that graduate students at the University Of
Washington were in the process of studying Native Americans. In
1984, Leininger reported that four Master's Degree prOgrams and
four Doctoral Degree programs provided a research emphasis on
transcultural nursing.

The field of transcultural nursing has existed since the
1960's. However, preparation at the generic level could be
greatly expanded. Anthropological concepts could be integrated
into the psychosocial education currently available to generic
students. Social anthrOpOlogy is the study of groups and their
behaviors. Social structure which includes political, economic,
kinship relationships, cultural orientation and values needs to
be known by health care providers. Popular, folk, and
professional care systems can be introduced and explored.
Closely allied is psychological anthropology. This arena deals
with individual behavior intra and cross culturally.
Psychological anthropology entails the study of personality
development with a cultural context.

Leininger identifies “cultural imposition“ as a serious and
largely unrecognized problem in nursing (1984). Cultural
imposition refers to the nurse's tendency to impose her/his
values upon the Client without being aware of the client's
values, feelings and beliefs. This problem was expressed by the

Native American staff at the center in Great Falls through hiring

139

practices. Native American nurses are preferred, regardless of
level Of educational preparation.

Nurses in advanced practice have the opportunity to learn
culturally-specific care by participation in existing services to
Native Americans. Continuing education programs focused on
"holistic care“ are sponsored by Native American groups. Advanced
practitioners working with Native Americans need to assume the
student role in order to understand the problems critical to this
group.

Conclusions and Discussion

The main conclusions are discussed and related to
implications for future research. The research question: "How
do clients';perceptions of barriers relate to stated compliance
with a hypertension regimen?" was not answered by this research.
The hypothesis: "the client's perception of barriers to therapy
will be negatively related to stated compliance with the
therapeutic regimen! was not tested due to limitations imposed by
the data.

The one-to-one interview provided descriptive data about the
sample. Consistent with Native American studies contained in the
review of literature, hypertension is a significant problem in
this group (Gillum, Torrey, Strotz, Alfred). The rate Of Obesity
is high, participation in exercise is low, and the level of blood
pressure control is adequate.

Compliance with medication was probably over-reported for

various reasons: lack of trust relationship between the

140

researcher and client, misinterpretation of the question by the
client, and unrecognized cultural barriers. Responses to the
barriers to medication, diet and exercise demonstrated very
little variability. Intangible barriers perceived by Native
Americans may be dissimilar to the majority pOpulation. Tangible
barriers may be of more significance to this group. The sample
has a lower education level, lower income level, and is highly
mobile within the City.

A major implication derived from this research is that a
culturally-specific tool to identify barriers needs to be
develOped. Compliance needs to be interpreted by the Native
American. Health beliefs need to be identified and defined.
Transcultural nursing theory needs to be integrated into the
basic and advanced education for nurses.

§pggestions for Future Research

Information related to the barriers Native Americans
perceive would be very helpful to nurses providing Chronic
illness care. Problems with compliance need to be identified and
remedied. Further research into barriers to compliance would
provide a framework for intervention to the nurse and other
members Of the interdisciplinary team. Although extensive study
has been done using the H.B.M., no studies have been done with
Native American groups. This model could.provide many avenues
for further research. King's theory of goal attainment could
also Offer several approaches to analyze relationships between

providers and clients. A few recommendations are listed below:

141

1. Exploratory/descriptive studies to determine
perceptions of barriers to therapy (both tangible and
intangible.

2. DevelOpment and testing Of tools to determine
compliance behavior in Native Americans.

3. Exploration of "perceptual accuracy" in nurse-client
interactions (King, 1981).

4. Analysis of communication patterns which increase
mutual goal setting (between provider and client).

5. Exploration of health beliefs using an Open-ended
interview technique.

Summary
A summary and interpretation of research findings were
discussed in Chapter VI. .Recommendations for nursing practice
were presented in relation to King‘s theory Of goal attainment.
Suggestions for nursing education were based on Leininger‘s
transcultural nursing theory. Conclusions Of this study were

presented. In the final section, there are recommendations for

future research.

APPENDICES

APPENDIX A

142

143

APPENDIX A

Consent Form

Patient ID#_ _

I"
N

The study in which you are about to participate is designed to
find.out the beliefs that persons with.hypertension have about
their disease and treatment. Your participation will involve
responding to a questionnaire permitting a University Researcher
to interview you, and permitting the nurse Clinician at the
Native American Center to review your past medical records. If
you agree to participate, please Sign the following statement.

1. I have freely consented to take part in a study Of patients
being conducted by the Native American Center and the
College of Nursing at Michigan State University.

2. The study has been described and explained to me and I
understand what my participation will involve.

3. I understand that if I withdraw from the study after
originally agreeing to participate, the amount and quality
of service provided me will not change. I understand that I
can withdraw from participating at any time.

4. I understand that the results Of the study will be treated
in strict confidence and that should they be;published. my
name will remain anonymous. I understand that within these
restrictions results can, upon request, be made available to

me.

I, , state that I understand

(print name)
what is required of me as a participant and agree to take part in
this study.

Signed
(Signature Of Patient)

Date

 

APPENDIX B

144

145
APPENDIX B

Hypertension Intake Information Medical Record Audit

Patient ID#_

H
NI

How many years has the patient had diagnosed hypertension?

(WRITE IN) Years
What was the patientis average blood pressure reading during
the past six months? (WRITE IN & SPECIFY POSITION)

Blood pressure: Position: Sitting

 

Lying Standing Not recorded

 

 

What is the patient's current BP?

 

Blood pressure: Position: Sitting

 

Lying Standing Not recorded

 

 

The patient's weight at the visit at which a definitive
diagnosis of hypertension was made was: (Write in)

lbs.

 

What is the patient's current height and weight? (Write in)
Height: Weight: lbs.
What is the patient's age? (Write in)

years

 

What is the patient's sex? (Check One)
1) Female 2) Male

What specific diet has been prescribed? (Write in)

 

 

10.

146

Patient ID#_

g...
NI

ml

What medications for hypertension have been prescribed?
Please list and state prescription.

 

 

Please Check if any of the following are indicated in the
record:

Stroke

End-stage renal disease
Blindness

Cancer

Psychiatric problems
Pregnancy

Lactation

None

APPENDIX C

147

148
APPENDIX C

Hypertension Patient Interview

Patient ID#_ _
1 2

Now I'm going to ask you some questions about the medicines
your doctor has prescribed for you and about some suggestions
he/she may have given you. I'd like you to tell me what
medicines you“ve taken during the last two weeks. Let's
start with the first one you think of. What's its name?
What other medicines have you taken in the last two weeks?
List:

 

 

 

Diuretics (l):Betablockers (2):Angiotension enzymes (3):
vasodialators (4): Others (5)

 

Med. Med. Med. Med. Med.
# 1 # 2 # 3 # 4 # 5
1. DO you take (name (34) (36) (38) (40) (42)
med)
(READ CATEGORIES.
CIRCLE ANSWER IN (35) (37) (39) (41) (43)
APPROPRIATE COL.)
1. All the time, 1 1 1 l l
2. More than
half the time, 2 2 2 2 2
3. Half the time, 3 3 3 3 3
4. Less than half
the time, or 4 4 4 4 4
5. None Of the
time 5 5 5 5 5
2. In the past two weeks
have you taken the (34) (36) (38) (40) (42)
prescribed dosagg (44) (45) (46) (47) (48)
Of (name-med)
1. All the time, 1 l 1 1 1
2. More than half
the time, 2 2 2 2 2
3 3 3 3 3

3. Half the time,

4. Less than half
the time, or 4 4 4 4 4

5. None of the

time 5 5 5 5 5

149
Patient ID#_

 

1 2
Date _____
3 4 5 6 7
Form _
8
In the past two weeks
have you taken (34) (36) (38) (40) (42)
(name-med) at the (49) (50) (51) (52) (53)
recommended time Of day
1. All the time, 1 l l 1 l
2. More than half
the time, 2 2 2 2 2
3. Half the time 3 3 3 3 3
4. Less than half
the time, or 4 4 4 4 4
5. None of the 5 5 5 5 5

time

Do you use any traditional Indian medicines to treat your high
blood pressure? NO Yes If yes:

1. Describe what it is:

 

 

2. Tell how it works:

 

 

Did the doctor suggest you follow a special diet? (Check one)
NO _ Yes _ If yg_s_, go to question 6: If 339, go to
question 8.

Would you say you follow the diet as suggested (READ
CATEGORIES) (Check One)

1. All the time 4. Less than half the time,
2. More than half the time, or
3. Half the time, 5. None of the time

When you're away from home, have you followed the diet
prescribed (READ CATEGORIES) (Check One)

1. All the time, 4. Less than half the time,
2. More than half the time, or
3. Half the time, 5. None of the time

List the foods you like best.

 

 

 

1. Carbohydrates (predominantly) 3. Fats (predominantly)
2. Proteins (predominantly)

150
Patient ID#_

H
NI

List the foods you eat most Often:

 

 

 

 

1. Carbohydrates (predominantly) 3. Fats (predominantly)
2. Proteins(predominantly)

How Often do you eat: (Write in)

a) during the day? times
h) during the night? thmes

List all the foods you eat in a typical day:

 

 

 

. All nutrients included in recommended amounts

. Over consumption of certain nutrients

. Under consumption of certain nutrients

. Over and under consumption of recommended quantities

#UNH

List all the liquids you usually drink in one day.

 

 

 

 

 

 

 

 

 

1. Consumption of recommended quantities. Yes No
2. Consumption of recommended kinds of fluids. Yes No

quantities. Yes No
3. Over consumption of recommended quantities Yes No
4. Under consumption of recommended quantities Yes No
5. Consumption of liquids not advised

(alcohol). Yes NO
6. Over and under consumption of recommended

quantities. Yes No
DO you add salt to your food? (Check one)
Always : Often : Seldom : Never

If no, go to question 14.

If always or Often, Check one of the following:
1. While cooking?

2. At the table?

3. Both.while cooking and at the table?

14.

15.

16.

17.

18.

19.

151
Patient ID#_ _

I-'
N

Form

Did the doctor suggest you change your physical activity in
any way because of your high blood pressure? (Check one)
Yes NO If no, go to Sociodemographic Question-
naire. If yes, go to number 18.

Would you say you follow the exercise recommended
(READ CATEGORIES) (Check one)

1. All the time, 4. Less than half the time,
2. More than half the time, or

3. Half the time, 5. None of the time

When you're away from home, do you follow the exercise
prescribed (READ CATEGORIES) (Check one)

1. All the time, 4. Less than half the time,
2. More than half the time, or

3. Half the time, 5. None of the time

How many times per week do you participate in exercise?
(Write in)

 

How long (in minutes) do you exercise? (Write in)

 

What kind(s) of exercise(s) do you do during the day?
Please specify:

 

1. Light
2. Moderate
3. Vigorous

APPENDIX D

152

153

 

APPENDIX D
SociodemOgraphic
Patient ID#_ _
1 2
Date _____
3 4 5 6 7
Form

ml

The following questions describe general things about you.
Please answer all the questions to the best Of your ability.

1. Sex (CHECK ONE)

1. Male
2. Female

2. Age in years (WRITE IN)
years

3. What is your racial or ethnic background? (CHECK ONE)

 

 

1. White

2. Black

3. Mexican-American

4. American Indian Specify tribe:
5. Oriental

6. Other (specify)

 

4. What is your marital status? (CHECK ONE)

1. Married
2. Single, never married
3. Divorced
4. Widowed
5. Taking all sources Of money into consideration, what was

your family's total income before taxes and other deductions
for the pgst 12 months? (CHECK ONE)

1. $2.000 - $ 2.999 6. $11.000 - $12.999
2. $3.000 - $ 4.999 7. 513.000 - $14.999
3. $5.000 - $ 6.999 8. 515.000 - $16.999
4. $7.000 - $ 8.999 9. $17.000 - $19.999
5. $9.000 - $10.999 10. 520.000 Or Over

11. NO response

6.

154

Patient ID#_ _
1 2

How much schooling have you had (highest grade completed)?
(CHECK ONE)

1.

commune-wt.)

Who lives in your household, besides yourself?

None or some grammar school (Less than 7 grades
completed)?

Junior high school (9 grades completed)?

Some high school (10 or 11 grades completed)?
Graduated high school?

Technical, business or trade school?

Some college (less than 4 years completed)?
Graduated college?

Post graduate college or professional?

0
T
W
0
N
s
U)

MANY AS APPLY)

 

 

 

 

1. NO one else

2. Husband/Wife

3. Children (write in number living at home)

4. Other relatives (write in relationship: example:
mother-in-law, niece, etc.)

5. Non-related persons (write in: example: friend,
boarder)

DO you smoke cigarettes? YES NO If no, go to

question 9.

If

(JIlfiUhIIKJI'ml
o 0

yes, specify how many:

Less than 5 per day
6 - 9 per day

10-19 per day

20-29 per day

30 or more per day

|||l|

10.

155

 

Patient ID#_ _

 

 

1 2
Date _____
3 4 5 6 7
Form _
8
Do you drink alcoholic beverages? YES NO
If no, go to question 10.
1. If yes, please check what kind.
a) Beer
b) Wine
c) Hard liquor (gin, vodka, etc.)
d) Other
2. If yes, please write in how Often you drink alcoholic
beverages?
a) Cans a day a week
b) Glasses a day a week
c) Bottles a day a week
d) Other a day a week
3. If yes, please write in the amount.
a) cans a day/or week
b) glasses a day/or week
c) bottles a day/or week
d) other a day/or week
How long have you lived in Great Falls? Years
How long have you lived at the same address? Years

APPENDIX E

156

157
APPENDIX E

Perceived Barriers to Therapy

Patient ID#_

EVERYONE WHO HAS HIGH BLOOD PRESSURE HAS TO FOLLOW SOME
GUIDELINES TO HELP CONTROL HIGH BLOOD PRESSURE. SOME PATIENTS
HAVE TO TAKE PILLS (MEDICATIONS) TO HELP CONTROL THEIR HIGH BLOOD
PRESSURE.

1.

DO you take any pills for your high blood pressure?
(CHECK ONE)

1. Yes, take pills i. No, do not take pills
IF NO, GO TO QUESTION 10

If YES, please indicate the extent of your agreement with
each statement by Circling one choice for each statement.

I am confused by all the medications the doctor has given
me.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

I would have to Change too many habits to take my medications.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

If I take my medications, I may become dependent upon them.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

I am not interested in taking my medications regularly.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

158
Patient ID#_ _

g.»
N

Taking my medications interferes with my normal daily
activities.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

I must take my high blood pressure medications even if I don't
think I am getting better.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

I believe that my medications will control my high blood
pressure.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

Taking medication is something a person must do no matter
how hard it is.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

EVERYONE WHO HAS HIGH BLOOD PRESSURE HAS TO FOLLOW SOME GUIDELINES
FOR EATING (OR A DIET) TO HELP CONTROL HIGH BLOOD PRESSURE. SOME
PATIENTS MUST BE CONCERNED WITH CALORIES OR CARBOHYDRATES. OTHERS
WITH FAT OR SALT RESTRICTIONS. THE FOLLOWING STATEMENTS DESCRIBE
BELIEFS SOME PEOPLE HAVE ABOUT THE DIET THEY MUST FOLLOW. PLEASE
INDICATE THE EXTENT OF YOUR AGREEMENT WITH EACH STATEMENT BY
CIRCLING ONE CHOICE FOR EACH STATEMENT.

10.

11.

DO you follow the diet suggested by your doctor?

1. Yes Please indicate the extent of your agreement
with each statement by circling one choice for each
statement.

2. NO GO to question 19

Following my diet does not interfere with my normal daily
activities.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

12.

13.

14.

15.

16.

17.

18.

19.

159

Patient ID#_ _

1 2
Date _____
3 4 5 6 7
Form _
8
I am always hungry when I stick to my diet.
Strongly Agree Undecided Disagree Strongly
Agree Disagree
I dislike the tastes of foods on my diet.
Strongly Agree Undecided Disagree Strongly
Agree Disagree
My personal life does not interfere with my diet.
Strongly Agree Undecided Disagree Strongly
Agree Disagree

It has been difficult following the diet prescribed for me.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

I have time to follow the diet the doctor ordered for me.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

I can count on my family when I need help following my diet.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

My husband/wife helps me to follow my diet.
(N/A: Spouse not available)

Strongly Agree Undecided Disagree Strongly
Agree Disagree

Some patients follow an exercise or activity program to help
control their high blood pressure. DO you follow exercise
recommendations suggested by your doctor for your high blood
pressure?

1. Yes 2. NO
_- 1, '—

GO TO END OF QUESTIONNAIRE

20.

21.

22.

23.

24.

25.

26.

27.

160

Patient ID#_ _
1 2

Following an exercise program does not interfere with my
normal daily activities.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

I am always tired when I exercise.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

I dislike exercising on a regular basis.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

My personal life does not interfere with my exercise program.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

It has been difficult following the exercise program
recommended for me.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

I have time to follow the exercise prOgram the doctor
(nurse) suggested for me.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

My family gives me the help I need in following my exercise
program.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

My spouse helps me to stick to my exercise program.
(N/A: Spouse not available)

Strongly Agree Undecided Disagree Strongly
Agree Disagree

161
Patient ID#_ _

1 2
Date _____
3 4 5 6 7
Form _
8
28. My body has aches and pains after I exercise.
Strongly Agree Undecided Disagree Strongly
Disagree

Agree

THANK YOU VERY MUCH FOR PARTICIPATING IN THIS STUDY. IF YOU
WISH TO KNOW THE RESULTS, A SUMMARY WILL BE SENT TO YOU UPON

REQUEST.

APPENDIX F

162

163
APPENDIX F

MICHIGAN STATE UNIVERSITY

 

UCRIHS Approval
UNIVERSITY COMMITTEE ON RESEARCH INVOLWNG EAST LANSING 0 MICHIGAN 0 488244046

HUMAN SUBJECTS (UCRIHS)
258 ADMINISTRATION BUILDING
(5:7) 355-2186

 

May 5, 1987

Ms. Lynda Kendall
3435 Sixth Avenue South
Great Falls, MT 59405

Dear Ms. Kendall:

Subject: Proposal Entitled, "The Relationship Between Perceived
Barriers to Treatment and Compliance with the
Hypertensive Therapeutic Regimen"

UCRIHS' review of the above referenced project has now been completed. I am
pleased to advise that the rights and welfare of the human subjects appear to
be adequately protected and the Committee, therefore, approved this project
at its meeting on May 4, 1987.

You are reminded that UCRIHS approval is valid for one calendar year. If you
plan to continue this project beyond one year, please make provisions for
obtaining appropriate UCRIHS approval prior to May 4, 1988.

Any changes in procedures involving human subjects must be reviewed by the
UCRIHS prior to initiation of the change. UCRIHS must also be notified

promptly of any problems (unexpected side effects, complaints, etc.)
involving human subjects during the course of the work.

Thank you for bringing this project to our attention. If we can be of any
future help, please do not hesitate to let us know.

Sincerely,

“'mewe

Henry E. Bredeck, Ph.D.
Chairman, UCRIHS

HEB/jms

cc: Dr. Barbara Given

MSL' IL: an Affirmative Action/Equal Opportunity Institution

164

L nda Kendall
3435 S xth Avenue South
Great Falls, nr 59405

RECEIVED-0RD

APR ~
March 23, 1987 021987

Dr. Henry E. Bredeck
Chairman, UCRIHS

238 Administration Building
MICHIGAN STATE UNIVERSITY
East Lansing, MI _ 48824

Dear Dr. Bredeck:

I am a graduate student in the Family Clinical Nurse Specialist
Program in the College of Nursing. Under the direction of Dr.
Barbara Given, I have developed a thesis proposal to study the
relationship between barriers to treatment and compliance with
the hypertensive therapeutic regimen to be done with the urban
American Plains Indian in Montana. I am submitting the enclosed
information for review by the University Committee on Research
Involving the Use of Human Subjects.

Consideration of this project would be greatly appreciated.
Questions regarding the project may be directed to me in Montana,
or to the Nursing Graduate Office (355-6526). I may be reached
at either home or work, as follows:

Home: 3435 Sixth Avenue South
Great Falls, MT 59405
(406) 452-5458
Work: Montana Deaconess Medical Center
1101 26th Street South
Great Falls, MT 59405
(406) 791-5507.
Thank you for your time.
Sincerely,

Lynda Kendall

Enclosure

165
MODIFICATION OF THE STUDY:

THE RELATIONSHIP BETWEEN PERCEIVED BARRIERS
TO TREATMENT AND COMPLIANCE WITH THE
HYPERTENSIVE THERAPEUTIC REGIMEN:
TO BE DONE WITH THE URBAN AMERICAN PLAINS INDIANS

IN GREAT FALLS, MONTANA

1. Abstract:

A descriptive study of 50 hypertensive urban American Plains
Indians will be undertaken to determine the relationship between
perceived treatment barriers and stated compliance with therapy.
Interviews, self-administered questionnaires, and medical record
audits based on the original instruments by Given and Given:
Patient Contributions to Care: Link to Process and Outcome,
1983, will be used for data collection. The present study will
be a modification of the research: The Relationship Between
Perceived Barriers to Treatment and Compliance with the
Hypertensive Therapeutic Regimen done by Harmon in 1983. The
participants will be a convenience sample of adults receiving
primary care at the Native American Center in Great Falls,
Montana.

Descriptive statistics will be used to analyze the
sociodemographic and audit data. Pearson r (product moment
correlations), multiple and step-wise regression techniques will
be used to analyze the relationships between perceived barriers
to treatment and stated compliance with prescribed diet, exercise
and medication. Extraneous variables, eg., alcohol consumption,

income and other client descriptors will be entered as barriers

166

to compliance in a step-wise regresSion analysis. .A
comprehension of the nature and significance of barriers will
afford the health professional opportunities and options to
improve compliance. 4

2. Subject Population:

The subject population will be composed of a voluntary
sample of accessible hypertensive clients under the care of
local physicians and Indian Health Service physicians and the
Native American Center in Great Falls, Montana. The sample will
include Plains Indians of several tribes residing in Great Falls'
city limits: able to speak and comprehend the English language:
have an established medical diagnosis of essential hypertension;
18-65 years of age: no evidence of stroke, end-stage renal
disease, blindness, cancer, psychiatric problems, pregnancy or
lactation: and on a prescribed medication and/or a dietary
regimen. No other studies are available at this time that deal
with compliance issues in Native American groups.

Recruitment of subjects will be done with the assistance of
the nurse clinician at the Native American Center. The initial
contact with the patient will be done by the nurse clinician
at the Native American Center. .A follow-up telephone call by the
researcher will be done to further describe the study. After
written consent to participate is obtained from the patient by
the researcher, a medical record audit will be done by the
nurse clinician at the Native American Center to determine

apprOpriateness for inclusion in the study. The Center has a

167

local medical advisor and a Board of Directors. The Board of
Directors has given written consent to conduct the study.
3. Risk-Benefit Ratio:
No physical risks would be encountered with this study.
Psychological Risks. Some questions seeking specific
behaviors: alcohol consumption, dietary habits, and cultural
medicines may be viewed as encroachment upon privacy. Alcohol
consumption is included in sociodemographic data which seeks a
written response, possibly leaving the participant more free to
decline to answer.

Social Risk. The study is being conducted by a non-Indian,

 

which may pose sociocultural misunderstandings. Disclosure of
Native American behavior may not be socially acceptable within
certain tribes. This approach allows the participant the
greatest freedom to respond and maximum control over the amount
and type of information disclosed.

Benefits. Specific barriers to compliance may be identified
which would facilitate an accurate assessment and resolution of
problems with.aompliance; Cross-cultural communication.may allow
for more appropriate care for hypertensive Native Americans. The
individual participant may become aware of actual and potential
barriers which impede complying with a therapeutic regimen. The
obvious overall benefit is that the physical risks of
hypertension may be reduced by adherence to a medical regimen.

4. Consent Procedures:
Initially subjects will be contacted by the nurse clinician

at the clinic to obtain the individual's interest and give an

168'

overview of the project. After the initial contact, a telephone
call will be made by the researcher to the individual to explain
the research project, to describe theinstruments to be used, the
time necessary to complete the instruments and to obtain verbal
consent to participate» If the participant verbally agrees to
enter the study, the individual will be asked to make an
appointment to come into the Native American Center to sign a
written consent form, participate in an interview and to complete
the questionnaires. The participant is free to leave the study
at any time with the guarantee that neither the quality nor
amount of service provided.by the Native American Center would

change.

APPENDIX G

169

170

APPENDIX C

901/10.» gm en'can Gen/er .712 corp ora/eof

700—1001 Street South
P-O- BOX 2572 ' American Center
Great Falls, Montana 59403 Natiggard Approval

Ph. (406) 761-3165

SELF DETERMINATION THROUGH EDUCATION

August 27, 1985

Ms. Linda Kendall, R.N.
3435 6th Avenue South
Great Falls, Montana 59405

Dear Ms. Kendall:

Please be advised that the NACI Board of Directors voted un-
animously to allow you to conduct your research project relating
to Native Americans and hypertension.

Since very few studies of this nature have been conducted in
relation to Urban Indians , we are, naturally, very interested in
the final outcome; and, therefore, request that a copy of the
study thesis be made available to our organization.

'Ihank you for yom‘ interest in the health and welfare of
our Native PeOple.

Sincerely,
”(154:3 re
Executive Director
jm

cc: NACI Board Members

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