IHESIS

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thesis entitled

THE RELATIONSHIP OF PERCEIVED
ILLNESS SEVERITY AND COMPLIANCE
WITH THE HYPERTENSIVE THERAPEUTIC REGIMEN

presented by
Phyllis Britto Brooks, R.N., CCRN

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Masters of Sciencfiegree in Nursing

 

 

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THE RELATIONSHIP OF PERCEIVED

ILLNESS SEVERITY AND COMPLIANCE

.- -_‘PN¢l-'§Qgh “.—

WITH THE HYPERTENSIVE

THERAPEUTIC REGIMEN

_,A-——--

BY
Phyllis Britto Brooks, R.N., CCRN 3

..~\. . ‘r'.... ~.;_-'- .m -\L§l ~

A THESIS

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

...I\‘..'_...._.__ -._.._ .

MASTER OF SCIENCE IN NURSING

College of Nursing

{lira-gull]. l 1 .51 L1 \txiilulll.f.. 1,

 

PHYLLIS BRITTO BROOKS
1983

Copyright by

 

ABSTRACT

THE RELATIONSHIP OF PERCEIVED ILLNESS
SEVERITY, AND COMPLIANCE WITH THE
HYPERTENSIVE THERAPEUTIC REGIMEN

BY

Phyllis Britto Brooks, R.N., CCRN

Hypertension is a chronic illness which constitutes a
major health problem in the United States today.
Compliance with treatment is of vital importance to prevent
heart disease, stroke and kidney failure. This descriptive
study based on data from a large study was designed to
identify hypertensives' perceptions of illness severity,
and barriers to treatment, as related to stated compliance
with the therapeutic regimen. Data were collected on 158
hypertensives by means of a self-administered instrument
and client interview.

Using Pearson Moment Correlation Coefficients,
statistically significant relationships between comparative
seriousness and medication compliance (r = .2568, p<:
.001); stated compliance with exercise (r = .2861, p<;
} .05); perceived illness severity barriers to treatment, and
stated compliance (r = .4524, p<: .001) were determined to
L exist in the sample. These findings could provide
guidelines for nursing interventions to develop a mutual

i and effective therapeutic plan for hypertensive clients.

 

 

 

 

This thesis is dedicated to

nurses and hypertensive clients.

T'_—__—__—==_——‘

ACKNOWLEDGMENTS

Sincere thanks and appreciation is extended to Barbara
Given, R.N., Ph.D., and Charles W. Given, Ph.D., for use of
their data, because without their devoted efforts and
willingness to share their statistics this research could
never have been successfully completed.

I am also grateful to my thesis committee members Gwen
Wyatt, R.N., M.S.N., Judy Longworth, R.N., M.S.N., and Dr.
Barbara and Charles Given, for their guidance and support
throughout the completion of this study. To Rob Hymes who
acted as a statistical consultant I wish to convey my
sincere appreciation. To Elaine Harmon, my thesis partner,
your support and enthusiasm proved to be invaluable.
Sincere thanks to Vicky and Richard Wheeler for the typing
of the manuscript and concern for perfection.

Most special appreciation is reserved for my husband
Frank for his love and support, for encouraging me never to
stop until the completion of this study. To my son Frank,
thank you for caring and understanding of the many new
roles I have acquired through growth and knowledge...Again,

a special thanks to everyone.

iv

 

 

TABLE OF CONTENTS

Page
LIST OF TABLES .......................................... viii
LIST OF FIGURES ......................................... ix
Chapter
I. THE PROBLEM

Introduction ................................... 1
Background ..................................... 2
Hypertension Defined ........................... 3

Efforts to Control Hypertension ................ 5
Compliance in Hypertension Control ............. 7
Problem Statement .............................. 9
Definition of Concepts ......................... 10
Hypotheses ..................................... 14
Description of Sample .......................... 17
Assumptions .................................... 17
Limitations .................................... 18
Overview of Chapters ........................... 19

II. CONCEPTUAL FRAMEWORK

Introduction ................................... 20
Pathophysiology of Hypertension ................ 20

Health Belief Model ............................ 25

Stated Compliance With The Therapeutic Regimen. 31

Nursing Theory ................................. 34
Nursing Intervention ........................... 39

Summary ........................................ 41

III. REVIEW OF THE LITERATURE

Introduction ................................... 43
Hypertensive Treatment ......................... 43
Compliance As A Health Care Concern ............ 49
Compliance Measures .......................... 52
Compliance with Medications .................. 57
Compliance With Diet ......................... 63
Compliance With Exercise ..................... 74

Health Belief Model ............................ 79
Perceived Illness Severity ................... 88
Perceived Barriers to Treatment .............. 93

Chapter Page
Nursing Intervention .......................... 102

IV. METHODOLOGY AND PROCEDURES

Design ........................................ 107
Hypotheses .................................... 108
Operationalization of Study Variables ......... 109
Perceived Illness Severity .................. 109
Perceived Barriers to Treatment ............. 110
Stated Compliance ........................... 112
Extraneous Variables and Socio-Demographic
Data ...................................... 112
Sample ........................................ 113
Development of Instruments .................... 115
Pretest of Instruments ...................... 116
Reliability and Validity .................... 116
Research Interviewers ......................... 118
Data Collection Procedures .................... 119
Sites ....................................... 119
Collection of Data .......................... 119
Human Subject Protection ...................... 121
Statistical Analysis Data ..................... 121
Summary ....................................... 123
V. DATA PRESENTATION AND ANALYSIS
Overview ...................................... 124
Sample Characteristics ........................ 124
Socio—Demographic Variables ................... 125
Reliability of Instruments .................... 127
Data Presentation of Inferential Statistics... 131
Primary Hypothesis 1 ........................ 131
Secondary Hypothesis 1a ..................... 133
Secondary Hypothesis 1b ..................... 133
Secondary Hypothesis lc ..................... 134
Secondary Hypothesis ld ..................... 134
Secondary Hypothesis 1e ..................... 135
Secondary Hypothesis 1f ..................... 135
Secondary Hypothesis 1g ..................... 136
Secondary Hypothesis 1h ..................... 136
Secondary Hypothesis li ..................... 137
Primary Hypothesis 2 ........................ 137
Extraneous Variables .......................... 138
Other Findings ................................ 140
Summary ....................................... 141

VI. SUMMARY AND CONCLUSIONS

Overview ..................................... 142

Socio-Demographic and Extraneous Variables... 142

Statement of the Research Question ........... 151
vi

 

 

A

 

 

Chapter Page
Research Hypotheses ......................... 151
Primary Hypothesis 1 ...................... 151
Secondary Hypothesis 1a ................... 152
Secondary Hypothesis lb ................... 155
Secondary Hypothesis 1c ................... 156
Secondary Hypothesis 1d ................... 157
Secondary Hypothesis 1e ................... 158
Secondary Hypothesis 1f ................... 159
Secondary Hypothesis 1g ................... 161
Secondary Hypothesis 1h ................... 162
Secondary Hypothesis 1i ................... 162
Primary Hypothesis 2 ...................... 163
Other Findings .............................. 165
Implication for Nursing Practice ............ 166
Implication for Nursing Education ........... 171
Recommendations for Future Research ......... 174
Summary ..................................... 176
BIBLIOGRAPHY ........................................... 177
APPENDICES
Appendix
A. Contact Letter ................................... 188
B Consent Form ..................................... 189
C. Instruments ...................................... 190
D The Relationship Between Age, Income, Duration of
Hypertension and Study Variables (Using Pearson
Product Moment Correlations) ................... 203

The Relationship Between Systolic and Diastolic

Blood Pressure and Study Variables (Using Pearson204

Product Moment Correlations) ...................

The Relationship Between Sex, Marital Status, Race,
Overweight and Study Variables (Using Point
Bi-Serial Correlations) ........................

205

 

LIST OF TABLES

Page

Distribution and Percentage of Subjects by

Demographics and Extraneous Variables ........ 128
Mean Scores and Reliability Coefficients

of Scales .................................... 132
Correlation Values Between Subscales and

Compliance ................................... 139
The Relationship Between Age, Income, Duration

of Hypertension and Study Variables (Using

Pearson Product Moment Correlations .......... 203
The Relationship Between Systolic and Diastolic

Blood Pressure and Study Variables (Using

Pearson Product Moment Correlations) ......... 204
The Relationship Between Sex. Marital Status,

Race, Overweight and Study Variables (Using

Point 31- Serial Correlations) ................. 205

viii

 

 

 

LIST OF FIGURES

Figure

1.

Schematic Representation of Hypotheses... ..... .

Health Belief Model As Modified For Chronic
Illness ...... ................................

King's Human Interaction Model.................

Combined Model For The Hypertensive Client.....

Page
16

30
38
,40

 

 

 

 

CHAPTER I
THE PROBLEM
Introduction

There is a general agreement among health care
providers that hypertension is a major contributor to heart
disease, stroke, and renal failure (Working Group, 1979).
These serious illnesses may be prevented if blood pressure
is brought toward normal, by compliance with therapeutic
treatment.

The purpose of this study is to determine which
variables significantly influence the hypertensive client's
compliance with the therapeutic regimen. In particular,
two components of the health belief model are examined:
perceived illness severity, and perceived barriers to
treatment, as they relate to compliance with therapeutic
treatment of the hypertensive client.

The data utilized in the study were collected as part
of a federally funded research project, Patient
Contributiongr to Care: Link to Proqgggg and Outcgmg
(SROINUOO662, 1982), B. Given and C.W. Given, co-principal
investigators. Additionally, portion of this research was

conducted in collaboration with Harmon (1983).

 

Background

Hypertension is a chronic illness with major
complications of stroke, coronary artery disease and renal
failure. Hypertension has been cited as the most common
cardiovascular disease, and one of the greatest public
health problems, accounting for approximately 50% of all
deaths (National Heart, Lung and Blood Institute, 1980).
Kannel (1978) reported on data from the Framingham study
which indicated hypertension as the dominant contributor to
cardiovascular disease. Degrees of elevated blood pressure
have been associated in direct proportion to cardiovascular
events. According to Kannel, (1978) adequate and
continuous treatment significantly prevents heart disease,
stroke and renal failure.

Hypertension has been acknowledged as a significant
health concern by the National Heart, Lung and Blood
Institute (High Blood Pressure Control, NHLBI, 1982). Over
one—fourth of the United States' population, approximately
60 million Americans suffer from elevated blood pressure,
with 35 million having readings greater than 160/95mm Hg,
and 25 million with readings ranging from 140/90 to
160/95mm Hg. The NHLBI supports the Framingham findings of:
(1) Hypertension as the most significant contributor to
stroke, the third leading cause of death in the United
States. (2) Hypertension as a major cause of accelerating

atherosclerosis, a disease contributing to 1.25 million

 

cases of heart attack per year. (3) Elevated blood
pressure being directly proportioned to the incidence of
renal failure. Health care cost for hypertension is
estimated at approximately eight billion per year,
including lost wages and productivity without taking into
account the toll of suffering (Levy, 1982).

According to the NHLBI report of the 35 million of
hypertensives with pressures greater than 160/95mm Hg,
approximately two—thirds know it, and 80% of the two-thirds
have their blood pressure checked regularly. Only 24% of
the 35 million have their blood pressure in control, with
24% being aware of their illness, yet not on treatment, 20%
being inadequately treated, and 32% still unaware of their
illness (High Blood Pressure Control, 1982).

In the-State of Michigan, there are 1.8 million adult
hypertensives which represents 28% of the adult
population. Only 46% are aware of their illness, and of
this number, half are uncontrolled. It is therefore
estimated that 23% of total hypertensives have their blood
pressure in control (Michigan Department of Public Health,

1982).
Hypertgpsion Defined

The World Health Organization (WHO) 1973 has adopted
the following definition of hypertension. The term
hypertension is synonymous with essential hypertension, and

is designated by physiological changes and characteristics

 

which ultimately leads to elevation of diastolic and
systolic blood pressure, anatomical changes in the vascular
tree, with functional impairment of the involved tissues.
Hypertensive disease is considered to be a clinical entity
in which vasoconstriction, elevated blood pressure and
vascular sequelae which is initiated by an unknown
pressor. The WHO criterion for hypertension is a systolic
and diastolic pressure 160/95mm Hg. Kaplan (1978) refers
to hypertension as a sequelae of arteriolar changes that
occur during the progression of the disease. As Kaplan
(1978) has indicated, the definition of hypertension by the
WHO is controversial, since others have suggested that
hypertension is not a specific disease with an arbitrary
dividing line separating it from normal. According to Egg
1980 Rgport of thg: Joint National Committee on Detgction,
Evaluation, and Treatment of High Blood Pressure
stratification of hypertension is as indicated: diastolic
pressure of 90-104mm Hg = mild, 105-114mm Hg = moderate,
115mm Hg = severe. Borhani (1981) indicated that "mild"
hypertension is a misnomer because even with low levels of
hypertension, there is a relationship to cardiovascular
disease. Thus, treatment of mild hypertension is
efficacious in decreasing mortality and morbidity. A large
number of hypertensives have a diastolic pressure of
90—100mm Hg. According to Borhani, successful treatment of
this group has a potential to decrease or eliminate 42%

mortality rate associated with hypertension.

 

 

5
In this research, hypertension out of control is
operationalized as a systolic pressure Z>140mm Hg and/or a
diastolic 95mm Hg on two occasions at least two months
apart, which is the standard of practice (Chobanian, 1982,

Given, Given, p. 61, 1982).
Coordination of Efforts to Control Hypertension

In 1972 the National High Blood Pressure Education
Program (NHBPEP) coordinated by the NHLBI, sponsored
efforts to (1) provide education to health professionals
and the public on hypertension, and (2) to mobilize
resources to detect, control and evaluate hypertension
(Guidelines for Education Nurses in High Blood Pressure
Control, 1981). Cunningham and Hill 1982 postulate that the
declining rate of hypertension coincides with, the
activities of the NHBPEP established in 1972. Activities of
the NHBPEP included establishment of task forces
representing various professional groups. In 1975 the
NHBPEP, in collaboration with the American Nurses'
Association and the National League of Nurses, sponsored a
Task Force on the Role of the Nurse in High Blood Pressure
Control. According to Grim, Grim (1981) their goal was to
review nursing role and delineate education necessary to
fulfill that role.

Nurses are the largest health professional group in
the United States, and are invaluable resources in

delivering health care services to those with

,.',".‘...

‘r——_—_Z—_‘

6

hypertension. Nurses provide the major portion of direct
patient care in a wide variety of health care settings.
Therefore, nurses have frequent opportunities for
detection, follow—up, and education concerning
hypertension. With specialized education, nurses can
assume major responsibility in primary care of those with
hypertension. Nurses are well qualified to monitor chronic
illnesses, to evaluate prescribed therapy, and to provide
psychosocial support and health education. One of the
major challenges is accomplishing long-term control which
hinges on compliance with a carefully tailored regimen
(Grim, Grim, 1981; Guidelines for Educating Nurses in High
Blood Pressure Control, 1981).

Specific Task Force recommendations that were
developed .for nurses were: (1) client and family
understanding of hypertension and prescribed treatment.
(2) Successful adjustment of client and family to diagnosis
and treatment. (3) Assumption of responsibility for self

care within the client's psychological and physical

 

limits. (4) Achievement of controlled blood pressure in
accordance with the medical goal. (5) Decreasing side
effects of medications. (6) Limitation of target organ
damage. Specific objectives were designated by the Task
Force to support and accomplish their recommendations. The
objectives were: (1) Greater emphasis on hypertension in
nursing curricula, and continuing education programs. (2)

Preparation of a larger number of nurses to provide primary

 

 

 

 

 

 

 

7

care for hypertensive clients. (3) Research relative to

the care of hypertensive clients (Grim, Grim, 1981).
Compliance in Hypertension Control

The National High Blood Pressure Education Program has
tasks of great magnitude to accomplish before achieving its
goals concerning hypertension. A major task is detection
of high blood pressure in those presently unaware of their
condition. A second task is to achieve adequate blood
pressure control for those individuals aware of their
diagnosis. Statistics reveal that adequate control of
hypertension has not been achieved for most of those with
high blood pressure although highly effective and
relatively safe therapy has been developed (Chobanian,
1982).

Baile and Gross (1979) state that noncompliance with
antihypertensive therapy is one of the most common problems
in failure to control hypertension. Webb (1980) agrees
poor compliance presents a particularly difficult challenge
in treating hypertension since only about 50% of
hypertensive clients comply with their prescribed
treatment. Noncompliant clients with uncontrolled
hypertension pose a serious health threat due to the
probable vascular consequences. Adherence with long—term
treatment is essential to reduce risk of heart disease,
stroke, and renal failure (Levy, 1982). Thus the compliance

issue has been found to be of great importance in the

 

 

control of hypertension.

Compliance with therapy is the extent to which clients
follow recommendations of health providers. Compliance
behavior, as such, is a human response to illness and
treatment. Professional nurses, by definition, provide
diagnosis and treatment of human responses to health
problems (American Nurses' Association, 1980). Therefore
client compliance is a relevant phenomenon for nursing
research, and according to the NHBPEP Task Force,
hypertension represents a pertinent issue for studying
methods to improve client compliance.

Past researchers have studied a multitude of factors
for their possible relationship to compliance behavior.
Examples of factors studied are: disease characteristics,
referral process, clinic setting, client—provider
interactions, and features of the therapeutic regimen
(Haynes, 1979; Hulka, 1979).

Becker et a1. (1979) examined correlations between
client perception factors and compliance behavior. Client
perception factors include perceptions of disease threat,
such as susceptibility to the disease and seriousness of
the disease, and perceptions of therapy benefits and/or
barriers. This group of factors about perceptions has been
placed in a formulation called the health belief model
(Becker, 1974; Becker et a1., 1979). The total or partial
health belief model has been used as a basis for

considerable study of client compliance with treatment

(Andreoli, 1981; Green et a1., 1982; Loustau, 1979;
Stunkard, 1981; Watts, 1981).

The health belief model was developed to describe how
a set of beliefs an individual has about an illness and its
treatment influences the person's decision to take a
health—related action. Therefore the model has value in
predicting client compliance. According to the model, an
individual's readiness to take action with regard to a
given health condition is based upon: (1) his/her perceived
susceptibility to the illness and the probable severity of
the consequences of that illness (the symptoms, disability,
and sequelae); (2) the perceived benefits from taking
action as compared to the perceived costs and/or barriers
to taking action (the financial and psychosocial costs of
recommended action); and (3) the gpgg to action which
trigger the behavior (Becker, 1974; Rosenstock, 1974).

From this complex health belief model two components,
perceived illness severity and perceived barriers to
treatment, have been selected for study. Although
components of the model are hypothesized to be
interrelated, it is beyond the scope of this research to

address all possible relationships.
Problem Statement

The specific problem is: ng do cligpt's perceptions

 

of illness severity relate to stated compliance with the

hypertensive therapeutic regimen? This problem warrants

 

A

 

 

10

further study, as it is vitally important for the health
provider to understand health-related behavior.
Understanding of such behavior is essential to obtain the
cooperation and participation of clients in their carrying
out major implementation of the therapeutic regimen.

The health belief model provides one approach to the
understanding of health-related behavior. The approach
implies that attempts to influence the behavior of clients
must be based on better knowledge of client health beliefs
and perceptions. For optimal health outcomes, problems
which relate to compliance behavior must be appropriately

overcome.
Definition of Concepts

The study variables include perceived severity of
illness, perceived barriers to treatment, and stated
compliance with the therapeutic regimen.

Perception refers to the individual's view of reality:
the awareness of persons, objects, and events (King, 1981,
p.20). Although people share common experiences,
individuals differ in what they select for their perceptual
milieu. Sensory and intellectual processes vary among
persons. The input which is sensed and assimilated is
related to past experience, to the concept of self, and to
biological heritage. As processes and contexts vary, so do

perceptions of common experiences.

WWW“

 

 

11

Nursing theorist King (1981, p. 24) 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, represents one's image of
reality, and influences one's behavior." Where as Ajzen
and Fishbein (1975) suggest that perceptions relate
activity with outcome. How a person views a particular
situation is influenced by experience, past memory and
attitude, this will effect whether certain behavior will
lead to a desired outcome or goal. According to Ajzen and
Fishbein (1980, p. 5) theory of reasoned action "people
consider the implications of their actions before they
decide to engage or not engage in a give behavior."

Client percgption of severity of illness is defined as

 

the expressed beliefs and attitudes of the client
concerning the effect of the condition upon present and
future health states (Given, Given, 1982, p. 27). The
dimensions included are (l) perceived comparative
seriousness of hypertension, (2) perceived psychosocial
effects of hypertension, and (3) perceived impact of

hypertension on work.

Comparative seriousness is the client's
perception of hypertension compared to other

worries, problems, and conditions such as
diabetes and pneumonia.

Perceived pgychosocial effects are the
social changes, and the extent of interference
with social roles, which are related to having
hypertension. Such effects may be changes in

12

type or frequency of entertainment, shopping,

recreation,' walking, visits with friends,

isolation Within the family, household chores,
family responsibilities, emotions, and sleep.

The perceived impact on work refers to illness/work
conflicts and the difficulties hypertension may present on
the job. Such difficulties may be absenteeism,
irritability, job change, or the extra effort required due
to the hypertensive condition.

The Joint National Committee on Detection, Evaluation
and Treatment of High Blood Pressure (1981) states that
clarification of clients' attitudes and perceptions about
high blood pressure may be helpful for long term compliance
with therapy. The hypertensive symptoms themselves often
do not impose awareness and changes in life style until
organ damage results (Haynes, 1980). Therefore it is
important to make sure the client understands the
asymptomatic nature, impact, and consequences of having
hypertension (The 1980 Report of the Joint National
Committee on Detection, Evaluation and Treatment of High
Blood Pressure).

For this study, client percgption 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, Given, 1982, p.
27; YOOS, 1981). The following dimensions of barriers to
implementation of therapy are addressed: (1) beliefs about

difficulties with medications, (2) beliefs about

 

l3

difficulties with changes required for diet, (3) disbelief
or doubt concerning efficacy of therapy, and (4) beliefs
about effects of job on therapy. Perceptions about
treatment were selected for study to address the need for
new patterns of behavior required for treatment, and to
address beliefs in efficacy of treatment.

Beliefs about difficultigg with mgdicationg

refer to the confusion of taking a number of
medications, the habit changes required, the

concern over medication dependency, the
disruption of daily activities to take
medications, and the necessity of continued
medication.

Specific beliefs about difficultigg with
Eggnges rgguired for diet 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.

Disbelief or doubt concerning efficagy of
therapy includes belief that treatment is
inappropriate or not worth it, confusion by
advice from a number of health providers,
disbelief in the doctor, and the belief that any
treatment would be of little benefit.

Client pgliefs about effgpts of job on
therapy include job interference with taking
medications, job interference with following a
diet, job interference with losing weight and
difficulty following prescribed work habits.
Recommended treatment of hypertension, while safe, has

the disadvantage of attendant life style changes
(Haynes, 1980). Baile and Gross (1979) suggest that inquiry
should be made about the meaning of hypertensive treatment

to the patient, and its impact on job status and behavior

change, for the purpose of identifying obstacles to

 

r————————:

14

therapy. Therefore this research is directed toward
beliefs about the intangible barriers to treatment:
difficulties incorporating required changes into life
style, and doubt or nonconviction concerning efficacy of
treatment.

Stated compliangg with the 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, Given, p.28,
1982). In this research measures of client compliance are
based on client report of compliance with medication, diet,
and exercise recommendations. The statement of compliance
is elicited during the research interview with questions
concerning: if medication was taken, if prescribed dosage
was taken, and if medication was taken at the recommended
time of day. Clients responded using a five-point scale
ranging from all the time to none of the time. Similar
questions were asked to elicit stated compliance with diet

and exercise.

Hypotheses

Primary hypothesis 1. There is a relationship between
client perception of illness severity and stated compliance

with the therapeutic regimen.

 

 

 

Secondary hypotheses:

a. There is a relationship between perceived
comparative seriousness and stated compliance with a

medication regimen.

b. There is a relationship between perceived
comparative seriousness and stated compliance with a

diet regimen.

c. there is a relationship between perceived
comparative seriousness and stated compliance with an

exercise regimen.

d. There is a relationship between perceived
psychosocial effects of hypertension and stated

compliance with a medication regimen.

e. There is a relationship between perceived
psychosocial effects of hypertension and stated

compliance with a diet regimen.

f. There is a relationship between perceived
psychosocial effects of hypertension and stated

compliance with an exercise regimen.

g. There is a relationship between percieved impact
of hypertension on work and stated compliance with a

medication regimen.

 

 

 

 

16

h. There is a relationship between perceived impact
of hypertension on work and stated compliance with a

diet regimen.

i. There is a relationship between perceived impact
of hypertension on work and stated compliance with an

exercise regimen.

Primary hypothesis 2. There is a relationship among client
perceptions of illness severity and barriers to treatment
upon stated compliance with the therapeutic regimen.

Primary hypothses 1 and 2, are schematically represented in

Figure 1.
Perceived Perceived
severity barriers
1. 2.

compliance—
medication
diet
exercise

Figure 1. Primary Hypotheses

Extraneous variables examined for possible

relationships to stated compliance are: age, sex, income,
marital status, blood pressure, percentage overweight, and

duration of hypertension.

T————————...

17

Description of Sample

The sample employed in this study were 158
hypertensives who voluntarily agreed and met the following
criteria: (1) were aged between 18 to 65 years; (2) were
medically diagnosed as having essential hypertension; (3)
were able to read and write the English language; (4) were
not documented as having a stroke, end stage renal disease,
blindness, cancer, psychiatric problems, and pregnancy or
lactation; (5) were on a prescribed diet 25 medication

regimen for control of hypertension.

Assumptions

The following assumptions are made in this research.

1. Compliance with a therapeutic regimen is a health
behavior that will improve present and future health
stated.

2. Health-related perceptions affect compliance and other
health-related behavior.

3. The concepts of perceived illness severity, 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 hypertensive clients.

 

fi — I “
18

5. The testing instruments are sensitive to the concepts

of perceived severity of illness, perceived barriers to

treatment, and stated compliance.

6. The sample is representative of hypertensive clients

receiving care in primary care sites.
Limitations
This research has the following limitations:

1. Subjects who agreed to participate in this study may be
different from those who refuse. Therefore it is possible
that research findings are not representative of all
hypertensives in primary care settings.

2. The type of compliance assessed is limited to
medication, diet, and exercise.

3. The one point in time 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.
4. Different, individual perceptions of the meanings of
answer choices may have affected individual responses.

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

6. All possible factors affecting compliance are not
addressed in this study. Findings may be due, in
actuality, to a interrelatedness of other factors with the
ones identified. Examples of factors which are not

included are: other aspects of the health belief model,

 

 

 

 

l9

provider-patient relationships, developmental stages, and

social support.
Overview of Chapters

Presentation of this research is organized into six
chapters. In Chapter I the introduction, the background
and purpose of research, the problem statements, definition
of terms, the hypotheses, and the assumptions and
limitations of the study were presented. In Chapter II the
concepts and relevant theory are integrated into a
conceptual framework upon which the study is based. A
review of the literature is presented in Chapter III for
the purpose of linking this study with the work and ideas
of others concerned with hypertension and compliance with
treatment. Included in Chapter IV are the methods of
research: design, instrumentation, procedures and human
rights protection. Data and analyses are presented in
Chapter V. A summary and discussion of findings,

implications, and recommendations comprise Chapter VI.

 

 

 

CHAPTER II
CONCEPTUAL FRAMEWORK
Introduction

This chapter was prepared in collaboration with Harmon
(1983). The framework presented in this chapter includes a
discussion of hypertension pathophysiology, the health
belief model, the dimensions of nursing theory as delineated
by King (1981), and the relationship of these concepts to
nursing care of the hypertensive client. The concepts of
perceived illness severity, perceived barriers to treatment,
and compliance behavior by the hypertensive client are to be
integrated within the larger context of nursing theory, and
the health belief model. The purpose of this study is to
describe the relationships of these concepts in a conceptual
framework to determine which variables significantly
influence the hypertensive client's compliance with the

therapeutic regimen.

Pathophysiology of Hypertension

There are two main classifications of hypertension:
primary/essential hypertension, in which the cause is
unknown, and secondary hypertension in which there is a
defined etiology. I

Ninety to 95% of the hypertensive population have

essential hypertension (Chobanian, 1982; Kaplan & Liebeiman,

20

 

 

 

21

1978; Kochar, 1981; Marcinek, 1982). As stated in Chapter I,
hypertension is a major health problem with approximately 60
million Americans having the illness. Control of
hypertension may be accomplished through following a
therapeutic regimen, which is known to reduce the associated
morbidity and mortality (Cummings & Kirscht et al., 1982;
Heine,1981; Hershey et al., 1980). This study will focus on
essential hypertension which accounts for the majority of
hypertensive clients seen in primary care sites.

There are many factors and organs responsible for
normal regulation of blood pressure. Some factors that are
involved are cardiac output, peripheral resistance, blood
volume, and blood viscosity. Body organs that are involved
in regulation are: the sympathetic nervous system, the
kidneys and the adrenals (Chobanian, 1982).

Cardiac output is defined as the heart rate times the
stroke volume, the amount of blood ejected by the left
ventricle into the aorta per minute. The average cardiac
output is approximately five liters per minute. Peripheral
resistance is the vascular capacity, the muscle tone in the
media of the arteriolar. Blood volume, which is the amount
of circulating blood, can also affect the blood pressure by
the exertion of pressure on the vascular walls. Blood
viscosity also affects blood pressure: when red blood cells
are increased, this causes subsequent elevation in blood
pressure. In summary, blood pressure equals cardiac output

times peripheral resistance, (BP = C0 X PR) (Kochar, 1981).

A

 

 

22

The sympathetic nervous system's role in the regulation
of blood pressure is performed by increasing sympathetic
activities which in response increase the secretion of
catecholamines (adrenalin and noradrenalin), which causes
the blood pressure to rise (Guyton, 1981). Therefore, stress
and increased sympathetic activity may contribute to
essential hypertension. Physiologic response to stress
which is a normal body response may persist to a pathologic
degree. Elevated blood noradrenalin and catecholamine
excretion have been found in the urine of a number of
hypertensive clients (Chobanian, 1982).

The kidneys play a significant role in the regulation
of blood pressure by maintaining fluid and electrolyte
balance. When the blood vessel is constricted, the kidneys
reabsorb sodium that is filtered in an attempt to expand the
volume of blood. In addition, the kidneys also secrete the
enzyme renin, which acts upon other enzymes. Renin is
increased in sodium deprivation and decreased by sodium
loading. Renin is also excreted in kidney ischemia. When
renin is released from the kidneys it catalyzes the
conversion of angiotensinogen to angiotension I.
Angiotension I is further changed to angiotension II by a
conversion enzyme found in the lung capillaries.
Angiotension II increases blood pressure by causing
vasoconstriction of peripheral areterioles, and in addition,
stimulates the adrenals to produce aldosterone. Sodium is

reabsorbed in the kidneys' response to elevated aldosterone

 

23

levels. In conjunction with sodium reabsorption there is
water reabsorption, and thus, blood volume is increased
which causes an increase in blood pressure (Guyton, 1981).
Some investigators have found that an altered
renin-angiotension-aldosterone balance may be a cause of
essential hypertension (Chobanian, 1982; Kochar, 1981).

Guyton (1981), postulated that many essential
hypertensives' kidneys during the early course of their
illness were unable to excrete salt and water in a normal
fashion. Since the kidneys were unable to excrete
sufficient sodium and water this caused a new steady state
with higher body fluid volume, resulting in an elevated
arterial blood pressure. Thus, the renal output curve was
shifted to a higher pressure level. Some possible causes
for the higher pressure are thickening of the glomerular
renal membrane, and increased afferent arteriolar resistance
caused by vascular sclerosis. Therefore, the blood pressure
is raised to maintain kidney function. Other factors
thought to influence the development of hypertension are
age, race, hormones, medicines, obesity, physical activity,
and genetics (Chobanian, 1982; Kochar, 1981).

The mosaic theory first proposed by Page in 1949
suggests that essential hypertension will prove to be not
one illness, but a combination of different conditions with
a variety of origins and development. Since various
theories have been offered over the years, it is concluded

that no present theory is adequate to encompass all the

 

24

known facts about essential hypertension (Mendlowitz, 1979).

The target organs that are most susceptible to the
effects of hypertension are the kidneys, brain, and heart.
As perfusion diminishes, due to thickening of renal vessels,
blood supply to the nephron unit decreases. The kidneys
then lose their normal ability to concentrate and form
urine. This may result is an increase in blood urea
nitrogen and serum creatinine, and eventually chronic renal
failure may develop (Marcinek, 1982).

Hypertension affects the brain by the development of
arteriOsclerosis and cerebral ischemia. This may result in
occipital morning headaches, fatigue, forgetfullness, and
irritability. Strokes in hypertensive clients are caused by
atherosclerosis acceleration and multiple microaneurysms
resulting in intracerebral hemorrhages (Marcinek, 1982).

Hypertensives tend to develop coronary artery disease
at a rate of two to three times greater than normotensives.
This is probably due to medial hypertrophy, vessel edema,
and accelerated atherosclerosis, resulting in reduced
coronary perfusion. Ultimately, the sclerotic vessels may
produce angina pectoris, and if severe enough myocardial
infarction may develop. Finally, because of increased
aortic pressure the left ventricle must pump harder. This
may result in an increased strain on the left ventricle and
eventually it hypertrophies, the end results being
congestive heart failure (Marcinek, 1982).

In summary, the literature supports the premise there

 

 

25

is no one cause of essential hypertension. There may be
multiple interrelated factors that contribute to the
incidence of essential hypertension. Complications can
result in chronic renal failure, cerebrovascular accidents,
and coronary heart disease. Since each hypertensive client
is unique, and presents with a combination of factors,
treatment of hypertension requires individualized and
optimum nursing care. For individualized nursing care the
psychosocial needs should be addressed. One way to assess
the psychosocial needs of the hypertensive client is by use

of the health belief model.
Health Belief Model

The health belief model as described in Chapter I is a
psychosocial.formulation developed to explain health-related
behaviors. The model was first used as an attempt to
explain why people engage in preventative health behavior at
an individual level of decision-making.

The health belief model variables were drawn and
adapted from the social psychological theory of Lewin
(1948). Lewin's theory postulates that an individual is
thought to exist in life space composed of regions, some
having positive valance, some negative, and some relatively
neutral. Illnesses, if they were represented in the life
space, would be a region of negative valence which would be
expected to exert a force moving the person away from that

region, unless doing so would require the person to enter a

r——_' ‘wll
26

region of even greater negative valence. Kurt Lewin's
theory also assumes the subjective world of the perceiver
determines behavior rather than the objective environment.
The theory is more concerned with the current subjective
state of the individual than with history or experience
(Becker, 1974; Becker et al., 1978; Becker et al., 1979;
Becker and Rosenstock, 1978).

According to the original health belief model
(Rosenstock, 1960)for individualsto take action to avoid a
disease they would need to believe: that they were
personally susceptible to illness, that the occurrence of
the disease would have at least moderate severity on some
component of their life, and that taking a particular action
would be in fact beneficial by reducing their susceptibility
to the condition or, if the disease occurred, by reducing
its severity, and that the benifits would not entail
overcoming important psychological barriers, such as cost,
convenience, and pain (Becker, 1974). Figure 2 illustrates a
schematic diagram of the interrelationship of the major
variables within the model. Based on the health belief
model even though an individual is ready to act, the
likelihood of taking action depends on beliefs about the
probable effectiveness of the action in reducing the health
threat and about the difficulties (barriers) that must be
encountered if such action is taken (Becker, 1974).

In addition, the health belief model proposes that a

stimulus (or cue to action) must occur to trigger the

 

 

 

27

appropriate behavior. This cue might be internal, like
perception of bodily states, or external, like interpersonal
interaction and the impact of mass media. There are also
modifying factors such as demographic variables; structural
variables such as complexity, cost, and duration of the
regimens; attitudinal variables such as satisfaction with
clinic staff and procedure; interaction variables such as
type of nurse/client relationships; and enabling variables
such as source of advice and social pressure (Becker, 1974).

The health belief model has been utilized in examining
preventative health behaviors: screening tests for
tuberculosis, cervical cancer, dental disease and rheumatic
fever (Becker, 1974) Although the health belief model
originally had been used to predict preventative behavior,
there are a number of studies which have used one or more of
these variables to predict patient compliance with the
therapeutic regimen for chronic illnesses (Becker, 1978;
Becker et al., 1979; Becker and Maiman, 1980; Cummings &
Kirscht et al., 1982; Given & Given, 1982; Greene et al.,
1982; Hershey et al., 1980; Morisky et al., 1982; Taylor,
1979).

The model presented in Figure 2 is modified from the
original health belief model formulated in the 1950's by
Hochbaum, Leventhal, Kegeles and Rosenstock. According to
Kasl (1974) the same variables of perceived susceptibility,
perceived severity, and benefits minus barriers are applied

to chronic illness. Susceptibility and severity are

 

28

perceived as threat components. The model assumption is
that even if individuals recognize personal threat, they
will not take action unless the course of action is believed
to be beneficial in reducing the threat.

The modified model includes motivation to take
necessary action, which is an added concept for application
to chronic illness. Motivation has been operationalized as
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.

Kasl further adds that illness behavior takes place in
the presence of symptoms which may provide motivation for
compliance, whereas in the original model the health
behavior takes place in the absence of symptoms or illness
and thus, the issue was educating people, and finding the
right cues for action, rather than motivation.

Therefore, the health belief model provides a framework
to examine the variables of this study which are the
hypertensive clients' perceived illness severity, and
pgrceived barriers as they relate to compliance with the
therapeutic regimen. The model provides some insight into
why people behave in certain ways with regard to the health
decision-making process. Figure 2 represents the
reformulation of the health belief model for use as a
predictor of compliance for hypertensive clients (Becker et

al., 1974; Kasl, 1974).

 

29

The concept of perceived severity of illness is found
in Figure 2 under Individual Illness Perceptions. How
individuals recognize the seriousness of their illness in
comparison to other illnesses, the possibility of
complications, and the impact of the illness on significant
others is implied. The perception of illness severity
includes the overall seriousness of consequences of having
hypertension and the extent of interference with social
roles (Becker, 1974; Kasl, 1974). Nelson et al. (1978)
found the impact of hypertension on lifestyle to be
associated with blood pressure control, and found that
perceived severity of hypertension and likelihood of
complications to be related to self-reported
medication-taking. The (1980) Joint National Committee on
Detection, Evaluation and Treatment of High Blood Pressure
indicated that clarification of clients' attitudes and
beliefs about high blood pressure may be helpful for
long-term compliance with therapy. Since perceived illness
severity may vary from person to person, it becomes
necessary for the nurse to assess the clients' perception of
their hypertension severity to provide guidelines for the
process of nurse—client interaction.

Perceived barriers to treatment may be found in Figure
2, under Individual Treatment Perceptions. Perceptions about
treatment were selected for study to address beliefs related
to the need for new patterns of behavior required for

treatment, and to address doubt in efficacy of treatment. A

‘

30

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31

number of studies which address the concept of barriers to
treatment focus on the more tangible costs, side effects,
and accessibility (Brand et al., 1977; Logan et al., 1979;
Nelson et al., 1980). Results were inconsistent in finding a
relationship between tangible barriers to treatment and
compliance. Other research examined the more affective and
intangible barriers of life style adjustments and did find
an association to their measurements of compliance (Cummings
et al., 1982; Hershey et al., 1980; Nelson et al., 1978).
Baile and Gross (1979) believe inquiry should be made about
the meaning of hypertensive treatment to the client, and its
impact on behavior change and employment status for the
purpose of identifying obstacles to therapy. Therefore,
this research is directed to beliefs about the intangible
barriers to treatment: difficulties incorporating required
changes into life style such as job/regimen conflicts,
problems with diet or medication, and doubt concerning
treatment efficacy.

Stated cqpplianqg with the 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 & Given, 1982, p.
28). In this research measures of client compliance are
based on client report of compliance with medication, diet,
and exercise recommendations. Self report of compliance is

elicited concerning if medication was taken, if prescribed

 

32

dosage was taken, and if medication was taken at the
recommended time of day. Similar questions were asked to
elicit stated compliance with diet and exercise.

Medication, diet, and exercise are the variables of
compliance with therapeutic recommendations selected for
this study. Medication and diet are the usual treatment for
hypertension (Chobanian, 1982; Kaplan, 1978). Medication
reduces blood pressure through diuresis, sympathetic
blocking, renin-angiotensin inhibition, or vasodilation.
Diet. is prescribed to enhance medication effects or to
independently normalize blood pressure through weight
control and limitation of sodium intake (Langford, 1981;
Reisin et al., 1978; Stamler et al., 1978). 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; Michigan
Heart Association, 1976).

Stated compliance is the method of measurement for this
study. No perfect method of measuring compliance has been
found, however there is evidence that stated compliance is
acceptable. (Rudd, 1979). Nelson et a1. (1978) found blood
pressure control and self-reported medication-taking to be
highly correlated with each other. Haynes et a1. (1980)
found self reports were more reliable as compliance measures
than blood pressure, or urine and blood tests of metabolites

when compared to pill counts. Interviewing the hypertensive

33

client is a practical, useful approach in addressing the
compliance issue (Haynes et al., 1980).

The term compliance is somewhat controversial. To some
it carries the connotation of a patronized, unreliable,
deviant patient; implying limitation in the client (Stanitis
& Ryan, 1982). For others (Linden, 1981) the terms
compliance, adherence, participation, follow-through, and
cooperation have a positive connotation. The terms
adherence and compliance are often used interchangeably with
no differences in their intended meanings (Glanz, 1980). In
this study the definition of compliance is not meant to be
judgmental. It is the most commonly used term in the
literature, and patient compliance is the key concept
utilized in the Index Medicus for literature related to the
subject of the extent to which the client carries out
therapeutic recommendations.

Hypertensive clients are a challenge to the nurse due
to their complex health problems. Individuals with
hypertension must begin to adjust life styles to illness
even when no symptoms are present (Sackett & Haynes, 1977).
Many aspects of one's daily life must be altered to control
this illness. The health regimen in many cases is complex
including special diet, medication, stress reduction, weight
reduction, exercise, and elimination of smoking. The level
of intervention by the nurse depends on such factors as the
stage of the illness, other health problems, and the

individual's ability to adapt to the illness and its

34

treatment.

Because of the complex nature of the illness, clients
often have misconceptions and a poor understanding of its
causes and consequences. Control of hypertension decreases
the risk of stroke, heart attack, and kidney failure. The
nurse should start at the client's level of understanding,
and should determine approaches to help clients take an
active role in their care (Foster & Kousch, 1978).

Thus, the health belief model could be useful in
assessing hypertensive clients' compliance with therapeutic
treatment, and also in identifying clients who are at risk
for noncompliance.

How this assessment may be utilized by the nurse during
the interaction with the hypertensive client is described by

using King's goal attainment theory.

NursingiTheory

King's goal attainment theory serves as a model for
nurse-client interaction whereby each perceives the other
and the situation through communication. The nurse and
client set goals and explore means to achieve them. For
example, one goal may be to help a hypertensive client think
of ways to decrease the complexity of the regimen. Whereas
the health belief model only focuses on health perceptions
and the behavior an individual will undertake according to
the perception of illness and treatment. For example, do

hypertensive clients perceive their illness severe enough to

35

take the medication daily? King focuses on the overall
communication and decision—making process, and the health
belief model represents the health behavior the client will
take. Because compliance with treatment for hypertensive
clients is a difficult challenge to nurses, the use of
King's theory and the health belief model provides the nurse
with a framework to guide knowledge and interventions
necessary to provide effective nursing care.

According to King, goal attainment is derived from
interpersonal systems whereby the nurse and client
represents one type of interpersonal system. Concepts from
the theory of goal attainment are: perception, judgment,
action, reaction, interaction, and transaction. In
addition, these concepts are congruent with the nursing
process whereby human interaction between nurse and client
take place, goals are set, ways to achieve them are
explored, and interventions are implemented and evaluated.
Furthermore, these concepts may have a significant impact
upon the hypertensive client's compliance behavior in terms
of the health belief model.

Perceptions about illnesses, about treatments, and
about other life events are subjective representations of
reality as defined by King (1981). The individual's
awareness of objects, events, persons, and self gives
meaning to experiences. Judgment of the value of events is
based on perceptions. King suggests that action orientation

is characteristic of persons based on their judgment of

36

reality. Verbal or nonverbal action involves a sequence of
behaviors related to recognition of and efforts to control
events.

Persons react as total organisms responding to their

unique perception of environment and experience. Using the

health belief model the nurse may predict how persons will
react depending upon their perceived illness severity and
perceived barriers to treatment.

Furthermore, taking into account a person's perceptions
and beliefs about illness and treatment is a means of
acknowledging their uniqueness, their knowledge, experience,
values, and expectations. In an effort to explore ways to
increase compliance the nurse can assess the hypertensive
client's perceived illness severity and perceived barriers
to treatment.

According to King (1981) interaction is defined as a
process of perception and communication between person and
environment. During the interaction, each individual brings
knowledge, needs, goals, past experiences, and perceptions
to the situation. The individual's uniqueness of mental
action affects the judgments to be made and final decision
making during the interaction. King believes that
individuals react to each other and the situation
accordingly.

As the nurse and client set goals they are said to
interact and react to each other. During this process the

nurse can use the health belief model to assess client

37

perceptions and health related behaviors thereby helping the
client overcome any barriers to treatment.

Transaction is viewed by King (1981) as an observable
behavior of human beings interacting with their
environment. Transaction involves bargaining, negotiation,
and social exchange. In addition, persons can share their
frame of reference about events in the present, identify
commonality, and mutually set goals, the final outcomes of
transaction. Transaction is viewed as growth and
development. It is the purposeful interaction that leads to
goal attainment. Therefore the nurse can facilitate client
knowledge and skills, allowing growth and development, and
finally maximizing the client potential to achieve
compliance with treatment.

In the process of perception, judgment, action,
reaction, interaction, and transaction, the nurse helps the
client set goals and discuss alternative measures to achieve
them. Figure 3 illustrates a diagram showing nurse and
client interaction. The nursing mode of goal attainment
involves communication with the client to help identify
goals and solve problems.

Nursing is defined as providing essential services to
society to maintain health (King, 1981). Health, as a goal
of nursing is the basis for nursing theory. King believes
that the nursing process is a mode of action applied through
knowledge in caring for the well, ill and dying. The

nursing process can be implemented through perception,

38

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39

judgment, action, reaction, interaction, and transaction
whereby the nurse assists the client to c0pe with illnesses

and promote health.

Nursing Intervention

The problem of hypertensive compliance with a
therapeutic regimen is a complex one. Compliance means
following recommendations in terms of medication, diet,
exercise, and adjusting life style adjustments. The nurse
can intervene in this process by using components of the
health belief model with King's goal attainment theory and
the nursing process. In King's conceptual model, the
hypertensive client and the nurse are equal partners. They
each bring to the relationship perceptions, knowledge,
judgments, skills, and abilities. Each is a part of the
environmental experience of the other. In the beginning of
King's process of human interaction (Figure 4), the client
may act by saying, "I have hypertension." "I've been told
my blood pressure is too high." "I'd like to make an
appointment." Then, a reaction by the other, "Could you
tell me more?" The process continues with the assessment of
health status.

The nurse can assess if clients perceive their
hypertension as being severe. In addition, do they perceive
hypertension as causing other health problems? Finally, do
clients perceive the hypertension as resulting in

complications? To assess barriers to treatment, the nurse

40

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41

could explore whether or not the client has difficulty
complying with the therapeutic regimen. In addition, the
nurse would assess what effect the regimen has on life style
and whether other family members are affected.

In the interaction phase and the planning stage of the
nursing process, the nurse and the client collaborate.
Planning, negotiating, and mutually identifying goals are
important. Means to achieve goals are explored and agreed
upon during client-nurse interaction. Using the health
belief model the nurse can start with the clients' health
beliefs about their illness, and build upon ways to help
achieve compliance. The nurse can help the client develop
awareness of their illness, and facilitate client behaviors
to maintain health. It is at this point transaction between
them begins. According to King, compliance behavior is an
indicator of transaction. Effective transaction leads to

compliance and ultimately blood pressure control.

Summary

In summary, King's theory of goal attainment provides a
framework into which components of the health belief model
may be integrated for nursing care. King's theory outlines
the interaction process whereby the nurse assesses the
client's perceived illness severity and perceived barriers
to treatment. During the process, the client and the nurse

mutually establish goals, evaluate progress, and adapt to

42

changes to ensure goal attainment and compliance with the

therapeutic regimen.

CHAPTER III

REVIEW OF THE LITERATURE

Introduction

 

This chapter was prepared jointly and in collaboration
with Harmon (1983). In this chapter relevant literature
pertaining to the study variables of perceived illness
severity, perceived barriers to treatment, and compliance
with the therapeutic regimen will be reviewed. The review
will include literature concerned with hypertension, the
health belief model, and nursing care relative to the
hypertensive client. Recent research findings and opinions
of experts applicable to these concepts will be presented.
The chapter will be divided into the following sections:
hypertensive treatment, compliance behavior, the health
belief model, illness severity, treatment barriers, and

nursing care of hypertensive clients.

Hypertensive Treatment

 

Most literature on treatment of hypertension is focused
on drug therapy. Some studies include nonpharmacological
interventions. However, major studies have not to date
reflected the establishment of standards for nondrug

therapy.

43

44

Several studies have reported the benefits of
antihypertensive drug treatment. Borhani, (1981) and Kochar
(1981) reported on the effects of antihypertensive
medication which have been demonstrated by the data from the
Veterans Administration Study conducted from 1967 to 1972.
This was a prospective, randomized, double blind therapeutic
trial which included 523 males from VA hospitals. The
participants were selected carefully for well documented,
sustained hypertension, and their degree of compliance with
the health regimen. Subjects were randomly assigned to
placebo and active treatment groups. The results
demonstrated the efficacy of antihypertensive therapy in
preventing congestive heart failure, myocardial infraction,
and strokes in men with diastolic blood pressure ranging
from 104 to 129mm Hg. Borhani (1981) added that this study
had a great influence on the medical profession due to
focusing on the need of treatment for hypertension.

The study conducted in Framingham Mass. has
demonstrated efficacy of treatment for hypertension (Kannel,
et al., 1978). The participants (n = 5,184) men and women
ages 30 to 62 years were free of stroke prior to entry into
the study. They were followed biannually for more than two
decades. It was concluded that hypertension was the most
powerful precursor of stroke. Hypertensives in the study
were found to have twice as much occlusive peripheral
arterial disease, three times as much coronary heart

disease, four times as much congestive heart failure, and

45

seven times as many brain infractions as did normotensive
participants. However, rates of morbidity and mortality for
hypertensives in control were reduced to approximately the
rates for normotensives.

Efficacy of antihypertensive therapy has been well
documented by a recent study with data collected from the
Hypertensive Detection and Follow-up Program Cooperative
Group (HDFP, 1982). This was a five-year study of 10,940'
hypertensive participants aged 30-69 with a diastolic blood
pressure greater than 90mm Hg. The report of the HDFP
compared the morbidity and mortality outcome in a population
treated with optimum antihypertensive drug therapy (called
stepped care), versus the customary medical care. The
subjects were randomized into two groups, "stepped care" and
referred care. The "stepped care" group received stepped
care therapy in the HDFP clinic, whereas the referred care
group was referred to the community physicians for care.

Mortality surveys were conducted yearly in both the
"stepped care" and referred care groups throughout the
five-year period (HDFP, 1982). Subsequently, interviews and
blood pressure measurements were repeated at yearly
intervals. Clinical assessments including physical
examinations were performed for baseline data, and repeated
at two and five years in both groups. The findings revealed
a 16.9% reduction in all causes of mortality among the
stepped care group compared to the community treated group

(p = .01). More specifically the data showed the following

46

for stepped care subjects: (1) a reduction in incidence of
stroke for all ranges of initial diastolic blood pressure,
there being a 45% reduction in stroke incidence for those
with diastolic pressure 115mm Hg or higher; (2) among white
women a 30% reduction of stroke incidence; (3) a 27%
reduction of stroke incidence among participants ages 30-49
at entry of study; and (4) a 45% reduction in the incidence
of stroke among stepped care participants age 60-69. These
findings support the premise that decreasing diastolic blood
pressure to normal levels reduces stroke morbidity and
mortality regardless of age, sex, race, and initial level of
blood pressure.

The results of a recently completed Australian study
demonstrated evidence for the efficacy of treatment of mild
hypertension (The Australian Therapeutic Trial, 1980). This
was a controlled trial of drug treatment. In this study (n
= 3,427) men and women, aged 30 to 69 years with a diastolic
blood pressure 95-110mm Hg,and systolic pressure less than
200mm Hg, were assigned to placebo or active treatment
groups. They were followed for four years. The results
indicated a significant decrease in mortality from
cardiovascular disease and cerebrovascular disease in the
active treatment group.

Kaplan (1983) emphasized the need for a more balanced
view of hypertensive drug therapy. He stated that the
decreased mortality findings of the HYpertension Detection

and follow-up Program may be due to more medical care in

47

general rather than just more frequent use of
antihypertensive drugs. Also, the Australian Therapeutic
Trial (1980) on mild hypertension showed less complications
when the diastolic blood pressure was brought below 100mm Hg
without drugs. In addition, the MRFIT Research Group (1982)
results confirmed the value of antihypertensives for those
with diastolics above 100mm Hg, however for the majority
with diastolic pressure of 90-100, a more conservative,
selective approach should be employed. Kaplan (1983)
suggested that for those at relatively low cardiovascular
risk, non-drug therapy is preferred: weight reduction for
the obese, moderate sodium restriction for all, and
relaxation techniques for those willing to use them. Kaplan
further adds that non-drug therapy should be offered as
adjunct to all on antihypertensive drugs as well.

Cummings, et a1. (1982) reported a study conducted to
evaluate the effectiveness of a blood pressure screening,
referral, and follow-up program in an inner city area of
Detroit. A comparison was made of two matched groups, one
exposed to the blood pressure program, and the other not
provided with any blood pressure services. The data
collected was from a cross-sectional survey of 800
predominately black adults selected at random from the inner
city directory. Results revealed that the prevalence of
hypertension was 38% for both men and women under age 55.
The prevalence of high blood pressure increased for both

sexes above age 55, with women being more likely to have

48

hypertension than men. Eighty percent of the 291
hypertensive subjects were aware of their illness prior to
participation. Eighty-six percent of the 234 aware
hypertensives were being treated and 26% of those adequately
controlled. Treatment, awareness and control rate seemed to
be age-related. The younger age group were less likely to
be aware of their hypertension, on a therapeutic regimen;
and in controlled (BP < 140/90mm Hg). Below the age of 54,
women were more likely to be aware of their hypertension
than men. Half of the men in the sample between ages 18-44
who had hypertension were unaware of their illness. In 1968
only 49% of hypertensives in Detroit were aware of their
illness and 33% were on treatment. Whereas in 1978, 80%
were aware of their hypertension and 69% were receiving
treatment. ' Cummings et a1. (1982) concluded that there
still remain a large number of hypertensives who are either
not on treatment, being inadequately treated, or
noncompliant with the therapeutic regimen. It was suggested
that in addition to widespread screening, interventions to
ensure long-term maintenance of appropriate antihypertensive
therapies should be employed.

Other relevant data were reported by the High Blood
Pressure Control Study Group (1982). The statistics showed
that the majority of hypertensives do not have their disease
under control. Data from the National Health Survey showed
only 24% of definite hypertensives (>160/95mm Hg) are in

control; 24% are aware of their illness, but not on

49

treatment; and 20% are on inadequate treatment. A
remarkable 32% of definite hypertensives are not even aware
of their illness. "The major problem in high blood pressure
control in America today is helping health professionals and
their clients work together to achieve long-term compliance
and blood pressure control."

In summary, the literature supports the premise that
pharmacological and nonpharmacological antihypertensive
therapy is of proven efficacy in reducing morbidity and
mortality for hypertensives. However, there still remain a
large number of hypertensives who are either inadequately
treated, or noncompliant with therapy. Therefore
interventions to ensure long-term compliance with therapy is
crucial to improving the morbidity and mortality of the

illness.

Compliance As A Health Care Concern

 

Considerable attention and literature have been devoted
to the subject of compliance (Haynes, Mattson,Engebretson,
1980; Haynes, Taylor,Sackett, 1979). Client compliance with
therapeutic regimens has been a potential problem throughout
the history of prescribed remedies. It has only been since
the development of treatment of established efficacy that
health providers have taken compliance seriously (Haynes,
1979).

Investigators of compliance do not always agree on the

concept definition. The word compliance has been criticized

50

for being authoritarian or condescending, a connotation of
professional dominance (Jonsen, 1979). Stanitis and Ryan
(1982) challenged the nursing diagnosis of noncompliance,
saying compliance may mean coerciveness, and noncompliance
blames the victim. They fear labeling the client will
subvert the provider/client relationship, and depreciate
self care and client decision making (Stanitis & Ryan,
1982). Other writers may use the word adherence to imply
greater participation by the client (Foster & Kousch, 1981;
Glanz, 1980)

Jonsen (1979) saw compliance as part of the issue of
free will: a question of why people knowingly neglect to do
what is in their own best interest. Here the assumption is
made that compliance is in their best interest. Dudley
(1979) viewed the compliance concept as only part of the
overall "delusion" by doctors and clients that medicine
exists for specific diseases, that doctors will always
diagnose correctly, that doctors will always prescribe
correctly, that clients will always comply with treatment,
and that clients will always respond to treatment. Dudley
notes that in addition to a background of noncompliant ways
(smoking, going on strike, driving over 55, etc.) clients
usually have had the experience of getting well despite
medical treatment.

Therapeutic compliance may be differentiated from other

types of compliance (Linden, 1981). Therapeutic compliance

 

is client behavior in terms of therapeutic recommendations

51

which may be individualized for that client. Standard

compliance is client behavior in terms of optimal medical

 

expectations for therapy. Aspirational compliance refers to

 

client behavior in terms of self expectations. Habitual

compliance is the client's predisposition to compliance.

 

The frame of reference for therapist compliance is the

 

medical standards for provider performance. Therapeutic
compliance is the usual definition referred to in "patient
compliance" literature as found by means of the nggx
Medicus (1980-1983).

In hypertensive studies compliance has been defined as:
maintaining the regimen (Cummings et al., 1982; Levine et
al., 1979); cooperative performance (Andreoli, 1981);
remaining under care and taking medication as prescribed
(Nelson et' al., 1980); remaining under care and taking
enough medication to achieve blood pressure control(Haynes,
Taylor et al.,1980). Most authors defined compliance as the
extent to which the client follows therapeutic
recommendations (Haynes, 1980; Hershey et al., 1980; Inui et
al., 1981; Morisky et al., 1982; Wagner et al., 1981). The
definitions do not imply judgment or fault by either the
client or health provider but simply that client behavior
coincides with health advice (Haynes, 1980).

Blackwell et a1. (1978) investigated provider
education on compliance. In a case comparison design 52
medical students were asked to role play client compliance

with prescribed therapy. All preregistrants at a compliance

52

conference were given a prescription for Vitamin C and a
special diet. The hypotheses concerned failure to fill the
prescription, extent and type of noncompliance, and
significant differences in attitudes between compliant and
noncompliant students. Only 21% were totally compliant.
Forty-three percent did not fill the prescription. Failure
to heed dietary precautions exceeded medication taking
errors. A significant difference in attitude (p < .05)
indicated that noncompliant individuals considered
themselves to be more independent than compliant students.
Criticisms of the research centered on nonvalidity due to
lack of reason to comply. However, findings supported an
enhanced learning experience for those who attempted
compliance.

In summary, the study of compliance is considered to be
involved with choice, free will, provider attitude, provider
responsibility, and client participation. Although several
authors have addressed these implications, the definition of
compliance in most hypertension literature is simply a
descriptor of what behavior occured, i.e. the extent to
which the behavior coincided with therapeutic

recommendations.

Compliance Measures

 

The 1980 Report of the Joint National Committee on
Detection, Evaluation, and Treatment of High Blood Pressure

reported that blood pressure measurement is one simple

53

indicator of compliance with hypertensive treatment.
Failure to maintain blood pressure control usually means
failure to follow therapeutic recommendations (The 1980
Report of the Joint National Committee). However, Dunbar
(1980) and Gordis (1979) emphasized that therapeutic
outcomes do not constitute a measure of compliance.
Compliance is only one variable which moderates the effect
of a given treatment. Other variables may be
bioavailability of drug and adequacy of prescribed dose.
Dunbar stated compliance and physiological response are to
be viewed as related, but not interchangeable.

Gordis (1979) reviewed measures of medication
compliance, noting other forms of compliance are described
in the literature: delay in seeking care, nonparticipation
in health programs, breaking appointments, and failure to
follow provider instructions. For compliance with
medication, Gordis listed the following methods of
measurement: direct methods of detecting the drug itself,
its metabolites, or its markers in urine or blood; and the
indirect methods of therapeutic outcome, patient interview,
pill counts, and physician assessment.

In Gordis' review, each method was found to have
drawbacks. The direct methods have the disadvantage of
bioavailability variations-~differences among individuals in
absorption, distribution, metabolism, and excretion of
drugs. These types of tests do not detect dosage level, or

consistency of administration (Dunbar, 1980; Gordis, 1979).

54

The indirect method of using therapeutic outcome (e.g.
blood pressure reduction) for a measurement of compliance
poses certain problems. Outcomes may depend on other
factors such as: (1) effects of concurrent therapy, (2)
environmental effects, (3) provider compliance or
non-compliance with current expert opinion, and (4) a good
outcome response to low compliance which maybe due to an
unexpected sensitivity to treatment or a labile condition
(Gordis, 1979).

Studies on pill counts were compared to urine or blood
tests for compliance measurement accuracy (Gordis, 1979).
The review of pill count research indicated serious
overestimation of compliance by comparing the amount of
medicine remaining to the amount the client should have
left. A second disadvantage is that pill counts do not
identify consistency of administration (Dunbar, 1980). Also,
some researchers were able to obtain only 39% usable pill
counts due to incomplete records or difficulty having
clients bring their prescription to the appointment (Rudd,
1979).

Physician assessment of client compliance was found to
be the least accurate method of measuring compliance, little
better than chance estimate (Gordis, 1979). Clinicians
overestimated compliance by as much as 50%, indicating
clinical judgment should not be used as a compliance
indicator, either in research or the clinical setting

(Dunbar, 1980). Glanz (1980) believes the error in

55

overestimation of compliance is due more to a lack of
information than to inaccurate information, and that
clinicians can obtain valid information by utilizing the
interview.

Client interview, when compared to the pill count or
urine test as a second measure of compliance was found to be
of variable accuracy. The interview studies reviewed by
Gordis were conducted with mental patients, patients on
digitalis, patients on PAS, and with pediatric patients.

Researchers agreed many noncompliers can be identified by

 

this practical indirect method. However, client interview
is less valid for identifying those who are compliant.
Generally, clients overreport compliance and underreport
noncompliance (Gordis, 1979).

Dudley (1979) claimed that simply by asking in an
interview, about 40% of the noncompliers can be identified.
Sackett (1980) reported in a study of 240 steelworkers that
asking in a nonjudgmental way found 40% of the noncompliant,
uncontrolled hypertensives. Sackett says answers of "no" to
the question of treatment compliance are virtually always
telling the truth.

In a series of randomized trials, Haynes, Taylor et
a1. (1980) found the self report by interview to be a more
reliable measure of compliance than blood pressure, urine
tests, or blood tests when compared to pill counts. Stated
compliance by interview correlated best with pill count (r =

.74, p < .0001). The sample consisted of 135 newly treated

56

male hypertensives who were studied over six months. On the
assumption the pill count is the most accurate measurement
of compliance, interviewing was found to be a useful
approach to asssessment of compliance with antihypertensive
therapy.

Valid assessment of compliance by interview depends on
what questions are asked and how they are asked (Glanz,
1980). As the interview is practical and offers information
on the complexity of the compliance problem (levels and
variability) it is important in the design of research to
give attention to interviewing, skills for the purpose of
eliciting accurate data (Glanz, 1980). Accuracy depends on
memory. Erratic medication taking may be related to poor
memory which in turn will hinder data collection regarding
the compliance level. Therefore it is necessary to
reinforce good accuracy in recall rather than good
compliance. The interview requires careful phrasing of
questions to make it socially acceptable to report errors
(Dunbar, 1980; Glanz, 1980).

Dunbar (1980) reported an additional compliance
measure--self monitoring. Self monitoring is observing and
recording one's own behavior. The advantages are it does
not rely on memory, it measures over time, it indicates
daily variability. The disadvantage of self monitoring is
it provides self feedback which tends to correct
noncompliance and alter natural compliance patterns. Dunbar

concluded it is a better intervention than research method.

57

Rudd (1979) believed most measures of compliance
sensitize the client to the monitoring of their behavior.
The ideal measurement would be unobtrusive, objective, and
practical. Rudd concluded that until the ideal is found,
the interview is the most useful and practical measure
compared to pill counts and blood tests.

A review of literature on compliance measurement is

limited by the comparison of one imperfect measure to

another. In summary, authors have found client interview to
be one of the most satisfactory, economical methods for
research if done with attention to interviewer attitude and
question phrasing. Comprehensiveness in the type of
questioning can provide information on compliance levels,
consistancy, and patterns. Such information is not elicited
by pill counts, urine and blood tests, blood pressure and
physician assessment. The interview also lends itself to
measurement of compliance with dietary and exercise
recommendations, as well as with antihypertensive

medications.
Compliance With Medications

Stepped care medications are the standard of
hypertensive therapy for moderate or severe hypertension.
Antihypertensive therapy clearly protects those with
diastolic pressures 105mm Hg or higher. The goal of therapy
is a diastolic of 90mm Hg and below, or the lowest diastolic

pressure consistent with safety and tolerance (The 1980

58

Report of the Joint National Committee; Kaplan & Liebeiman,
1978).

The stepped care approach entails initiating therapy
with a small dose of diuretic at step one. If not effective
the dose is increased, then adding sequentially one drug
after another as needed. At step two, adrenergic inhibitors
are utilized. Vasodilators are added at step three, and the
additional adrenergic inhibiting agent, quanethidine, is
added at step four (The 1980 Report of the Joint National
Committee).

All patients need nondrug modalities to lower blood
pressure and improve health. Therapy for those with a
diastolic between 90-105mm Hg should be individualized.
Drugs may be indicated for mild hypertensives with the
additional cardiovascular risk factors of smoking, diabetes,
family history of cardiovascular disease,a systolic above
165, hyper cholesterolemia, and target organ damage (The
1980 Report of the Joint National Committee; Kaplan &
Liebeiman, 1978). Chobanian (1982) indicated that
antihypertensive drugs should be considered for the mild
hypertensive if the nonpharmacological approach is not
effective.

In a quasi-experimental design, Haynes et al., (1983)
studied the effects of pharmacological treatment, and
compliance with treatment on diastolic blood pressure. A
random two-thirds of 5400 steelworkers on no previous

treatment for hypertension were screened for high blood

59

pressure (mean diastolic pressure > 95mm Hg). The 230
hypertensives found were randomly assigned to plant or
family physician, but not randomized for treatment. The
decision to treat with medication was made by the individual
physician. This study on effects of medications on blood
pressure was done to take into account the decision to treat
or not, and the relative pharmacologic vigor of regimens.
The researchers classified drug dosage by units of vigor,
one unit being equal to 50mg chlorthalidone. The
classification was done on the assumption multiple doses of
the same and other drugs are additive. Results showed the
63% who were treated with antihypertensives had a
significantly greater decrease in diastolic than those not
on medication (12.2 vs 7.8mm Hg mean decrease, p < .001).
Clients on more vigorous treatment had a lower diastolic
pressure (p < .005). Clients were dichotomized into two
groups, grater than 80% and less than 80% compliant, as
measured by pill count. Twenty seven percent of the low
compliers and 44% of the high compliers had a diastolic less
90mm Hg. Using the product of patient compliance and vigor
of regimen, the researchers were able to find a higher
association with diastolic response (p (.0001) than by using
either indicator alone. A limitation of the study is that a
unit of vigor of medication is not equal to another
depending, among other things, upon size and age of the
person. Results showed an association between therapeutic

outcome and the items of care: decision to medicate, vigor

60

of treatment, and client compliance (Haynes et al., 1982).
Wagner et a1. (1981) also studied the influence of
drug compliance and treatment regimen on blood pressure
control. In a survey design an available sample of 385
treated hypertensives were identified in a biracial
community. Controlled hypertension was defined as a
diastolic below 90mm Hg. Compliance with antihypertensives,
measured by "rarely" or "never missed" doses, was reported
by 74% of the available sample. Four groups were

identified: (1) compliant-and-controlled, 53% of the sample,

(2) compliant-and-uncontrolled, 21% (due to inadequate
treatment, resistant hypertension, or misclassed as
compliant), (3) noncompliant-and-controlled, 16% (may be

misclassed as noncompliant, or sensitive to drugs), (4)
noncompliant-and-uncontrolled, 10% (the assumption is made
that noncompliance accounts for the noncontrol). Those who
had discontinued drug treatment were not represented in the
study. The number in the noncompliant-and-controlled group
suggests overtreatment, a problem more consequental due to
HDFP findings which support treatment of diastolics as low
as 90mm Hg. The overtreatment and undertreatment found to
coexist in this community underlines the importance of
following the standards developed by the Hypertension
Detection and Follow-up Program(l979). If the noncompliant
are not identified as such they are in danger of continued

overprescription.

By measuring pharmaceutical records of prescription

61

refills, Inui et al., (1980) researched variations in
compliance with common drugs. The sample of 419 VA hospital
outpatients, including those from a nurse practitioner
hypertensive clinic, were on free, long-term medications.
Their measure was validated by a significant correlation (p
< .05) of hydrochlorothiazide-refill-record with mean
diastolic pressure on a random sample (n = 25). Of those
patients on hypertensive therapy, the following compliance
rates were reported: furosemide (72.7%, n = 33);
hydrochlorothiazide(63.5%, n = 192); methyldopa (63.4%, n =
47); propranolal (62.5%, n = 89); potassium chloride (60.7%,
n = 114); and hydralazine (50.4%, n =25). Findings suggested
low correlations between compliance rates with different
drugs in the same regimen. The researchers speculated this
may be due to differing properties or side effects of drugs
themselves, or client and doctor attitude. Therefore, drug
mix has been demonstrated to be an important confounding
variable in compliance with medication.

In 1981 Inui et al. reported on noncompliance
screening research to identify the best available measure of
compliance with medication. The sample consisted of 241
predominantly middle-age, low income, black, female
hypertensives under the care of medical residents.
Compliance was measured by pill count, self report, and a
combined rule of blood pressure and self report. The
combined rule defined compliance as stated compliance and

diastolic below 100mm Hg; and noncompliance as stated

62

noncompliance with any diastolic, or stated compliance with
diastolic above 100mm Hg. The researchers found their
combined decision rule of blood pressure/self—report was
more sensitive for identifying noncompliance than
self-report alone. The combined rule identified 83% of the
noncompliers while self-report identified 55% of
noncompliers as defined by pill count. The prevalence of
noncompliance by pill count was:

(1) controlled-and compliant 31%

(2) uncontrolled-and-compliant 7%

(3) controlled-and-noncompliant 23%

(4) uncontrolled-and-noncompliant 39%.

Therefore, the combined rule may identify some patients as
noncompliant who are compliant-and-uncontrolled due to an
inadequate regimen. Also, findings emphasize the problem of
nonidentification of the noncompliant who indicate they are
compliant on verbal inquiry, as they may then be given more
drugs, have more side effects, and have more tests and
visits. A question was raised regarding the need to step
down the drug regimen for those who are well-controlled but
noncompliant.

In summary, compliance with medications has been found
to be beneficial in the care of hypertensive clients.
However compliance rates are often low and noncompliant
clients are often not identified. Compliance levels may
even vary for different drugs in a single regimen. The

compliance issue needs to be addressed to prevent

63

undertreatment, to prevent over prescription, to increase
awareness of the possible need to step down care, and to
focus on increased effectiveness within the standards of
care.

Compliance with medication has been measured by a
variety of means with expected variable results. Further
research is indicated to identify predictors and
determinants of compliance, and address ways to apply the

findings to clinical practice.

Compliance With Diet

 

A review of the literature brings to our attention the
importance of diet in the therapeutic management of
hypertension. Epidemiologic studies show a strong
correlation between blood pressure and body weight, and
blood pressure and sodium intake (Berchtold & Sims, 1981;
Freis, 1976; Langford, 1981). Dietary management is a
reasonable initial approach for those with mild hypertension
and no additional cardiovascular risk. Diet is definitive
therapy if blood pressure is then reduced and maintained at
normal levels (The 1980 Report of the Joint National
Committee).

Weight reduction is often associated with significant
decreases in blood pressure and is particularly useful
treatment for mild hypertension (Chobanian, 1982). A
25-pound weight loss in the obese may reduce the systolic by

10mm Hg. The obese should decrease intake of saturated fats

64

and cholesterol as well as lose weight to decrease their
cardiovascular risk (Kaplan & Liebeiman, 1978).

Stamler et al. (1978) reported findings related to
weight and blood pressure from the hypertensive screening of
one million Americans. Persons were self-classified as
overweight, normal weight or underweight. The
self-classified overweight group had 50-300% higher rates of
hypertension. The frequency of hypertension in the
overweight, age 20 to 39, was double that in the normal
weight, and triple that of the underweight. Age 40 to 64,
the overweight group had a 50% higher rate of hypertension
than the normal weight, and 100% higher than the
underweight. With each higher degree of blood pressure, the
relative frequency of hypertension with overweight was
higher. Stamler et a1, concluded that consistent findings
on the relationship of weight and blood pressure, together
with reported effectiveness of weight loss in blood pressure
reduction in the hypertensive, indicates the association
between overweight and elevated blood pressure is probably
causative. Overweight is probably one factor in the complex
etiology of hypertension. Therefore, it is assumed that the
prevalence of hypertension in the population could be
lowered through the prevention and control of obesity.

Reisin et a1. (1978) studied the effect of weight loss
without salt restriction on blood pressure. The sample of
overweight hypertensive patients in Israel included 24 on no

drugs and a group of 83 on inadequate drug therapy. All of

65

the no-drug group and 57 randomly selected from the
inadequate drug group were placed on a weight loss regimen.
For those 10 to 20% overweight, males were assigned a 1200
calorie diet and females a 1000 calorie diet. Those over
20% overweight were given 1000 and 800 calorie diets, males
and females respectively. Dieting patients visited a
dietitian every two weeks. After six months, all dieters
lost at least three kilograms (mean, 10.5 kg). Seventy-five
percent of the no drug group, and 61% of the dieting drug
group attained a normal blood pressure, a significant (p <
.001) and direct association with weight loss. In the
nondieters there was no change in blood pressure or weight.
The researchers concluded that weight loss is an important
part of hypertensive therapy: being efficient, low cost, and
free of side effects. Since a large proportion of
hypertensives are obese, weight loss should be the initial
step. The authors acknowledged the problem of compliance
with diet as being the major reason physicians do not see
weight loss as a reliable means of blood pressure
reduction.

Knapp (1978) reported on a one-year Canadian study of
dietary compliance in obesity. The sample of 100 patients
30% or more overweight were placed on 1000 calorie diets of
various composition. Diastolic blood pressure was above
90mm Hg in 13 of the patients at the beginning of the
study. Within 12 weeks, the diastolic fell below 90mm Hg in

all but one. The relationship of blood pressure to weight

66

loss was not calculated. Additional results showed weight
loss was related to ingestion of fewer calories regardless
of dietary composition. All experienced weight loss when
the diet was complied with; however, there was a dropout
rate 39% at eight weeks, 50% at 12 weeks, and 78 to 95% at
one year.

Tuck et al., (1981) investigated the effect of weight
loss on blood pressure. Twenty-five obese patients, 30 to
182% overweight, were placed on a stringent 320-calorie diet
for 12 weeks. Twelve of the subjects had blood pressure
140/95 to 180/114mm Hg. More severe hypertensives were
excluded from study. Subjects were randomly assigned to a
group of 15 who received 120mmol sodium per day, and a group
of 10 who received 40mmol sodium. Mean arterial pressure
fell significantly and equally in both groups correlating (r
= .58, p < .05) with weight loss throughout the study. A
reduction in urinary sodium excretion indicated a smaller
sodium intake in both groups compared to usual amounts. The
mechanism accounting for decline in blood pressure may be
the reduction in plasma renin activity and aldosterone which
accompanied weight loss in this study. Renin and
aldosterone were not shown to be influenced by sodium
intake. Results did not necessitate attainment of ideal
body weight as only six reached their goal. A 10 to 30%
reduction toward normal was sufficient to lower blood
pressure to the normotensive range.

Berchtold and Sims (1981) have summarized the known

67

physiology of the association between obesity and
hypertension. Noting that the mechanisms have not been
clarified, obesity and overeating apparently bring about
endocrine and metabolic derangements which contribute to
hypertension. Possible mechanisms may be intracellular
accumulation of sodium, hyperinsulinemia, and increased
sympathetic tone, all of which will decline with physical
training and decrease in caloric intake. As a large
proportion of hypertensive patients lack physical training
and over eat, the treatment for mild and moderate
hypertension should be exercise and a decrease in calories.
The issue of sodium restriction is still a matter of debate
(Berchtold & Sims, 1981). Needed are large-scale studies on
diet, weight loss, and physical training as a fair trial of
prepharmacological therapy in mild and moderate
hypertensions.

Other authors claim epidemiological studies evidence a
reduction of salt in the diet to below two grams a day will
prevent essential hypertension as a major public health
problem (Freis, 1976). Hypertension may be a homeostatic
response to the maintained increase in extracellular fluid
volume resulting from high sodium intake.

Parfrey et a1. (1981) studied 16 mild hypertensives
and eight normotensives in England. In a crossover,
randomized, observer-blind design subjects were placed on a
normal diet plus 100mmol sodium for 12 weeks, and on a

no-added-salt diet plus 100mmol potassium for 12 weeks. On

68

the no-added-salt diet plus potassium, blood pressure fell
sharply within two weeks. At six weeks, the hypertensives'

blood pressures were a mean of 8.9mm Hg lower,

normotensives' blood pressures were 3.7mm Hg higher. On the
normal diet plus sodium, blood pressure rose slowly in both
hypertensives and normotensives. At 12 weeks, the mean
elevation was 8.9mm Hg in hypertensives, and 5.3mm Hg
(non-significant) in the normotensives. The researchers
indicated the fall in blood pressure may be due mainly to
the increased potassium intake, the mechanism of which is
unknown.

MacGregor et a1. (1982) reported a double blind
randomized crossover research of moderate sodium restriction
in essesntial hypertension. In a 10-week study, 19 English
patients with mild hypertension were placed on a
no-added-salt diet and avoidance of sodium-laden foods. For
one month the subject was on 7-12 tablets of lOmmol sodium,
enough to estimate past usual intake. The alternate month
the subject was on the same number of placebo tablets,
during which the mean blood pressure (mean of diastolic and
systolic) was 7.1mm Hg lower than the month sodium was
administered. The authors concluded the fall in mean blood
pressure was the same as that obtained with a diuretic alone
or a beta blocker alone. Therefore, the first line of
treatment for mild or moderate hypertension should be
moderate sodium restriction. The authors noted two problems

in application of findings: compliance with diet which

69

requires careful reinforcement and encouragement, and the
need for food labeling as to sodium content.

Ram et al. (1981) investigated sodium restriction with
diuretic therapy for the effects of potassium wasting and
blood pressure control. In a times series crossover design,
12 patients with mild hypertension were randomly assigned
various diuretics with a high or low sodium diet.
Chlorthalidone, hydrochlorothiazide, or furosemide were
given for four-week intervals. Mean fall in blood pressure
was 13.9mm Hg with the lower sodium diet and 9.1 mm Hg with
the higher sodium diet. Potassium fell a mean of 225 mEq on
the lower sodium intake, and 455 mEq on the higher sodium
intake. Findings indicate a diet moderately restricted in
sodium and a single morning dose of diuretic of intermediate
duration offers the best balance of efficacy and safety of
treatment.

Morgan et al. (1978) studied hypertension treated by
salt restriction over a two-year period. Thirty-one
Australian clients with a diastolic pressure of 95-109mm Hg
were placed on a moderately sodium restricted diet by
avoiding salty foods and not adding salt at the table.
Diastolic fell a mean of 7.3mm Hg, compared to a control
group of 31 on no treatment whose disastolic rose 1.8mm Hg.
A third group of 62 on antihypertensives experienced a drOp
in diastolic similar to the low-sodium group, plus a greater
decline in systolic. However, the 31 thiazide treated

subjects experienced a decline in serum potassium and

70

elevation of serum uric acide (significance level not
reported). The authors did not suggest salt restriction to

100mmol/day is a suitable treatment for clients with

 

established hypertension, but that findings may indicate the

epidemic of hypertension in Australia could be prevented if

 

mean sodium intake were reduced to 100mmol/day. The authors
added that the high sodium content of many prepared foods
make it difficult to reduce intake and comply with a low
sodiunm diet.

Kaplan and Liebeiman (1978) stated the usual amounts of
15 to 20 grams of salt ingested by many clients may negate
the antihypertensive effects of diuretics. Restricted
sodium intake lowers blood pressure by reducing plasma
volume, potentiating the effects of diuretics. Chobanian
(1982) reported that restriction of sodium chloride intake
to less than 50 grams daily should reduce blood pressure 10
to 15mm Hg in at least half of those with mild
hypertension. Sodium restriction minimizes the kaliuretic
effects of diuretics.

In literature concerned with dietary compliance it was
noted that there are similar compliance problems as with
pharmacological therapy (Report of Working Group on Critical
Patient Behaviors, 1981). However Glanz (1980) emphasized
specific differences in compliance problems with dietary and
pharmocologic therapy: whereas medication adds new, fairly
simple behaviors, the diet imposes restrictive behavior.

Diet behaviors are widely variable resulting in more

71

dimensions on which to error. Dietary regimens present
unique problems for clients. They must be applied across
usual meals, snacks, eating out, weekends , vacations,
changes in schedule, and special occasions (Glanz, 1980).

Other factors which present unique problems for dietary
compliance are: (1) diet regimens control rather than cure,
and (2) the medical profession has not been educated to
provide ongoing support for dietary management (Glanz,
1980).

Becker et al., (1977) noted compliance with weight
reduction is unusual because the obesity health threat is
future oriented, not immediate. Obesity may not be regarded
as an illness even when identified as a health problem.
Also, compliance with diet may be undertaken for non health
reasons such as body image and social acceptance.

The widely variable pattern of the regimen presents
unique problems in measurement for the researcher of dietary
compliance (Glanz, 1980). Validity of information by
self-report depends on question phrasing and interview
skills. Researchers have been inconsistant in including
numbers of meals, times of day, across the week, snacks,
eating out. The different methods and criteria used make
data on dietary compliance difficult to interpret. Glanz
suggested different types of dietary regimens may require
specific approaches for assessment, but recommends
standardization of methods and scoring for useful

comparisons of compliance findings.

72

Although weight loss usually correlated with stated
compliance, Glanz criticized the use of weight loss as a
compliance measure. Weight loss may be due to laxatives,
diuretics, or vigorous exercise when weight loss behavior,
and not eating-related behavior, is reinforced.

It is not valid to compare the very obese to those less
overweight as actual weight loss favors the obese in measure
of compliance. Weight loss compared with initial weight is
arbitrary but may be satisfactory for an indirect,
therapeutic outcome measure of compliance (Glanz, 1980).

In a review of studies on dietary compliance for
cardiovascular disease Glanz (1980) found rates of
compliance ranging from 13 to 76%. For weight loss,
compliance research problems of small sample size, volunteer
participants, and high attrition rates were cited. For
further research Glanz recommends sound measures of dietary
compliance, attention to determinants of compliance, and
evaluation of the outcomes of interventions.

Studies supported the validity of information on
compliance using interviews for measurement. Weight loss
usually correlated with reported compliance. Inadequate
information was more of a problem than inaccurate
information. Glanz found difficulties with weight loss
itself as a compliance measure. Further research needs
sound measures of dietary compliance, attention to
determinants of compliance, and evaluation of the outcomes

of interventions.

73

Possible determinants of compliance include
demographics, illness characteristics, treatment
characteristics, knowledge, psychosocial factors, provider
relationships, motivations, and attitudes. Glanz noted the
health belief model has been somewhat successful in
predicting compliance with low sodium and low calorie diets
among hypertensives.

The specific researched interventions of written
messages, nurse phone calls, self monitoring, and social
support were not found to be related to compliance with diet
and medication in a three year study by Glanz et al.
(1981). Compliance with the different antihypertensive
therapies was rated by various means for 432 hypertensive
clients. The low sodium diet was measured by self report:
26% compliance; the weight loss diet was measured by weight
loss as compared to physician recommendations: 12%
compliance. Medication was measured by self report: 42%
compliant; as compared to pharmacy records: 63% compliant.

The Report of the Working Group on Critical Patient
Behaviors (1981) emphasized health professionals have an
obligation to explain rationale for dietary alterations and
assist behavioral changes. Providers must deal with
individual beliefs, backgrounds, support systems, and
needs.

In summary, the value of diet therapy in the management
of hypertension is widely recognized. Authors and

researchers agree weight control is important for blood

74

pressure control. The role of sodium and potassium in the
prevention and treatment of hypertension is controversial
but supported by experts in a number of recent small
studies. The problem of dietary compliance has not been
satisfactorily addressed and apparently has prevented some
health providers from considering dietary management
seriously.

Few studies were found in the literature review for
rates of compliance with diet in hypertensive regimens.
Rates of non compliance in obesity were found to be high,
39-95% (Knapp, 1978). Measurement of dietary compliance is
difficult due to the complexity of measuring restrictive
behavior across various situations by interviewing the
client. The problems of the use of weight loss as a measure
of dietary compliance have been enumerated by Glanz (1980).

Research is also needed to discover determinants and
predictors of dietary compliance so appropriate

interventions may be designed and implemented.
Compliance with Exercise

A classic study often cited as the rationale for
exercise prescription for hypertension is "Exercise Therapy
in Hypertensive Men", Boyer and Kasch, 1970. Over a
six-month period, 23 hypertensive and 22 normotensive
middle-aged men participated in a walk/jog exercise
program. Hypertension was defined as a diastolic pressure

above 95mm Hg. The hypertensive group experienced a drop of

75

11.8mm Hg in mean diastolic and 13.5mm Hg in mean systolic
pressure (p = 0.01). In the normotensive group a mean
diastolic decrease of 6.0mm Hg occurred but without
significant change in systolic.

Messerli (1981) stated that although exercise is
regularly prescribed for hypertension, the antihypertensive
mechanism of prolonged exercise remains obscure. Noting
that general vasodilatation occurs immediately after
exercise Messerli hypoethsized aerobic exercise reduces
total peripheral resistance. In addition blood volume is
lowered through the fluid and electrolyte loss of sweat and
respiration, plus a fluid shift to the extravascular space.

In a review of literature on the association of
hypertension with obesity, and the role of diet and exercise
management, Horton (1981) speculated exercise may result in
(1) altered renal tubular handling of sodium secondary to
decrease in plasma insulin, (2) less sympathetic nervous
system activity with lower plasma concentration of
norepinephrine and epinephrine, and (3) reduced peripheral
vascular resistance.

Roman et al., (1981) researched the effects of
long-term physical training on 30 female hypertensives not
on hypertensive medications. Subjects were prescribed a
combination of callisthenic and walk/jog exercises 30
minutes three times a week. In a time series design, four
phases were described: three months low intensity training,

training discontinued for three months, 12 months low

76

intensity training, and 12 months high intensity training.
The most significant decreases in resting blood pressure
occurred at the end of three and twelve months low intensity
phases: mean 182/1l4mm Hg that decreased to 154/97mm Hg (p <
0.001). When training was discontinued during the
three-month phase, blood pressure rose to pretraining
levels. Increasing the intensity of training did not bring
further lowering of blood pressure. A 30% dropout rate was
reported by the end of the study.

Stamler et al. (1980) studied 115 men with mild
hypertension, diastolic pressure 90-110mm Hg, and 101 men
with high normal diastolic pressure 80-89mm Hg in a
five-year time series design. A nondrug therapeutic regimen
was initiated for the purpose of coronary artery disease
prevention. Individualized recommendations were made for
life style changes in regards to diet, exercise, and
smoking. Results indicated long-term normalization of blood
pressure by a sustained fall in diastolic pressure of 13mm
Hg for the hypertensives, and 4mm Hg reduction for the high
normal group (p <.05). Weight loss averaged 10 pounds.
Findings could not be independently assigned to exercise,
diet, etc. The authors concluded long-term improvements in
eating and exercise habits yielding moderate sustained
weight loss are useful in preventing high blood pressure in
hypertension prone individuals, and in controlling mild
hypertension.

Uman and Hazard (1981) investigated life style changes

77

in hypertensives age 75 and older. The program was designed
to provide the elderly with knowledge, skills, and support
needed to make life style changes which are likely to lower
blood pressure. Sample subjects evaluated over one year
were 100 clients, 52 of whom had a blood pressure above
160/95mm Hg. The plan for potential life style change
included areas of diet, exercise, medications, and visits to
their physician. Aerobic exercise (as measured by self
report) was complied with almost as well as diet. Although,
among those whose blood pressure remained or became elevated
there was less compliance. Exercise was more complied with
than medication and physician visits. Of the 67 patients
who initially had an acceptable blood pressure, one-third
became elevated to > 160/95mm Hg. Half of the initial 33
with elevated blood pressure changed to the acceptable
range. ( < l60/95mm Hg). Compliance percentages,
correlations with compliance, and significance levels were
not reported.

Reid and Morgan (1979) studied compliance with exercise
for 124 firefighters randomly assigned to three groups of
control, health, education intervention, and health
education plus self-monitoring. "Compliance" was defined as
self-reported compliance plus predicted increase of maximum
oxygen uptake (VO ) by 9.5%. "Possible compliers" were
defined as self-reported compliance plus no increase in
maximum oxygen uptake. Noncompliers were all the others.

At six months compliers comprised 26% of the control group,

78

32% of the health education group and 32% of the health
education plus monitoring group. No significant differences
in compliance were found among groups.

In research on client compliance with home exercise
programs, Mulder (1981) found 55.2% continued to achieve
greater than 75% of their exercise goal after 32 weeks of
participation. Subjects were randomly selected from
individuals presenting for outpatient exercise stress
testing. Twenty-two men and seven women, of whom five males
were classified as cardiac patients and the rest basically
healthy, agreed to participate. After an exercise stress
test aerobic exercise was prescribed to raise the pulse to
78-85% of maximum rate for 30 to 60 minutes, three times a
week. Phone contact was made every four to six weeks. It
was hypothesized non-compliant predictors would be negative
answers to: motivation, understanding of disease, alcohol
abuse, exercising at four weeks, regular scheduling of
exercise, and specific reasons for noncompliance.
Predictors were found to be correct in all cases. Clients
with two negative entries were noncompliant. Clients with
zero or one negative entries were compliant. The author
concluded individualized exercise prescription is a
beneficial, reasonable therapy and the physician/client
relationship may have a bearing on compliance.

In summary, a number of recent small studies show
aerobic-type exercise to be useful in the treatment of

hypertension. Exercise may lower blood pressure through

79

direct hemodymanics, or indirectly by contributions to
weight loss and stress reduction. In addition, physical
training is thought to reduce cardiovascular risk by
increasing efficiency of oxygenation. Compliance rates with
exercise prescription for hypertension were not found in the
literature review, with the exception of the Roman et al.,
(1981) report of 30% dropout rate.

Measures for compliance with exercise included drop out
rate, self report, and increase in maximum oxygen uptake,
making it difficult to compare results. Several researchers
addressed compliance but did not report compliance rates
(Mulder, 1981; Uman & Hazard, 1981). Further research is
needed to determine rates of compliance with exercise for
the hypertensive regimen. Predictors and factors related to
compliance with prescribed exercise have not been identified
except in the Mulder study (1981). This gap in research
literature will need to be addressed so that exercise may be
appropriately utilized for effective hypertensive

treatment.

The Health Belief Model

 

Mikhail (1981), in a review and critical evaluation of
health belief model research and literature, noted that the
health belief model developed as a psychosocial formulation
to explain health-related behavior. Development was based
on the twentieth century belief that behavior can be

understood and controlled through science. The assumption

80

is made the subjective world of the perceiver determines
behavior rather than the objective environment.

According to Rosenstock (1974) the original health
belief model proposed that the likelihood a person will take
a health related action is determined by the individuals
psychological readiness to take that action and by the
perceived benefit of action weighed against the perceived
barriers involved. The state of psychological readiness
includes perceived susceptibility to the particular health
condition and the perceived seriousness of the consequences
of having the condition. Perceived susceptibility and
seriousness together have been identifiedas the threat
component of the model which indicates the need for
perceived treatment benefits to lower the threat.

A perceived benefit of taking action is the
individual's evaluation of the advocated action in terms of
its efficacy and feasibility. The perceived benefit is
weighed against perceived psychological, physical, and
financial barriers, or difficulties in taking action. It is
also proposed that a cue to action must occur to trigger the
behavior, and a group of modifying factors serve to
condition the individuals perception. Modifying factors may
be demographics, structural variables, professional
attitudinal variables, and relationships (Mikhail, 1981;
Rosenstock, 1974).

Reformulation of the model was required for explaining

behavior related to chronic illnesses. Chronic illness

81

required the person to stay in treatment indefinitely even
when not feeling sick, and when health state is not
changing, and to do so with minimal social and institutional
support. In reformulation for chronic illness, the concept
of motivation was added to the model. Motivation to take
recommended health action includes the dimensions of concern
about health in general, willingness to seek and accept
medical direction, and positive health activities (Kasl,
1974; Mikhail, 1981).

Mikhail reviewed the health belief model research
literature published from 1959 to 1979. Fifteen studies
supported the perceived susceptibility variable and the
perceived severity variable in their relationship to a
variety of preventive health, sick role, and chronic illness
behaviors. Two studies indicated that when the threat is
high, and ways to cope unknown or unavailable, health
related action is not taken (Ben-Sira, 1977; Leventhal,
1970). Eight studies were cited to support that belief in
efficacy of treatment will promote compliance with health
recommendations. Barriers, conceptualized in a variety of
ways, have been found to be negatively associated with
compliance behavior(Haefner et al., 1970; Haynes et al.,
1976; Kirscht et al., 1977; Taylor, 1979). Cost,
convenience, accessability, side effects, safety,
complexity, and duration of treatment have been studied as
barriers. Mikhail (1981) stated more data are needed on

what constitutes barriers.

82

The health belief model is useful, as well as flexible
in its approach for enabling practitioners to choose the
intervention which best suits the situation (Mikhail, 1981).
Additional studies are needed for different age groups and
cultural backgrounds. Diversity of measures make it
difficult to establish validity of measures and
comparability among studies.

The health belief model is useful in nursing
intervention as it provides a means of understanding
behavior for the purpose of obtaining cooperation and
participation of clients in their own care. Use of the
model implies the attempt to influence client behavior
should be based on better knowledge of their individual
differences and health beliefs. The model is useful to
identify risk of noncompliant behavior. Nurses can
contribute to health belief model development by refining
operational definitions of constructs and testing them
(Mikhail, 1981).

Leventhal et a1. (1980) critically reviewed the health
belief model as one theory, a motivational model, for the
study of compliance. Leventhal et al., noted most studies
fail to test the entire health belief model. It was
reported that the model only accounts for a small proportion
of explained variance in health decisions. Increased
perceived severity often fails to increase compliance with
health recommendations. Cues to action were shown to have

no observable effect on compliance in a number of studies;

83

people may not think in terms of probabilities and scaled
threat which may be defined as cues. Also, the problem is
defined in the model from a health perspective. Non-health
values, self image, and risk inducing behavior such as
smoking, may also be incentives to action. Leventhal et
al., noted the model makes few specific suggestions for
intervention, and successful intervention program features
are unclear. The question was offered: Does belief change
preceed behavior change, or behavior change occur first? It
was concluded that the health belief model has the weakness
of all models for study of compliance--1ack of operational
specificity making it difficult to compare outcomes.

In Loustau's (1979) review of the health belief model
the following intervening variables were added to the model:
knowledge of illness, complexity of treatment, and
interpersonal relations. The review included 16 studies
published 1960 to 1978 in which relationships were found
between the model variables of susceptibility, severity,
treatment benefits and costs, to compliance with the
therapeutic regimen. Severity studies were concerned with
such health conditions as rheumatic fever, otitis media,
strep throat, and weight problems. Barrier studies were
operationalized by access to care, clinic waiting time,
transportation, convenience, interference with life style,
financial considerations, or treatment side effects.
Results of the studies supported the use of the health

belief model to predict patient compliance. Loustau

84

recommended assessing health beliefs to identify misbeliefs
and misunderstanding about illness and treatment, and
concluded it is important to enable the client to
participate in management of care.

Andreoli (1981) investigated compliance with
antihypertensive therapy, using the health belief model as a
conceptual framework. Of 71 male outpatients, 41 were found
to be complaint with medications and 30 non-compliant.
Noncompliance was defined as five diastolic pressure
readings above 92mm Hg in one year when the patient had a
previous record of control on the same medication.
Compliance was defined as a maximum of one diastolic
pressure above 92mm Hg in one year plus "nurse
interpretation". It is unclear what the interpretation was
based on. Questionnaires measured health beliefs about
susceptibility to hypertension, severity of hypertension,
benefits of therapy, and a self-concept scale. Means of
scores on the self-concept scale and the health belief scale
were compared for complier and noncomplier groups by means
of a two-tailed t test. Analysis revealed no statistically
significant differences (p .05) in scores on self-concept
and health beliefs for the two groups. The author concluded
there is no difference in self-concept and health beliefs
between compliers and noncompliers, and recommended further
research to identify other factors of behavior differences.

In a retrospective cross-sectional investigation,

Greene et a1. (1982) studied compliance with medications

85

among 190 chronically ill, inner-city patients. Data were
collected by client interview and from the medical record.
Compliance was categorized by self-report: 28% subjects were
compliant all the time, 16% 3/4 of the time, 30% 1/2 to 3/4
the time, and 26% 1/2 the time. The independent variables
explored were health beliefs, perceptions and knowledge of
illness; social support; regimen complexity; satisfaction
with provider. Relationships to compliance for
susceptibility and severity were negitive, although
originally hypothesized positive. The relationship to
compliance for social support was r = .13( p (.033), for
complexity r = -.35( p <.001), for satisfaction r =.17( p
(.011). The authors found the greatest predictors of
compliance to be the patients' ability to name and describe
their drugs, the patients' ability to describe functions of
their drugs, and complexity of the medication regimen. As
no cause and effect is established by a retrospective
design, recommendations were made for a prospective study.
Stunkard (1981) reviewed health belief model literature
related to weight control. Of the variables perceived
susceptibility, perceived seriousness, perceived benefits,
and perceived barriers, studies showed three variables
failed to predict compliance with medical treatment:
susceptibility, severity, and benefits. Perceived
seriousness was defined as the client's perception of
severity, some studies including the presence and degree of

illness symptoms in the definition. Perceived barriers were

86

variously defined as treatment costs, side effects,
discomforts, complexity, duration, and associated life style
changes. Stunkard suggested that application of the health
belief model may require adaptation to particular
circumstances. The conclusion was made that the model is
more useful after the patient has had experience with
treatment.

Wyatt (1980) developed a health perception instrument
based on the health belief model. The perceptions assessed
were health motivation, susceptibility to illness, severity
of illness, benefits of recommended actions and barriers to
recommended actions. Severity was operationalized as the
degree of worry about hypertension and its effects.
Barriers included perception of ease of treatment
implementation, treatment interference with life style, and
treatment discomfort. The sample of 78 hypertensives, age
28 to 80, were tested twice at two and four-week intervals
to compute a test-retest correlation for reliability.
Twenty of twenty-eight items were reliable. All perception
sets, except motivation, were found to be reliable and have
internal consistency. Content, predictive, and construct
validity were evaluated. Content validity was established
by four nursing faculty members. Items were predictive of
self-administration of medication, diet, and exercise
therapy, but not for appointment keeping behavior.

In sum, a considerable body of literature has developed

around the health belief model in exploration of the

87

compliance issue. Limitations cited by some authors are
incorporated as an integral part of the model by others, as
motivators, barriers, or structural variables. The lack of
operational specificity is cited by some reviewers as a
weakness, by others as flexibility which enhances its
usefulness. The attention the model has received attests to
its importance and contribution in the study of compliance
despite the criticism it makes no contribution to
interventions for improving compliance.

Perceived severity of illness and perceived barriers to
treatment are presented as components of the health belief
model which impact on compliance behavior. However, the
research design is not experimental in most studies
utilizing the health belief model as the conceptual
framework. Therefore causal relationships were not
determined. It has not been established which is first:
health beliefs, or compliance behavior.

There is no consistancy in the definition and
measurement of health belief model variables, making it
difficult to compare research results. Perceived severity
has been defined as perceived worries, effects of illness on
health, and illness related life style changes, usually
elicited by interview and questionnaire. Some researchers
included signs and symptoms from the clients perception or
from medical record audit. In many studies the severity
concept was not defined.

Perceived barriers have been operationalized as access

88

to care, convenience, treatment interference with life
style, side effects, costs, discomforts, complexity, and
duration. Measures of barriers included client self-report
and researcher assessment of costs and clinic
characteristics.

In the following two sections a review will be
presented of recent literature on the health belief model
variables which are the focus of this thesis: perceived

illness severity, and perceived barriers to treatment.

Perceived Illness Severity

 

Perceived illness severity has been one of the primary
variables of the health belief model studied for its
relationship to client's compliance with the therapeutic
regimen. Becker (1979, p. 10) suggested that a prescribed
regimen indicates that a diagnosis of illness has been made,
and the individual is either experiencing symptoms or has
experienced them before. Therefore the presence of physical
symptoms may produce an elevating or "unrealistic" effect on
perceived severity, motivating the individual to follow the
perscribed regimen. However with hypertension elevated
blood pressure may be picked up on routine exam without
symptoms.

In reviewing the literature on perceived severity
Andreoli (1981) reported on a sample of 71 male clients
enrolled in a hypertensive clinic in a VA Medical Center.

The study was conducted to determine if there were

89

differences in self-concept and health beliefs in
hypertensive patients who were compliant, and these who were
noncompliant with prescribed therapy. Severity was
measured by using a health belief questionnaire developed by
the investigators which consisted of 15 perceptual
statements in which a person was asked to rate himself in
three categories of health beliefs, susceptibility to
hypertension, severity of hypertension, and the benefits of
complying with the therapeutic regimen. The results
revealed that there was no difference in perceived severity
of hypertension in clients who practice compliance than in
those who practice noncompliance. It was recommended that
further studies should be done on hypertensives from a
variety of settings, including females, and different sets
of definitive criteria be used to classify compliers and
noncompliers.

Nelson et a1. (1978) examined patients' perception of
health, disease and medical treatment and compliance through
interviews with 142 patients under treatment for
hypertension. Severity was measured using four items
concerning the subject perception about hypertension leading
to a stroke, the probability of sequela without treatment,
the necessity of life time therapy, and the estimated
current level of blood pressure. One item on symptoms of
hypertension, eight items on impact of hypertension on life
style, three items on side effects of medications, and one

item on perceived hypertension symptoms when first diagnosed

 

90

were also used. The multivariate analzysis of data
indicated a positive correlation between perceived severity
of illness with full compliance.

Greene et al. (1982) studied a group of 190 patients
under treatment for chronic medical illnesses to determine
levels of compliance. Interviews with clients on perceived
severity of illness included worries about health, recent
change in health status, and extent of life-style changes.
The findings indicated that clients seeing their illness as
severe were less likely to follow the recommended therapy.

Taylor (1979) conducted a randomized controlled study
to test health belief in relationship to compliance with
antihypertensive regimens in a group of 230 males.
Subjects' perception of seriousness of hypertension was
assessed by a standardized interview which included
questions on medical history and symptoms of hypertension.
The results showed that there was a positive correlation
between perceived illness severity and compliance with
treatment (p = .05) both at the beginning and at the end of
a five-month period.

Gillum et a1. (1979) reported on a retrospective
cohort study of 249 randomly selected hypertensives in a
medical clinic. The median age was 53 years, with 70%
females, and 51% blacks, the remainder white. The study was
conducted to determine the likelihood of clients being
treated for hypertension that would drop out of treatment,

and to determine the characteristics that predispose them to

91

drop out. Information about medications, side effects,
complications of hypertension, and occurrence of symptoms,
were obtained from medical records to determine perceived
severity. Gillum et al. concluded that low perceived
severity of illness coupled with cost and inconvenience and
a lack of physician enthusiasm for the treatment of mild
hypertension were the major factors leading to drop out from
treatment.

Cummings et al. (1982) also looked at perception of
hypertension in relationship to compliance with treatment.
Two hundred and six hypertensives were asked to rate how
serious a health problem they perceived their hypertension
to be. A four point scale ranging from very serious to
not-at-all serious was used. The results showed that
participants who considered their hypertension as severe
were slightly more likely to continue taking medications
than those who considered their hypertension as less
serious.

Morisky et a1. (1982) reported on a study that
examined the effects of a series of educational
interventions designed to positively influence client
attitudes and behaviors toward blood pressure control. The
sample consisted of 200 participants divided into two groups
of which one group received the educational intervention. A
four item scale with a reliability of .62 measured the
belief in the seriousness of hypertension in terms of

causing target organ damage. Results of the study showed

92

that belief in seriousness displayed no statistically
significant difference between the two groups in
relationship to blood pressure control.

Johnson (1979) reported on perception of severity from
a survey of 85 hypertensive participants in a university
family medicine practice. Results showed that 37% indicated
they were bothered by having hypertension. The principal
fears were: stroke 51%, heart attack 49%, and kidney disease
35%. Demographic data indicated that those ages 40 to 59
were more likely to worry about their chance of stroke and
heart attack. Fifty six percent of females as compared to
36% of males were more likely to worry about their chance of
stroke and heart attack. Blacks 82%, as compared to whites
61%, were more likely to believe a kidney problem could
result from hypertension. Other findings indicated that
although nearly all the participants believed stroke and
heart attacks to be complications, only about three-fourths
see decreased chance of these complications as a benefit of
treatment, and only half of these participants have a
definite fear of the complications.

In sum, there are numerous studies that report a
relationship between perceived illness severity and
compliance with the therapeutic regimen. Many authors did
not specify how they operationalized the definition of
perceived illness severity. Some researchers indicated the
consequences of target organ damage were perceived severity,

others looked at the "overall seriousness" of hypertension.

93

There were also studies that showed negative relationships
between severity and compliance. Generally speaking, one
could say that there are more studies that show a positive
relationship to overall perceived severity in relationship

to compliance with the therapeutic regimen.

Perceived Barriers to Treatment

 

Perceived barriers to treatment have been studied in
relationship to outcome health behaviors in a variety of
research designs and methods. Studies have varied in the
operational definitions of both the independent variable,
barriers, and the dependent variable, compliance behavior.
The outcome health behaviors have included compliance
measures of taking medication, keeping appointments,
following diets, and/or rating the therapeutic outcomes such
as blood pressure. Barriers and compliance may or may not
have been conceptualized as components of the health belief
model.

Kirscht and Rosenstock (1977) tested the variables of
the health belief model for their relationship to compliance
in a sample of 132 clients of private physicians. In an
association-testing survey, compliance was measured by
pharmacy records, and self-report of medication and dietary
compliance. Compliance was found to be significantly
related in a positive direction to susceptibility to
illness, illness severity and knowledge of regimen purpose.

Significant negative relationships to compliance were

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correlation of low personal control, dependence on
physician, and psychological barriers. Psychological
barriers included economic costs, convenience, side effects,
and efforts necessary to comply. Understanding of disease
was not related to compliance. Less compliance occurred in
those over 60, especially to diet. The authors emphasized
the importance of assessing client health beliefs for
individualized care and possible modification of the medical
regimen for the purpose of improved compliance. Barriers to
treatment are but one of many interrelated concepts that
were found to affect adherence.

Brand et a1. (1977) investigated the effect of
economic barriers on patient compliance. Barriers were
defined as low income status, number of drugs prescribed,
and frequency of dosage. In an association-testing survey,
six months post hospital discharge, 225 patients were
classified by age, education, income, marital status, and
disease severity. Significant factors relating to
noncompliance were: (1) age--the youngest and oldest groups;
(2) marital status--single and widowed; (3) education--0-6
years; (4) low income; (5) inadequate communication between
physician, health agencies, and clients; (6) more severe
disease; and (7) heavy prescription load. The combination
of prescription load when combined with high drug cost had a
most marked effect. The recommendations of this study were:
(1) reduce unnecessary use of drugs that resulted from

unwarranted demands by clients and overprescription by

95
physicians. (2) develop cooperation between doctors and
pharmacists in prescribing. (3) examine the prescribing
habits of providers. (4) provide drugs without charge for
the needy over 60.

In an association-testing survey Hershey et al., (1980)
examined beliefs of disease susceptibility; disease
severity; disease duration; treatment benefits; general
health concerns; dependence on provider; satisfaction with
care; and the barriers of (1) drug side effects, (2)
treatment/life style conflicts, and (3) treatment duration.
One hundred thirty-two subjects were randomly selected from
an outpatient hypertension program. Beliefs on health
control, and dependence on provider were found to have a
significant positive relationship to compliance; and the
barriers of side effects, life style conflicts and treatment
duration were found to have a significant negative
relationship to compliance, as measured by self-report of
medication taking (p<.05).

Foster et al. (1978) looked at the barriers of
antihypertensive medication side effects associated with
life style impact such as family, social life, sexual
relationships, activities, and job impact. The sample
consisted of 25 hypertensive outpatients selected by order
of appearance at two Midwest hypertensive clinics. Eighteen
were black, the remainder white. Twenty-four were taking
two or more antihypertensives. Ninety-six percent reported

side effects, the most common being postural hypotension

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36%, weakness 36%, failure of erection and/ or ejaculation
42% of males and drowsiness 32%. Most stated side effects
compromised their life style, affecting jobs 38%, sexual
performance 33%, family life 33%, social life 25%,
medication routine 21%, and diet 4%. Rates of compliance
24%, occasional noncompliance 32%, and frequent
noncompliance 44% were attributetd to the burden of side
effects on life style (significance level not reported).

As the treatment dropout rate by hypertensive clients
is high, the National High Blood Pressure Program is
focusing on therapy continuation with treatment goals of
(1). blood pressure diastolic below 90mm Hg, Optimally below
84mm Hg; and (2). few side effects, optimally none. To
address these two goals, Finnerty (1981) studied 51 patients
for step-down therapy: reduction in number of drugs or
dosage. The patients had been on two or three drugs and had
their blood pressure under control at least six months. The
purpose was to reduce side effects and determine minimal
medication for blood pressure control. Subjects were seen
at six-week intervals in a time series design over 30
months. Dosages were reduced before drug elimination
trials. In final analysis, one drug was eliminated in 27
clients and the dosage of another decreased in 43. Thirteen
required restep-up therapy. Of 161 side effect complaints,
18% were unchanged, 26% were significantly decreased, and
56% absent. Finnerty stated step-down therapy has the

potential to decrease side effects, maintain well-being, and

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enhance compliance and cost effectiveness.

Haviland (1982) conducted descriptive research on the
relationship between perceived social stressors and barriers
to dietary compliance with a sample of 71 middle-aged
hypertensive women. Data collected by questionnaire were
analyzed using Pearson-product moment correlations, ANOVA,
and descriptive statistics. Significant relationships were

found between barriers to diet and the social stressors of

parenting (r = -.57, p = .022), homemaking (r = .41, p
.015), singlehood (r = -.57, p = .009), and finances (r =
-.24, p = .002). No relationship was found between barriers
to diet and the social stressors of job, homemaking/job,
marriage, unemployment, and retirement/disability. The
author concluded nurses should assess social stressors as
factors which may influence long-term dietary compliance
behaviors for hypertensive women.

Nelson et al. (1978) examined the impact of clients'
perceptions of health, disease and medical treatment on
compliance with hypertensive treatment. The barriers to
treatment included in the study were perceived time costs
and convenience of clinic visits, perceived medication side
effects, and perceived impact of hypertensive treatment on
life style. By means of personal interviews with 142
clients, compliance was measured in terms of blood pressure
control, self-reported medication-taking, and appointment
keeping. Blood pressure control was found to be associated

with perceived efficacy of therapy, taking medications for

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other chronic conditions, a high anxiety level when
hypertension was first diagnosed, the impact of hypertensive
treatment on life style, and a higher educational level.
Older age and being employed contributed independently to
improved appointment keeping behavior. The researchers
concluded that emphasis on the effectiveness of treatment
and on the potential consequences of having hypertension
would motivate improved blood pressure control.

To summarize these and other studies concerned with
perceived barriers to treatment, the relationships between
barriers and compliance will be reported in the following
section according to the operational definition of barriers:

The side effects of antihypertensive drugs have
frequently been studied for their possible association with
compliance, as medical treatment does make some adherents
feel worse physically and psychologically (High Blood
Pressure Control, 1982; Baile et al., 1979). Foster et al.
(1978), Hershey et al. (1980), Kirscht et al. (1977), and
Nelson et al. (1980) found a negative relationship of side
effects to compliance behavior. Cummings et al. (1982)
found no relationship. Finnerty (1981) and Isiadinso (1979)
stated their findings suggest side effects of medication
have a negative efffect on compliance behavior.

Research addressing the monetary cost of medication and
service usually reports a negative relationship to
compliance (Brand et al., 1977; Kirscht et al., 1977)

however Cummings et al. (1982) reported no relationship.

99

Complexity of treatment (Brand et al., 1977; Isiadinso,
1979) and duration (Hershey et al., 1980) have been shown to
have a negative relationship to compliance.

Access to treatment as a study variable has resulted in
conflicting findings. Cummings et al. (1982) found a
negative relationship, and Logan et a1. (1979) found a
positive relationship to compliance. Wasserman's (1982)
observations suggested a positive relationship, but
statistical significance (p) was not reported.

In this review of literature all research studies
addressing treatment impaCt on life style found a negative
relationship to compliance as a behavioral outcome (Foster
et al., 1978; Bowler et al., 1980; Hershey et al., 1980;
Kirscht et al., 1977; Levine et al., 1979, Nelson et al.,
1978). The JNCDET (1981) says adjustment to life style
change is a problem for compliance and therapeutic
outcomes. There is no discernible benefit, such as relief
of symptoms to impel compliance with treatment.

The operational definition of barriers specifically for
diet has varied among studies. MacGregor et al. (1982)
cited the barriers of inadequate food labeling as to sodium
content, and lack of encouragement and reinforcement by the
provider, but these barriers were not addressed in the
study. Morgan et al. (1978) suggested the high sodium
content of many prepared foods is a barrier, but did not
investigate the relationship to dietary compliance in their

research.

100

Glanz (1980) stated certain characteristics of dietary
treatment are problems and possible barriers to compliance:
(1) complex restrictive behavior resulting in many
dimensions upon which to error, usual meals, special
occasions, snacks, eating out, and so forth; (2) diets are
identified with control, not cure; (3) dietary regimen
duration; and (4) lack of provider skill in ongoing
support. Glanz noted a lack of research on determinants and
predictors which are dietary barriers. According to Glanz,
much of the data regarding determinants of compliance are of
poor quality, difficult to interpret, and do not adequately
address chronic illness.

Becker et al. (1977) found a negative relationship of
dietary barriers to compliance by the mothers of obese
children. Barriers were operationalized as nonsafety of
diet, difficulty of implementation, difficulty getting
through the day, and family problems. However, Kirscht and
Rosenstock (1977) found no correlation of dietary compliance
to the barriers of nonconvenience and efforts necessary to
comply.

Glanz (1979) cited the dietary barrier of interference
with family habits, food cost, lack of access to proper
foods and effort necessary to prepare foods. However, the
concept was not examined for its association with dietary
compliance.

Few barriers specific for compliance with exercise have

been identified in the literature review. Reid and Morgan

101
(1979) found that exercise tailored to life style was more
associated with exercise compliance by firefighters. To
carry this out subjects designed their own fitness program
to overcome a possible life style conflict.

Mulder (1981) specifically addressed the exercise
barriers of alcohol abuse, lack of motivation, inadequate
understanding of illness, irregular exercise schedule,
weather-dependent exercise, lack of time, chronic illness,
and regular travel associated with employment. He found any
two such barriers correlated with noncompliance with
exercise.

In summary, it may be concluded from the review of
literature on perceived barriers to treatment that barriers
are negatively associated with compliance behavior. However
in terms of treatment cost and accessability this
association is not clear. The intangible barriers of
treatment impact on life style have more consistently
demonstrated this negative effect.

Research design has complicated the literature review,
as have the differences in conceptual definitions.
Perceived barriers have been addressed as a component of the
health belief model, or studied alone in research on
compliance. The same definition of a research variable may
be termed "barrier" in one study, and "modifier" in
another. Some barriers were a measurement of client
perception by self-report, others were researcher evaluated

(costs and accessability).

102

Compounding the difficulty of comparing research which
addresses barriers operationalized in numerous ways, the
outcome variable of compliance varried from study to study
(taking medication, following a diet, keeping appointments)
as did its measurement (self-report, pill counts, blood
pressure).

Needed are replicated studies of barriers addressed to
hypertensive treatment which can be used as a basis for the

design of appropriate interventions to enhance compliance.

Nursing Intervention

 

Heine (1981), cited that nurses play an important role
in helping hypertensive clients comply with a therapeutic
regimen. Nurses have demonstrated their effectiveness in
working with these clients through community health
projects, health clinics, and various other hypertensive
programs. Strategies included develoPment of a therapeutic
relationship which consists of establishing good rapport
with open, honest communication. Guidance is another method
suggested in which the nurse assists the client in making
decisions and acquiring skills necessary to carry out the
therapeutic plan. Determining what methods of teaching are
most effective for that individual, and what factors
facilitate or hinder the adaptation of clients to their
illness is also important. All health care providers
working with hypertensives need to explore solutions to the

problems of compliance.

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Daniels and Kochar (1980) described their experience in
a joint practice with a nationally recognized community
hypertensive control program, an inner city hypertensive
clinic, and a work site hypertensive program. Monitoring
and facilitating compliance to the therapeutic regimen was
the responsibility of the nurse. Monitoring compliance was
done on an individual level using a therapeutic
relationship. The individuals' life style, perception of
their illness, goals accomplished, and previous compliance
with the therapeutic regimen were assessed. Strategies for
compliance were based on individual needs. The clinical
setting was also considered. Services were designed and
delivered to facilitate compliance decrease waiting time,
and assure adequate medication supply. Clear instructions
were given should side effects occur. Joint decision-making
by the clinician and client and also significant others were
included in defining the priority and required activities of
the therapeutic regimen.

Hogue (1979) described the effect of nursing
intervention on compliance with hypertensive therapy. In
this study 220 participants were divided into two groups.
The experimental group received reinforcement from public
health nurses over a two-year period. Control of
hypertension increased from 15% to 80% in the experimental
group, and increased from 15% to 34% in the control group.
Two years after the visits stopped, rates of hypertension

control decreased from 80% to 29% in the experimental group

104

and from 34% to 21% in the control group. It was suggested
extended supervision was the reason nursing intervention was
effective.

Tagliacozzo et al.(1974) reported on the impact of
nurse teaching on the compliance behavior of 192 diabetic
and hypertensive clients. Participants in the experimental
group received four teaching sessions while the control
group received none. Results of the study showed within the
experimental group participants with higher education,
income, initial disease knowledge, and lower dependence
showed higher rates of compliance with medication than those
with the opposite characteristics.

Grissom and Gibbs (1976) described goals to help the
hypertensives. These objectives were understanding of the
disease, normalizing the blood pressure, relative freedom
from drug side effects, control of salt intake, and
elimination of other controllable risk factors for coronary
heart disease and stroke. In addition, it was suggested
that appointment time should be used more wisely by
incorporation of client teaching.

Assuming access difficulty factors are barriers to
compliance, work-site nurse-provided care was compared to
regular family physician care in a randomized controlled
trial by researchers Logan et al., (1979). Four hundred
fifty-seven subjects were selected from 21,906 volunteers
screened at business locations, then stratified by age, sex,

diastolic blood pressure, and work site, and randomized to

105

received care by their family physician or by a specially
trained nurse. Nursing care was provided during work
hours. Physician care occurred outside work time. More
work-site clients were prescribed antihypertensive
medications (94.7% vs 62.7%), more work-site clients reached
their goal in six months (48.5% vs. 27.5%), more work-site
clients were compliant (67.6% vs. 49.1%) as measured by
pill counts and stated compliance. The researchers
concluded these significantly improved outcomes were due to
a combination of enhanced access and provider type.

McCombs et al. (1980) reported on the Working Group
study to define behaviors critical to hypertensives
achieving therapeutic control and assuming active
responsibility for their own care. The group focused on
achievement and maintenance of long-term hypertensive
control through drug thereapy and concentrated on the
interactions between clients and health professionals as
critical factors. The objectives of the group were to
define the client's knowledge, attitudes, and skills
necessary to control hypertension over a lifetime. Three
premises were identified: active client participation,
assisting the client in achieving self care, and interaction
between provider and client, will lead to improved
compliance. Critical behaviors identified were: decision to
control hypertension, follow the therapeutic regimen as
prescribed, monitor progress toward blood pressure control,

and solve problems that blocked achievement toward blood

106

pressure control. McCombs et al. further applied the
nursing process of assessment, planning, intervention and
evaluation in the interaction with the hypertensives. Thus,
the Working Group approach provides a basic framework into
which the nurse could use the nursing process to facilitate
critical client behaviors to achieve outcomes in
hypertensive control.

In summary, the literature supports the premise that
nurses have been effective in providing services to millions
of clients with hypertension. Nurses have made significant
contributions in the control of hypertension. However,
there still remain a large number of hypertensives who are
noncompliant with treatment. .Therefore alternative
interventions to help hypertensives achieve therapeutic

control remains crucial to the nursing profession.

CHAPTER IV

METHODOLOGY AND PROCEDURES

Design

A survey design is used in this study to examine the
relationship between perceived severity of illness, and
stated compliance with the hypertensive therapeutic
regimen. Also, in collaboration with Harmon (1983) the
joint hypothesis, client perception of illness severity and
barriers to treatment upon stated compliance with the
therapeutic regimen will be examined. Data will be used
from the intake survey phase of the hypertensive and
diabetic research project conducted by B. Given and C.
Given at four ambulatory sites in Michigan. The project was
federally funded by the Public Health Services, Division of
Nursing, Grant # 5 ROI NU 00662-03. Only intake data from
one point in time will be used.

The following sections of this Chapter include the
design hypotheses, Operationalization of study variables,
sample, instrument development, interviewers, data
collection procedures, human subject protection and data

analysis.

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108

Hypotheses

Primary hypothesis 1. There is a relationship between
client perception of illness severity and stated compliance

with the therapeutic regimen.
Secondary hypotheses:

a. There is a relationship between perceived
seriousness and stated compliance with a medication

regimen.

b. There is a relationship between perceived

seriousness and stated compliance with a diet regimen.

c. There is a relationship between perceived
seriousness and stated compliance with an exercise

regimen.

d. There is a relationship between perceived
psychosocial effects of hypertension and stated

compliance with a medication regimen.

e. There is a relationship between perceived
psychosocial effects of hypertension and stated

compliance with a diet regimen.

f. There is a relationship between perceived
psychosocial effects of hypertension and stated

compliance with an exercise regimen.

109

9. There is a relationship between perceived impact
of hypertension on work and stated compliance with a

medication regimen.

h. There is a relationship between perceived impact
of hypertension on work and stated compliance with a

diet regimen.

i. There is a relationship between perceived impact
of hypertension on work and stated compliance with an

exercise regimen.

Primary hypothesis 2. There is a relationship among client
perceptions of illness severity and barriers to treatment

upon stated compliance with the therapeutic regimen.

Operationalization of Study Variables

Perceived illness severity is defined as the expressed
beliefs and attitudes of the client concerning the effect
of the condition upon present and future health states
(Given, Given, p. 27, 1982). The dimensions included are:
(l) perceived comparative seriousness of hypertension, (2)
perceived psychosocial effects of hypertension, (3) and
perceived impact of hypertension on work.

The perception of illness severity was measured using
a total of 34 questions (Appendix C) developed by (Given &
Given, 1982). Dimension I, which is concerned with

comparative seriousness of hypertension compared to other

110

worries, problems, and illnesses such as diabetes and
pneumonia, was measured with six items on the Belief About
High Blood Pressure Scale (items 1—6). Dimension II
concerned with perceived Apsychosocial effects of
hypertension, such as social change, interference with
social roles, change in entertainment style, shopping,
recreation, leaving home, walking, visiting, isolation
within the family, household chores, family
responsibilities, emotions, and sleep was measured with 21
items on the Effects of High Blood Pressure Scale (items
12-27). Dimension III concerned with perceived impact of
hypertension on work concerned with illness, work conflict,
difficulties hypertension may present on the job,
absenteeism, irritability, job change or extra effort
required to work, was measured with seven items on the
Effects of High Blood Pressure Scale (items 22-28).

The format used for measuring illness severity was a
questionnaire with Likert-type responses ranging from
"strongly agree," agree, undecided, disagree, to "strongly
disagree". Respondents recorded their level of agreement
with each item describing each of the concepts. A high
score was indicative of a high perceived impact of illness

severity.

Perceived Barriers to Treatment

Perception of barriers to treatment is defined as the

expressed belief and attitudes of the client concerning the

111

barriers to undertaking aspects of the therapeutic regimen,
(Given, Given, p. 27, 1982; Yoos, 1981). The following
dimensions of barriers to implementation of therapy are
measured: (1) belief about effects of job on therapy, (2)
beliefs about difficulties with changes required for diet,
(3) beliefs about difficulties with medications, and (4)
disbelief or doubt concerning efficacy of therapy.
Perception of barriers to treatment was measured by a
total of 28 questions on the Belief About High Blood
Pressure Scale. Dimension I, concerned with belief about
effects of ,job therapy including job interference with
taking medications, following a diet, losing weight and
difficulty following prescribed work habits was measured
with seven items (items 28-34). Dimension II was concerned
with specific belief about difficulties with changgg
required for diet including interference with normal
activities, personal life, feelings of hunger, dislike of
allowed foods, time required to follow diet, and need for
family support (items 7-14). Dimension III, beliefs about
difficulties with medications, referring to habit change
required, concern with medication dependency, disruption of
daily activities and long-term therapy, was measured using
eight items (items 15-22). Dimension IV, disbelief or doubt
concernipg efficacy of therapy, including belief of
inappropriateness of treatment, confusion about advice from
different health providers, disbelief in health providers,

and belief that any treatment would be of little benefit,

112

was measured using five items (items 23-27).

A questionnaire was used with Likert-type response
presented in (Appendix C). The degree of barriers was
ascertained by assigning a numerical score to each possible
response such that a high degree of barriers was indicative
of high perceived barriers.

Stated compliance with the therapeutic regimen was
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 & Given, p. 28,
1982). Compliance was measured by use of a total of seven
questions (Appendix C) which measured the patient's stated
frequency of compliance with the use of medication (items
l-3), diet (items 4-5), and exercise (items 6-7) on the
Hypertension Patient Interview Scale.

The format of the questions was a statement of action
followed by a five-point Likert-scale of which the subject
was able to indicate whether they carried out the action.
A Numerical score was assigned to each of the possible
responses such that a low score was indicative of a high

degree of compliance.
Extraneous Variables and Socio-Demographic Data

Polit and Hungler (1978) define extraneous variables
as a kind of independent variable which may influence the

results of the study. The extraneous and socio-demographic

113

variables in this study which may influence the results
are: age,sex, race/ethnicity, yearly income, duration of
diagnosed hypertension, highest blood pressure reading in
the past six months, and percentage of body overweight at
diagnosis. These variables were measured using items (1-6)
on the Socio-Demographic Scale and items (1-3) on the
Medical Record Audit Scale (Appendix C). Descriptive

statistics were utilized for analysis. The range, mean and

percentages was computed.

m

The sample in this study was selected in three
phases. First, a population of hypertensive patients was
identified at four sites in Michigan: Grand Rapids,
Kalamazoo, Lansing, and Saginaw.

The study participants were a sample of 158
hypertensives who voluntarily agreed and met the following

criteria:
(1) were between aged 18 and 65 years of age;

(2) were medically diagnosed as having essential

hypertension;
(3) were able to read and write the English language;

(4) were not documented as having a stroke, end stage
renal disease, blindness, cancer, psychiatric

problems, and pregnancy or lactation;

114
(5) were on a prescribed diet 2; medication regimen.

In the second phase of the sample selection auditors,
consisting of graduate nursing students who had been
briefed on screening procedures, abstracted data from the
(medical records of those participants who met the criteria
for the study. Medical records were screened for the
following data: name of medications, dosages, and dates
prescribed, type of diet, and two weight measures taken at
least two months apart.

Finally, hypertensive clients had to have had a
systolic pressure of 140mm Hg or above or a diastolic
pressure of 95mm Hg or above on two or more occasions.
Using this criteria 256 potential participants were
identified, (Given and Given, 1982).

Letters were sent to all members of the eligible
individuals who met the criteria requesting their
participation in the study. One hundred fifty-eight
subjects aged 24 to 65 voluntarily agreed to be included in
the study. It is the intake data on these participants at
one point in time that is being analyzed for this thesis.

Because the sample was voluntary and not randomly
selected, the results of this study can be generalized only
to hypertensive clients possessing characteristics which
are similar to those of the sample. Therefore, results
should not be considered to be representative of all

clients with hypertension, especially those in specialty

115

care such as internal medicine, as this sample was being

medically managed by residents and family physicians.

DevelOpment of Instruments

The instruments used in this study were developed for
the Contributions to Care: Link to Process and Outcome
research project (5ROINU00662, Given, Given, 1982). The
Beliefs About. Hypertension and Effects of Hypertension
scales were developed in the following manner. Questions
were develOped from a review of patient education material
and a literature review concerning what the hypertensive
client should know about his/her treatment. Statements
describing clients' beliefs about hypertension and benefits
of and barriers to treatment were developed from two
sources. First, statements were written concerning beliefs
about severity of hypertension, and impact and degree of
control of hypertension. Second, a sample of 25
hypertensive clients were interviewed in depth to develop
statements about the nature of hypertension effects upon
health, feelings about therapy, and factors that helped or
made the treatment difficult to follow. From these
interviews, 35 statements about perceptual dimensions were
identified.

A five-point Likert scale ranging from strongly agree
to strongly disagree was used to record responses. With
each instrument, statements were balanced in terms of

positive and negative wording responses.

116

Pretest of Instruments

The instruments were administered to a sample of 154
hypertensive clients and responses were factor analyzed.
For purposes of further validation, the instruments were
then administered to a second sample of 97 hypertensive
clients. The second sample used was drawn from populations
of hypertensive clients receiving treatment at 11
geographically distinct ambulatory care centers that served
as training sites for residents in family practice.
Criteria for inclusion into the sample were the same as

those stated for this research study.
Reliability and Validity

Measures of reliability were conducted for the
instruments used in this study. Reliability is the degree
of consistency or accuracy in which an instrument measures
an attribute. The Reliability coefficient normally ranges
from 0.00 and 1.00. The higher the coefficient alpha, the
more stable the measure. Reliability coefficient above .70
are considered satisfactory, (Borg & Gall 1979).
Reliability is concerned with the degree of internal
consistency within the instrument. The internal
consistency refers to the extent to which all of the
instrument items, or subscales, measure the same
attribute. One way to evaluate internal consistency is

using the Cronbach's alpha method, which was used for

117

scales in this study.

Validity refers to the degree to which an instrument
measures what it is designed to measure, and is concerned
with the sampling adequacy. There are no objective methods
of confirming the adequate content coverage of an
instrument. One way to evaluate validity is by having
someone with expertise and knowledge in that area analyze
the items to see if they represent adequately the
hypothetical context universe in the correct proportions
(Polit and Hungler 1978).

Content validity is concerned with the degree to which
the itmes comprising the scale represent all possible
positions on the particular domain under consideration
(Crano & Brewer, 1973). The content validity of an
instrument is based on judgment. For the scales used in
this study, the items were developed by literature review,
interviewing of hypertensive clients, pretesting with two
samples of hypertensive clients and knowledge and judgment
of the investigators.

Construct validity is concerned with the underlying
attribute rather than with the scores the instrument
produces. The question is: What is this instrument really
measuring? (Polit and Hungler, 1978).

In sum, three types of analysis were employed by Given
and Given (1982) to develop psychometrically scales used
for this study. First, factor and cluster analytic

techniques were to identify items on each scale. Second,

118

criterion measures were used to determine internal and
external consistency. Third, coefficient of invariance
were computed to compare stability of the scales between
both samples. Finally, to measure construct validity a
correlation matrix of the scales was produced. The alpha
coefficient for each scale is reported in Chapter V with

the data analysis.
Research Interviewers

The research interviewers included three graduate
students from Michigan State University College of
Nursing,speciality trained interviewers.

Staff personnel contacted the potential research
interviewers at their particular sites, and, in addition,
the research staff interviewed them prior to being hired.
The research interviewers received two days of instruction
and debriefing, which included an overview of the research
project, ethics of interviewing and interviewing
procedures, and participated in role-playing activities
until able to carry out the procedure.

After interviewing skills were mastered, assignments
were given to interviewers which included a list of
participants to contact. Progress was monitored weekly by
research associates and spot-checks were performed to
assure accuracy and quality of performance. Research staff
members were available by phone on an ongoing basis, and

were present at the sites for the initial client

119

interview.

Data Collection Procedures

The data were collected from two sources: (1)
structured self-administered and interviewer-administered
patient questionnaires; and (2) patients' medical records.
This section describes the sites used for procuring the
data, the type and way in which data were collected and,

training and supervision of interviewers.
Sites

Data was collected from four sites within the state of
Michigan. Three of the sites (Lansing, Grand Rapids,
Saginaw) were ambulatory care centers staffed by residents
in training as family physicians. The fourth site
(Kalamazoo) shared by four internists in private practice

and consisted of two offices.
Collection of Data

After receiving approval of written consent from the
participants indicating willingness to participate in the
study, subjects were contacted via telephone by the
interviewer. Questions and concerns were answered and
additional information given about the study as needed.
The participants were asked when would be a convenient time
to meet the interviewer at the site to complete the

questionnaires.

120

When the interviewer met with the participant at the
site, he/she again described the study, answered questions
and concerns, and upon eliciting the participant agreement
to participate in the study, placed him/her in a private
room. Then, the interviewer explained the content of the
instruments. Finally, before proceeding with the study,
the interviewer asked the participant to sign a consent
form (APPENDIX B) indicating willingness to participate in
the study. Upon obtaining the participant written consent,
five self-administered instruments were given to the
participant in which four were used for this thesis: The
Effects of High Blood Pressure Instrument, The Beliefs
About High Blood Pressure, The Hypertensive Patient
Interview, and The Socio—Demographic Instrument.
Instructions and explanations were given. Then, the
interviewer assured the participant that he/she would be
available if questions arose and participant was left alone
to complete the instruments.

The interviewer periodically checked the participant's
progress and allowed 40 to 70 minutes to complete the
questionnaires. Finally, the interviewer collected the
questionnaires, checked for omission of information and
returned them to the project personnel for coding. The
questionnaires were pre-coded with the date of completion,

site, and participant code number.

121

Human Subject Protection

Specific procedures were employed to assure the rights
of the study sample participants. The rights of the
participants were protected using the standards from the
University Committee on Research Involving Human Subjects
(UCRIHS). Contact letters were sent to subjects describing
the purpose 0f the study, its potential benefit to the
participant, length of time of the study, and requirements
for participation. The letters were also signed by the
medical director of the health care center where the
participant sought care, or by the participant's private
physician. Assurance of anonymity and confidentiality were
provided as part of the contact letter and consent form
(APPENDIX A and B). In addition, code numbers were used on

questionnaires for identifying data collected.
Statistical Analysis Data

Descriptive statistics were used to analyze the
sociodemographic and extraneous variables. The range, mean
and percentages, along with tables summarizing distribution
and percentages of subjects by demographic variables are
presented in Chapter V. Because all hypotheses consisted of
statements that described relationships between variables,
the Pearson Product-Moment Correlation (Pearson r) was used
in the development of the correlation matrix. The level of

significance was set at .05. According to Borg ard Gall

122

(1979), the Pearson r describes the strength of
relationship between two variables.

The correlation coefficient is a numerical index (r)
that expresses the direction and magnitude of a
relationship. The value ranges from -l.00 to 1.00. All
correlations that fall between 0.00 and -l.00 are negative
relationships, and correlations that fall between 0.00 and
+1.00 are positive relationships (Polit & Hungler, 1979).
For this study, the criteria for the strength of
correlations between the variables for deciding acceptance
of the hypotheses is as follows and were taken from Borg
and Gall (1979, p. 513-514):

0.00 - 0.20 no relationship

0.20 - 0.35 very slight relationship

0.35 - 0.85 moderate to fair relationship

0.85 - 1.00 high to perfect positive relationship.

A regression was conducted and a multiple correlation
coefficient was obtained to determine the relationship
among variables for Primary Hypothesis 2: There is a
relationship among client perception of illness severity
and barrierse to treatment upon stated compliance with the
therapeutic regimen. According to Borg and Gall (1979),
multiple regression correlation may be used to determine
whether two or more of the predictor variables can be
combined to predict the criterion better than any one

predictor variable alone.

123

Summary

In this chapter the methodology utlized for this study
was presented. ‘Specific topics discussed were the
hypotheses, Operationalization of study variables, sample,
develOpment of instruments, research interviewers, data
correction procedures, human subject protection, and
statistical analysis procedures. In Chapter V the analysis
of data and a discussion of the results relevant to the

research hypotheses and question is presented.

CHAPTER V
DATA PRESENTATION AND ANALYSIS
Overview

In this chapter a description and analysis of the
sample will be presented. A discussion of the reliability
measures established for each of the instruments used in
measurement of study variables will be discussed. The data
obtained in this study will be presented in relation to the
hypothesis perceived illness severity and stated
compliance. The joint hypothesis perceived illness
severity and perceived barriers to treatment with stated
compliance in collaboration with Harmon (1983) will also be
included. 'Additional findings will be presented in areas
of social demographics and extraneous variables. A summary
of the results of statistical procedures will be

discussed.

Sample Characteristics

The sample consisted of 158 persons who were medically
diagnosed and under medical treatment for hypertension.
Subjects ranged in age from 24 to 65 years; were literate,
showed no evidence of stroke, cancer, psychiatric problems,
end-stage renal disease, blindness, pregnancy, or

lactation. The participants were also on a prescribed diet

124

125

and/or medication treatment for control of hypertension.
Subjects screened into the study had two elevated blood
pressure readings 140/95mm Hg or above within six months

prior to the administration of the questionnaire and

interview.

Socio-demographic Variables

The extraneous variables addressed in this study were:
age, sex, race, marital status, income, duration of
diagnosed hypertension, blood pressure, and percentage
overweight.

Age. Subjects ranged in age from 24 to 65. The mean
age was 46.8 years, standard deviation 10.4 years.

§e§. Approximately half were male (n = 78, 49.4%) and
half female (n = 80, 50.6%).

Eggs. Of this samples, 86.1% were white and 12.0% were
black. The absolute frequency of race recorded was: white
n = 136, black n = 19, Mexican-American n = 1, other n = l,
and one subject did not respond.

Marital Status. A majority (n = 124, 78.5%) of the
subjects were married. Others were single (n = 11, 7.0%);
separated (n = 5, 3.2%); divorced (n = 10, 6.3%); and
widowed (n = 8, 5.1%).

Income. The yearly total income elicited from 151 of
subjects (95.6%). The mean range of reported income was

$17,000 - $19,999. Eighteen of the subjects (11.9%) had

126

yearly incomes less than $9,000; 25 (16.6%) were in the
$9,000 - $16,999 range; 41 (27.1%) were in the $17,000 -
$24,999 range; and 67 (44.4%) reported an income above
$25,000.

Duration of Hypertension. The duration of diagnosed

hypertension was determined for 152 subjects. The mean
range of hypertensive duration was 6-8 years.
Approximately half (n = 83, 54.6%) had diagnosed

hypertension five years or less. Twenty-two had (14.5%)
hypertension 15 or more years.

Blood Pressure. The highest blood pressure reading in
the six months prior to the study was ascertained for 151
subjects (95.6%). Systolic blood pressure ranged from 108
to 210mm Hg, mean 149.3mm Hg, standard deviation 18.0mm Hg.
Diastolic blood pressures ranged from 70 to 120mm Hg, mean
96.7mm Hg, and standard deviation 9.6mm Hg.

Percentage Overweigpp. The sample subjects' weight at
the time of definitive diagnosis of hypertension was
compared to the ideal body weight for 150 participants
(94.9%). One hundred one (67.3%) were more than 20%
overweight. Forty-nine participants (32.7%) were either
normal or less than 20% overweight.

Table l. The distribution and percentages of subjects
by socio-demographic and extraneous variables are presented
in Table 1. Age, sex, race, marital status, distribution of
income level, duration of diagnosed hypertension, blood

pressure ranges, and percentage overweight are summarized

127

in Table 1.

Summary

In sum, the presentation of descriptive statistics
shows the study sample to be evenly divided between male
and female, and evenly distributed over an age range of 24
to 65. The. average duration of diagnosed hypertension
experienced by the sample subjects was approximately seven
years. The participants' blood pressure readings ranged
from 108 to 210mm Hg systolic and 70 to 120mm Hg
diastolic. Two-thirds of the sample subjects were more
than 20% overweight at diagnosis of hypertension. The
majority were white and married with a middle class

income.

Reliability of Instruments

Total Severity. The statistical procedure utilized for
determining reliability of the study instruments was
Cronback coefficient alpha. The reliability coefficient
obtained for total severity was .94. The degree of severity
was ascertained by assigning a numerical score of one to
five for each possible response. A high number indicated a
greater degree of perceived severity. The mean score
obtained for total severity was 2.672 with 158 subjects

responding.

128

TABLE 1. DISTRIBUTION AND PERCENTAGES OF SUBJECTS BY
DEMOGRAPHICS AND EXTRANEOUS VARIABLES

 

Number of

 

Variable Participants Percentage
Age n = 158
24-35 22 13.9
36-45 45 28.5
46-55 53 33.5
56-65 38 24.1
Sex ' n = 158
Male 78 49.4
Female 80 50.6
Race n = 157
White 136 86.6
Black 19 12.1
Mexican-American 1 .6
Other 1 .6
Marital n - 158
Married 124 78.5
Single 11 7.0
Separated 5 3.2
Divorced 10 6.3
Widowed 8 5.1
Income n = 151
Less than $9,000 18 11.9
9,000 - 16,999 25 16.6
17,000- 24,999 41 27.1
25,000 or more 67 44.4

Duration of Hypertension n = 152

Less than 2 years 45 29.6
3 - 5 years 38 25.0
6 - 8 years 27 17.8
9 - 11 years 15 9.9
12 - 14 years 5 3.3
15 years or more 22 14.5

129

TABLE 1. - CONTINUED

 

Number of
Variable Participants Percentage

 

Systolic Blood Pressure n - 151

108 - 140mm Hg 56 37.1
141 - 165mm Hg 64 49.0
166 - 190mm Hg 17 11.3
191 - 210mm Hg 4 2.6
Diastolic Blood Pressure n = 151
70 - 89mm Hg 22 14.6
90 - 104mm Hg 103 68.2
105 - 114mm Hg 23 15.2
115 - 120mm Hg 3 2.0
Percentage Overweight n = 150
20% over ideal 101 67.3
body weight
Less than 20% 49 32.7

over ideal body weight

130

Comparative Seriousness. On the comparative
seriousness subscale with 158 subjects responding to six
items, a mean score of 3.985, was obtained with a standard
deviation of .503 and a reliability of .70.

Psychosocial Effects. The psychosocial effects
subscale consisted of 21 items with 158 subjects
responding. The mean score was 1.919, with a standard
deviation of .534, and reliability coefficient of .95.

Impact of Hypertension On Work. The seven items for
measuring impact of hypertension on work showed a response
of 111. The mean score obtained was 1.749, with a standard
deviation of .549 and a reliability of .90.

Total Compliance. The total compliance subscale showed
158 subjects responding. The mean score obtained was 4.413
with a standard deviation of .592 and a reliability
coefficient of .76.

Medication Compliance. The medication compliance
subscale consisted of three items and showed 158 subjects
responding. The mean score obtained was 4.737, with a
standard deviation of .612 and a reliability coefficient of
.77.

Dietagy Compliance. The dietary compliance subscale
consisted of two items with 125 subjects responding. The
mean obtained score was 3.408, standard deviation 1.207,
and a reliability coefficient of .81.

Exercise Compliance. With 50 subjects responding to

three items on the exercise compliance subscale, a mean of

131

3.210 was obtained. The standard deviation was 1.282 with
a reliability coefficient of .87.

Total Barriers. On the total barriers scale with 158
subjects responding, a mean score of 2.076 was obtained
with a standard deviation of .464. The reliability
coefficient was determined at .91.

The mean scores and reliability coefficient computed
for all scales used in this study is summarized in Table 2.
All the scales showed acceptable levels of internal

consistency.

Data Presentation of Inferential Statistics

In this section, each primary and secondary hypothesis
will be presented with corresponding data. Hypotheses will
be stated in the null with a statement of acceptance or
non-acceptance. The statistical techniques utilized to
calculate relationships among the study variables were
Pearson product moment correlations and a multiple
regression correlation. The degree and direction of the
relationship will be presented with the level of
statistical significance. The confidence level established

for this study was p = .05.

Primary hypothesis 1. There is no
relationship between total perceived illness
severity scores of hypertensive clients and their
total stated compliance with the therapeutic
regimen scores.

132

TABLE 2. MEAN SCORES AND RELIABILITY COEFFICIENTS OF SCALES

 

 

Mean

Number of Possible Standard
Variable Participants (Range 1-5) Deviation Reliability
Subscale
Total
Severity 158 2.672 .407 .94
Comparative
Seriousness 158 3.985 .503 .70
Psychosocial
Effects 158 1.919 .534 .95
Impact on
Work 111 1.749 .549 .90
Total
Compliance 158 4.413 .592 .76
Medication
Compliance 155 4.737 .612 .77
Dietary
Compliance 125 3.408 1.207 .81
Exercise
Compliance 50 3.210 1.282 .87
Total

Barriers 158 2.076 .464 .91

133

The correlation (r) between total perceived illness
severity scores of hypertensive clients and their total
stated compliance scores was .1197 with a significance
level (p) of .068. The null hypothesis was not rejected.
There was no significant relationship between the total
perceived illness severity scores of hypertensive clients
and their total stated compliance with the therapeutic
regimen scores. Both the correlation coefficient and level
of significance were below acceptable level of

significance.

Secondary hypothesis la. There is no
relationship between the perceived comparative
seriousness score of hypertensive clients and
their stated compliance with medication score.

The correlation between the perceived comparative
seriousness score and the stated compliance with medication
score was r = .25 (p = .001), with 155 subjects
responding. The null hypothesis was rejected; there was a
low, positive relationship between perceived seriousness
scores of hypertensive clients, and their stated compliance
with medication scores, indicating that perceived
seriousness, compared to other problems and illnesses,

accounts for compliance with medication to a slight

degree.

Secondary hypothesis lb. There is no
relationship between perceived comparative

134

seriousness scores and stated compliance with

diet scores.

The correlation between perceived seriousness scores
and stated compliance with diet scores was r = .0052 (p =
.447), with 125 subjects responding. The null hypothesis
was not rejected; there was no significant relationship
between perceived comparative seriousness scores and stated
compliance with diet scores, suggesting that dietary

compliance is not accounted for by perceived seriousness.

Secondary hypothesis 1c. There is no
relationship between perceived comparative
seriousness scores and stated compliance with
exercise scores.

The correlation between perceived comparative
seriousness scores and stated compliance with exercise
scores was r = .2861 (p = .022), with 50 subjects
responding. The null hypothesis was rejected. There was a
low, positive relationship between perceived seriousness
scores and stated compliance with exercise scores. The
small relationship indicates that other factors besides

perceived seriousness are impacting on compliance with

exercise.

Secondary hypothesis 1d. There is no
relationship between perceived psychosocial
effects of hypertension scores and stated
compliance with medication scores.

The correlation between perceived psychosocial effects

135
scores and stated compliance with medication scores was r =
-.0576 (p = .238), with 155 subjects responding. The null
hypothesis was not rejected; there was no
significantrelationship between perceived psychosocial
effects of hypertension scores and stated compliance with
medication scores, giving evidence that psychosocial

effects do not account for compliance with medication.

Secondapy hypothesis 1e. There is no
relationship between perceived psychosocial
effects scores and stated compliance with diet
scores.

The correlation between perceived psychosocial effects
scores and stated compliance with diet scores was r =
-.1204 (p = .091), with 125 responding. The null
hypothesis was not rejected; there was no significant
relationship between perceived psychosocial effects scores
and compliance with diet scores, indicating psychosocial

effects as tapped here are not directly related to dietary

compliance.

Secondary hypothesis 1f. There is no
relationship between perceiVed psychosocial
effects scores and stated compliance with
exercise scores.

The correlation between perceived psychosocial effects
scores and stated compliance with exercise scores was r =

.1572 (p = .138), with 50 subjects responding. The null

hypothesis was not rejected; there was no significant

136

relationship between perceived psychosocial effects scores
and stated compliance with exercise scores, indicating that
psychosocial effects as measured in this study do not

affect compliance with exercise.

Secondary hypothesis lg; There is no
relationship between perceived impact of
hypertension on work scores and stated compliance
with medication scores.

The correlation between perceived impact of

hypertension on work scores and stated compliance with

medication scores was r .04656 (p = .315), 109 subjects
responding. The null hypothesis was not rejected; there
was no significant relationship between perceived impact of
hypertension on work scores and stated compliance with

medication scores, indicating compliance with medication is

not accounted for by the impact of hypertension on work.

Secondapy hypothesis 1h. There is no
relationship between perceived hypertension
impact on work scores and stated compliance with
diet scores.

The correlation between perceived hypertension impact
on work scores and stated compliance with diet scores was r
= .0185 (p = .432), 89 responding. The null hypothesis was
not rejected; there was no significant relationship between
perceived hypertension impact on work scores and stated

compliance with diet scores, indicating that impact on work

as measured here does not have an effect on dietary

137

compliance.

Secondagy hypothesis 11. There is no
relationship between perceived hypertension
impact on work scores and stated compliance with
exercise scores.

The correlation between perceived hypertension impact
on work scores and stated compliance with exercise scores
was r = .1936 (p ‘= .122), 38 responding. The null
hypothesis was not rejected; there was no significant
relationship betwen perceived hypertension impact on work

scores and stated compliance with exercise scores, as the

significance level surpassed acceptable limits.

Primary hypothesis 2. There is no
relationship among perceived illness severity
scores, and perceived barriers to treatment
scores upon stated compliance with the
therapeutic regimen scores.

The multiple correlation coefficient for perceived
illness severity scores and perceived barriers to treatment
scores as combined for predictors of stated compliance
scores was multiple r = .4524 (p .001). The null
hypothesis was rejected; there is a moderate statistically
significant relationship among perceived illness severity
scores, perceived barriers to treatment scores, and stated
compliance scores, indicating improved prediction of

compliance by use of both severity and barriers over use of

either one alone. The independent variables of total

138
severity scores and total barriers scores were first
correlated with each other, with a moderate relationship
indicated (r = .3884, p .001). If the independent
variables had correlated highly with each other, there
would have been little or no improvement in use of the
multiple correlation over the use of just one for the
prediction of compliance. Therefore, by using both
perceived illness severity and perceived barriers to
treatment, more of the factors impacting compliance are
accounted for. Correlation coefficients computed between

the study variables are summarized in Table 3.

Extraneous Variables

No significant relationships were found between the
extraneous variables of race, income, blood pressure
measurements, duration of hypertension, and marital status,
and the major study variables. Using Pearson product
moment correlations, low relationships were found between
age and stated compliance with medication (r = .2303, p =
.002), and age and perceived barriers to diet (r = -.2240,
p = .003). These results indicate that with increasing age,
participants reported more compliance with medication, and
less barriers to dietary treatment.

Males were observed to have a higher level of stated
compliance with exercise than females (r = .2718, p =

.028), using a point bi-serial correlation. Twenty percent

139

TABLE 3. THE CORRELATION VALUES BETWEEN SUBSCALES AND

 

 

COMPLIANCE
Medication Dietary Exercise Total

Subscale Compliance ‘Compliance Compliance Compliance
Comparative
Seriousness .2568*** .0052 .2861* .2088**
Psychosocial
Effects -.0576 -.1204 .1572 -.0342
Impact on .
Job .0466 .0185 .1936 .0646
Total Severity .1152 -.0615 .3756** .1197
Total
Barriers -.3476*** -.3358*** -.1157 -.3555***

* <1 .05 significance
** <1 .01
*** < .001

 

. 140

overweight correlated negatively with dietary compliance (r
= -.2205, p = .008), and positively with barriers to diet
(r = .2989, p = .001), and doubt of therapy efficacy (r =
.2193, p = .004). These findings indicate that overweight
subjects reported less dietary compliance, more barriers to
diet and more doubt in therapy efficacy. A summary of the
correlation values observed among the extraneous variables

are summarized in Tables 4, 5, and 6 Appendix D.

Other Findingg

Other sigfnificant findings among the variables of the
study not included in the hypotheses are presented in this
section.

There was a low, positive relationship between
perceived comparative seriousness scores and total stated
compliance with therapy scores (r = .2088, p =.004, n =
157), indicating the seriousness of hypertension compared
to other worries and conditions has a small effect on
reported compliance.

There was a low, positive relationship between total
perceived illness severity scores and stated compliance
with exercise scsores (r = .3756, p = .004, n = 50),
suggesting that the parameters of severity as tapped in
this study account for a small part of the factors which

impact on exercise compliance.

141

Summary

In Chapter V, data were presented that described the
study sample in relation to socio-demographic and
extraneous variables. Reliabilities of scales designed to
measure the study variables were reported using coefficient
alpha. The correlation between study variables were
summarized.

In Chapter VI, the research and the data described in
Chapter V will be interpreted and summarized. Conclusions
will be drawn based on the findings and recommendations for

nursing practice and future research will be presented.

CHAPTER VI
SUMMARY AND CONCLUSIONS
Q‘s—rm

In Chapter VI, a summary and interpretation of the
research findings will be presented. The sociodemographic
characteristics of the sample will be discussed. The
hypotheses are presented in the null form and conclusions
are drawn according to acceptance or rejection of
hypotheses. The implications of findings relevant to
nursing practice and education will be discussed, along

with recommendations for future research.
Sociodemographic and Extraneous Variables

A brief summary of the socio-demographic and
extraneous variables of sample subjects will be presented.
The variables age, sex, race, marital status, income,
duration of diagnosed hypertension, blood pressure, and
percentage overweight will be addressed in relation to
their influence on this study.

Age and Sex. The sample consisted of 158 individuals,
80 females (50.6%), and 78 males (49.4%). Distribution of
subjects by age was fairly even with an age range from 24
to 65. The mean age of study participants was 46.8 years

similar in age to hypertensives studied by Hershey et al.

142

143

(1980) whose sample mean was 52 years. The Framingham
study reported by Kannel et al. (1978) on hypertensive
patients age ranged from 30 to 62 years. The more recent
study reported by the HDFP (1980) participants were aged 30
to 69, similar in age to this study.

The percentage for female is somewhat less than in the
Public and High Blood Pressure (PHBP, 1981) sample of 1,168
controlled and uncontrolled hypertensives of whom 58.0%
were females. The PHBP sample was representative of four
regions of the United States: East, South, Midwest, and
West. Borhani (1982) reported on the prevalence of actual
hypertension in 1978, which indicated more women than men
had sought and received effective treatment for
hypertension. Participants identified for inclusion in
this study sample were drawn from hypertensives who were
not well controlled, blood pressure ( 140/95mm Hg).
Therefore, it is expected there would be fewer females in a
sample with both controlled and uncontrolled hypertension.

The PHBP study sample had 20.4% under age 35; 30.2%
age 35 to 49; and 49.4% age 50 to 64. Whereas in this study
sample 43.1% of subjects were in the age group below 35.
Nelson et al. (1980) reported that age was not associated
with compliance; however, sex was found to be significantly
related to noncompliance. Nelson found 70% males were
noncompliant as opposed to 45% females. Other studies
reported no significant relationship between age or sex and

compliance, Cummings et al. (1982), Hershey et al.

144

(1980). The data analysis in this study did not show
differences between males and females regarding diet and
medication compliance. However, males were found to have
more stated exercise compliance than females. Other
studies that reported the differences in exercise
compliance between males and females were not found by this
author.

Nelson et al. (1978) reported on a study sample that
showed a significant positive relationship of compliance
with age 50 or above. Brand (1977) reported less
medication compliance with oldest and youngest groups, and
Kirscht et al. (1977) found that individuals above age 60
had less compliance with diet.. Whereas in this study
sample, low significant relationships were found between
age and medication compliance, and between age and dietary
barriers. Cummings et al. (1982) reported studying a
group of 206 hypertensives average age 58, in which there
was a slight tendency for participants who were
noncompliant to view hypertension as less serious an
illness than those who were more compliant. Whereas in
this study sample, the mean age was 46.8 and there was a
low significant relationship between comparative
seriousness and medication compliance. In sum, this sample
was a fair representation of hypertensives compared to
other studies.

3322. This study sample consisted of 86.6% white,

12.1% black, and 1.2% other. There were proportionally

145

more whites, and less blacks and other races than the PHBP
hypertensive survey. The PHBP study included an oversample
of 1,147 blacks, using weighted percentages to reflect the
adult American population. The PHBP study sample consisted
of 79.0% white, 1610% black, and 5.0% other after weighing
the percentages. Kaplan (1982) reported on the findings
from the U.S. Public Health Service and Nutrition
Examination Survey (HANES), performed from 1971 to 1974 on
a representative sample of over 17,000 persons in the
United States. Findings revealed a higher level of blood
pressure at virtually every age for black men and women.
Furthermore, blacks suffer a proportionately higher
morbidity and mortality rate from hypertension than other
racial groups. Research conducted by Cummings et al.
(1982) on an inner city hypertensive population included
97% blacks. Table 6, Appendix D illustrates a tendency
toward more psychosocial impact of having hypertension for
blacks. According to Borhani, (12981) this may be due to
blacks having more severe hypertension. The findings from
this study should be generalized to a population with
similar characteristics.

Marital Status. Works by Cummings (1982) and Haynes
(1982) found no relationship between marital status and
compliance. Nelson et al. (1980) reported that
noncompliance was found to be positively correlated with
having little social interaction and living alone. Brand

et al. (1977) found that living alone correlated with less

146

medication compliance. In this study sample, the majority
of the participants were married (n=124, 78.5%). Results
showed no relationship between marital status and the study
variables (Table 6, Appendix D).

Income. In this study sample, 11.9% of participants
reported less than $9,000 income annually, and 44.4% above
$25,000; as compared to the PHBP hypertensive (sample of
61.6% below $10,000, and 19.0% above $15,000. The mean
income reported for this sample ranged from $17,000 to
$19,999. This study sample was represented by a higher
income level than the PHBP sample. This research indicates
that lower income was related to perceiving greater
psychosocial effects of having hypertension thus as income
increases, psychosocial impact of hypertension decreases.
There were no other correlations found among the study
variables (Table 4, Appendix D).

Duration of Hypertension. Duration of diagnosed
hypertension by participants were: less than two years,
29.6%; three to five years, 25.0%; six to eleven years,
27.7%; and longer than 15 years, 14.5%. The characteristics
were similar to the PHBP sample whose duration of
hypertension was: 28% less than two years, 26% three to
five years, 20% six to ten years, and 25 % longer than ten
years. Duration of the illness would indicate that over
time, the participants would have had considerable
experience with diagnosis and treatment, therefore would

have formed and set their perceptions, beliefs and behavior

147

about the illness. However, in this study sample, duration
of hypertension showed no relationship with the study
variables.

Blood Pressure. This study sample blood pressure
readings ranged from 108 to 210mm Hg systolic (mean 149.3)
and 70 to 120mm Hg diastolic (mean 96.7). No relationships
were found among the study variables and blood pressure
levels.

In Nelson et al. (1978) study of hypertension
clients, the sample mean diastolic was 103mm Hg
pretreatment and 90mm Hg during treatment. Diastolic blood
pressure correlated highly with self-reported medication
taking. Haynes et al. (1980) indicated that blood
pressure correlated with pill count compliance. However,
these two studies began with clients prior to being treated
with medication.

It is possible that this investigator found no
correlation between blood pressure and compliance because
compliance may have been over reported despite the
attention paid to interviewers' training. Another possible
alternative explanation may be that the therapeutic regimen
may have been inadequate.

Percentage Overweighp. Two-thirds of the study sample
was more than 20% over their ideal body weight as judged by
their actual weight at their diagnosis of hypertension. A
statistically significant relationship between overweight

and less stated dietary compliance, and increased

1"3

perceptions of doubt of therapy efficacy was observed in
this study. In addition, correlations approaching
significance were found between obesity and increased
psychosocial effects of hypertension, increased barriers to
medication, and a tendency toward less exercise
compliance. (Table 6, Appendix D).

For this sample overweight is a prevailing problem.
Obesity was also found in the hypertensive screening of
1,000,000 Americans, reported by Stamler et al. (1978).
Stamler stated that the frequency of hypertension in
reported overweight individuals doubled for ages 20 to 39,
and 50% more for those 40 to 64. Being overweight was
measured by self estimates of being 25% over ideal body
weight. Stamler's findings indicated that there was a
higher relationship of obese hypertensives found in whites
than in blacks.

The Hypertension Detection and Follow-Up Program study
of hypertensives showed that 62% of the individuals were
more than 20% overweight. In the PHBP sample study, 55% of
the hypertensives considered themselves to be overweight,
44% had been told to go on a weight reducing diet, 22% were
on a weight reducing diet, and 6.6% of total hypertensives
felt they were very successful with their weight loss
program (11.7% felt slightly successful).

Kaplan (1978) reported that obese individuals tend to
have higher blood pressures. Weight gain has been shown to

be associated with the develOpment of hypertension in young

149
people. Further, Kaplan adds that in the Framingham study,
obese individuals had over twice the incidence of angina or
sudden death than did nonobese individuals.

Other findings by Stewart, and Brook (1983) indicated
that obesity is a common ailment affecting 20 to 50% of
adults in the United States. Williams (1978) stated that
obesity is a health hazard which increases the risk of a
number of diseases such as coronary artherosclerosis and
hypertension. Mayer (1980) categorized obesity as a
condition with an accumulation of fat in excess of that
necessary for optimal functioning. Miller (1983) implied
that obesity is a chronic illness and at least one out of
every five Americans is overweight and most obese
individuals will not remain in treatment.

This author did not find any studies that addressed
two chronic illnesses such as obesity and hypertension in
relation to compliance. However, studies by Brand et a1.
(1977) and Isiadinso (1979) indicated that the complexity
of hypertensive therapy is associated with lack of
noncompliance. Treatment for obesity is complex requiring
changes in life-style behaviors, and of long duration.
Diets may intefere with family habits; barriers, such as
the cost of food, access to proper foods, and time required
to prepare meals further increased the likelihood of
noncompliance with dietary recommendations (Glanz, 1979).
In addition, with hypertension this further increases the

complexity of the regimen.

150.

The findings from this study and other research
indicates that obesity is a major health problem in the
control of hypertension, this indicates the need for
nursing interventions. The nurse is in a key position to
monitor this chronic illness. In primary care, the nurse
can provide longitudinal follow-up through continuity of
care. The nurse can provide support in deve10ping
meaningful relationship with the client. According to
Miller (1983) making an assessment of the individual's
eating behaviors, including the stimuli that provoke eating
is the first step in develoPing client/nurse perception
into the unique client situation.

In advanced practice, the nurse can use advanced
knowledge and skills to monitor the client on a long-term
basis. Detailed assessment of environmental factors,
significant others and psychosocial effect would be
assessed. Assessment of social stress is also significant
to plan for helping to overcome barriers to compliance.
The client's perception of the severity of the consequences
of the illness, and whether obesity is perceived as a
chronic illness is also important. The nurse's overall
goal would be to promote client perceived control of

dietary behaviors.

151

Statement of the Research Question

The research question stated in this study was: Is
there a relationship between perceived illness severity,

and compliance with the hypertensive therapeutic regimen?

Research Hypotheses

In this section each hypothesis is presented
separately in the null form, followed by a brief discussion

of the findings in relation to the hypothesis.

Primary hypothesis I: There is no relationship between
total perceived illness severity
scores of hypertensive clients
and their total stated compliance
with the therapeutic regimen

scores 0

A statistically significant relationship was not found
between total perceived illness severity scores and total
stated compliance scores. Therefore, the null hypothesis
was not rejected. These results support the findings of
Andreoli (1981) Greene et al. (1982) who reported that
hypertensive clients perceived illness severity showed no
significant relationship to compliance. Other studies by
Taylor (1979) Cummings et a1. (1982) did find

statistically significant difference between perceived

152

illness severity with hypertensive clients. The lack of
agreement between perceived illness severity and stated
compliance could be attributed to the different ways in
which perceived severipy illness is defined and measured by
different studies. Many authors did not specify how they
operationalized the definition of perceived illness
severity. Some researchers examined overall seriousness of
hypertension, whereas others indicated consequences of
target organ damage as perceived severity. In this study,
perceived illness severity was operationalized as perceived
comparative seriousness of hypertension, perceived impact
of hypertension on work, and perceived psychosocial effects
of hypertension. The findings in this study may be
attributed to the variation in definition of the concepts.
Another alternative explanation for this finding is that
some individuals may fail to experience or recognize
symptoms of hypertension thereby not perceiving the illness
as severe thereby not complying with the regimen, or
comparative seriousness may not be an adequate measure of

seriousness.

Secondary hypothesis la: There is no relationship between
the perceived comparative
seriousness scores of hyper-
tensive clients and their stated

compliance with medication score.

There was a low positive relationship between

153

perceived comparative seriousness scores of hypertensive
clients and their stated compliance with medication scores
r = .2568 (p = .001). Therefore, the null hypothesis was
rejected. This finding is in agreement with studies
reported by Nelson (1978) and Taylor (1979) which indicated
a positive relationship, between comparative seriousness
and stated compliance with medication. However, studies
reported by Inui (1981) and Wagner et al. (1981) showed a
negative relationship toward comparative seriousness and
stated compliance with medication. Taylor (1979) measure
of comparative seriousness was constructed to parallel
those employed by vulnerability. Questions were
constructed to elicit information regarding how worried a
person would be if an illness was acquired. Whereas Nelson
(1978) measure of comparative seriousness focused on target
organ damage caused by hypertension and the necessity to
stay in treatment for life. Different measures of
compliance were used in the studies, such as pill count,
self-report, combined rule of blood pressure and
prescription refills.

According to Gordis (1979) there are many techniques
used in measuring compliance. Perhaps the major focus
should be on the methologic aspects of measuring compliance
and the conceptual issues involved in the classification of
clients' behavior as complier and noncomplier. The finding
in this study and incongruence with other research findings

may be attributed to the different measures of compliance.

154

This study used stated compliance to medication. It is
possible that clients who perceived their hypertension as
serious compared to other illnesses such as diabetes may
comply with medications. Another alternative explanation
may be that some individuals may perceive medication as an
easy and simple regimen to follow, thereby complying with
therapy, regardless of comparative seriousness.

The findings in this study would indicate the need for
awareness by nurses that the hypertensive client may need
ongoing assessment of the therapeutic plan. The nurse
could assess the complexity of the medication regimen, such
as number of pills the client has to take, and the schedule
to follow. Side effects of medication should also be
explored. Assessment of levels of compliance and the
client's perception of illness severity is essential. The
assessment should be thorough enough to determine areas of
noncompliance behaviors. Since individuals are unique in
their behavior, the client's perception of the degree to
which compliance is or is not carried out is vital for
nursing assessment. This information is essential as a
basis for nursing interventions. The clinical nurse
specialist possesses the skills and knowledge to monitor

the hypertensive client on an ongoing basis.

155

Secondary hypothesis lb: There is no relationship between
perceived comparative seriousness
scores and stated compliance with

diet scores.

There was no significant relationship between
perceived comparative seriousness scores and stated
compliance with diet scores r = .0052 (p = .447). The null
hypothesis was not rejected. Both the correlation
coefficient and level of significance were below acceptable
levels. This finding is in agreement with Glanz (1980).
Glanz suggests that the widely variable pattern of the
regimen presents unique problems in measurement for the
investigator. For future research, Glanz recommends
efficient measures of dietary compliance, attention to
determinants of dietary compliance and methods to evaluate
the outcomes of interventions.

It was not determined in this study whether subjects
were on a special diet such as low salt or cholesterol,
therefore, diet may not have been recommended as a
treatment for hypertension. Another alternative
explanation for these findings may be that two-thirds of
the participants were more than 20% overweight, probably
indicating there is less dietary compliance or maybe
identifying noncompliers! personality. As 78.5% of the

subjects responded this may also have attenuated the

156

results.

Secondarthypothesis lc: There is no relationship between
perceived comparative seriousness
scores and stated compliance with

exercise scores.

A statistically significant positive relationship
between comparative seriousness scores and stated
compliance with exercise scores was observed in this study
r = .2861 (p = .022). As 50 subjects responded 79%, this
may indicate that compliers' personality may be different
than noncompliers. Mulder (1981) suggests that
understanding of hypertension, and having a chronic illness
may be significant predictors of exercise compliance. No
other literature was found by this author that hypothesized
a relationship between perceived comparative seriousness
and stated compliance with exercise. It is possible,
therefore, that this sample may be responding to marketing
of physical fitness, and health care providers may be
facilitating exercise as a prescription for hypertension.
According to Reid et al. (1979) physicians' involvement in
exercise programs are growing.

The nurse's role in this situation would be to assess
the client's perception of exercise as a treatment for
hypertension, and level of compliance with exercise. In
addition, thorough assessment of the client's ability to

exercise, such as limited range of motion, shortness of

157

breath while walking, easily fatigued, or access to a safe
place to exercise. Also, does the client perceive
hypertension as severe enough to exercise? This data would
provide some guidelines for nursing interventions to help
the client comply with the treatment and control

hypertension.

Secondary hypothesis 1d: There is no relationship between
perceived psychosocial effects of
hypertension scores and stated
compliance with medication

scores .

A statistically significant positive relationship
between perceived psychosocial effects of hypertension
scores and stated compliance with medication scores was not
observed in this study r = -.0576 (p = .238). The null
hypothesis was not rejected. Nelson et al. (1980)
reported that hypertensive clients who indicated that their
illness had disrupted their life-styles tended to be poor
compliers (saliency of hypertension) (p = 0.02). Nelson
(1978) reported that a high degree of impact of
hypertension on life—style was negatively related to
compliance as 155 subjects out of 158 responded to items on
the psychosocial scale. An alternative explanation may be
that medications are easily taken and perhaps does not
interfere with life-style. Another plausible explanation

may be that this sample of hypertensives' blood pressure

. 158
was out of control (:>'140/95mm Hg.), therefore, the
subjects may have been noncompliant to their medication
regimen, or on inadequate treatment. No other literature
was found to support or disprove this finding.

These findings would indicate the need for nurses to
assess the client's family or significant other as a
support system. The resources the client has available and
the inteference of the medical regimen with the client's
social and family relationships are important. The medical
regimen may be causing disruptions in life-style. This
information could aid in assisting the client to deve10p an

individual plan of care tailored to his/her life-style.

Secondary hypothesis 1e: There is no relationship between
perceived psychosocial effects
scores and stated compliance

with diet scores.

Although the null hypothesis was not rejected for this
study, the findings are approaching significance level r =
-.1204 (p = .091). The findings in this study were
approaching the level of significance meaning that the
obtained results are unlikely to have been due to chance.
As 125 subjects responded to the items on the scale
indicating that psychosocial effects tapped may have an
approaching relationship to compliance. Again no other
literature was found to support or disprove this finding.

According to Glanz (1980), the widely variable pattern

159

of the regimen presents unique problems in measurement for
the investigator of dietary compliance. Validity of
information by self-report depends on memory, question
phrasing and interview skills. Investigators have been
inconsistent in data recording such as number of meals,
times of day, snacks and eating out across the week.
Therefore, the different methods of measures make data on
diet compliance difficult to interpret.

Glanz (1980) also suggested that many of the available
data concerning dietary compliance are of poor quality, and
there is lack of data on dietary compliance in published
reports of chronic illness. The feature of the illness may
have an effect on dietary compliance and different types of
dietary regimens may require specific approaches for
assessment. Glanz recommends sound measures of dietary
compliance, attention to determinants of compliance, and

evaluation of the outcome of interventions.

Secondary hypothesis 1f: There is no relationship between
perceived psychosocial effects
scores and stated compliance

with exercise scores.

The results of this study revealed a positive
correlation approaching significance between perceived
psychosocial effects scores and stated compliance with
exercise scores r = -.1572 (p = .138). The null hypothesis

was not rejected. Several researchers addressed compliance

160
with exercise Mulder (1981); Uman et al. (1981), however,
they did not report significant findings between perceived
psychosocial effects scores and stated compliance with
exercise.

There may be a few plausible explanations for the
findings in this study. As 50 out of 158 subjects who
responded to the items on the scale that low response
number may account for the data obtained. Since the
results showed relationship approaching significance with a
low number of respondents, a higher number could have
probably resulted in a significant relationship.
Seemingly, the number that responded felt that the
psychosocial effects of having hypertension influenced
their compliance with exercise. Also, it can be speculated
that this sample was either noncompliant with their
treatment, or exercise was not prescribed as part of the
treatment plan.

Based on these findings, the nurse could assess how
exercise inteferes with the client's life-style and also if
the client perceives exercise as a beneficial treatment.
Most physicians do not prescribe exercise as a treatment
for hypertension with support and follow-up. Therefore,
this could be an ideal situation for the nurse to gather
information and use as a data base to help the client

develop a treatment plan.

161

Hypothesis lg: There is no relationship between perceived
impact of hypertension on work scores and

stated compliance with medication scores.

The hypothesized relationship between perceived impact
of hypertension on work scores and stated compliance with
medication was not supported by this study's findings r =
.04656 (p = .315). The null hypothesis was not rejected.
It may be speculated that perhaps since the subjects' blood
pressure were out of control ( 140/95), they were not
following their treatment. Data was not collected
regarding employment status. However, as 70.3% responded
to the items on work, it can be assumed that they were
employed and did not perceive the impact of hypertension on
work as related to compliance.

Nelson et al. (1978) examined clients' perceptions of
health, disease, and medical treatment and compliance
through interviews with 142 clients under treatment for
hypertension. The results showed a high degree of impact
of hypertension on life-style was negatively related to
compliance. Foster et al. (1978) examined impact of
antihypertensive therapy on job. The sample consisted of
25 hypertensive outpatients. Thirty-eight percent stated
that side effects compromised their life-style affecting
jobs. Foster et al. (1978), Bowler et al. (l980)reported

negative relationships between impact of hypertension on

162

work and stated compliance.

Secondary hypothesis 1h: There is no relationship between
perceived hypertension impact on
work scores and stated compliance

with diet scores.

A statistically significant relationship between
perceived hypertension on work and stated compliance with
diet was not observed in this study. Therefore, the null
hypothesis was not rejected. Literature was not found to
support or dispute this finding. It may be postulated that
since more than two-thirds of the sample were 20%
overweight, they were not following a diet, or did not
perceive compliance as related to work. Another
alternative explanation may be that diets may have not been
prescribed as treatment for hypertension, or if prescribed
not reinforced with follow-up or referral. Empirical
observations made by this author indicate that normally
physicians do not prescribe diets as treatment for

hypertension.

Secondary hypothesis 1i: There is no relationship between
perceived hypertension impact on
work scores and stated compliance

with exercise scores.

The null hypothesis was not rejected. There was no

significant relationship between perceived impact of

163
hypertension on work scores and stated compliance with
exercise scores r = .1936 (p = .122). The search of the
literature revealed no studies that measured perceived
hypertension impact on work scores and stated compliance
with exercise scores. Therefore, this study is a
contribution to the gap in research. Scientific studies
are needed to guide nursing practice to understand and
explain the function and forms of nursing care in meeting
the needs of society, and in helping clients regain or
maintain health. In sum, based on findings from this study
the impact of hypertension on work does not seem to

influence compliance with treatment.

Primary hypothesis 2: There is no relationship among
perceived illness severity scores,
and perceived barriers to treatment
scores upon stated compliance with

the therapeutic regimen scores.

A moderate statistically significant relationship was
observed among perceived illness severity scores, perceived
barriers to treatment scores, and stated compliance scores
r = .4524 (p 22>.001). The total variance accounted for in
compliance by severity and barriers resulted in 22.5%.
Therefore, the null hypothesis was rejected. When four
components of the health belief model were combined, there
was a total relationship to compliance found by Becker et

a1. (1977). Whereas Andreoli (1981) found no difference in

164

combined health beliefs of susceptibility, severity,
benefits, and barriers with compliant and noncompliant male
hypertensives. Both Nelson et a1. (1980) and Greene et
a1. (1982) have combined parts of the health belief model
with other variables, however, results have been difficult
to make comparisons.

One point may be made about the findings in this
study. The moderate correlation found may be due to the
specific use of measures which addressed perceived
life-style barriers, and perceived severity as compared to
other problems and concerns. The assumption of the health
belief model as reported by Kirscht and Rosenstock (1977)
indicated that compliance behavior is accounted for by
multiple perceptions; this supports the moderate
correlation found in this study between the variables
severity, barriers and compliance. A search of the
literature did not locate other studies seeking a
relationship between severity, barriers, and compliance.

Based on these findings, the nurse could
develOp an assessment tool to assess the client's illness
severity, barriers to treatment, and stated compliance.
Questions that would yield the most useful information
could be constructed. Questions such as: Is the client
experiencing side effects from the medications or
treatment?' How serious do you think your present illness
is? After an assessment is completed, the nurse would be

able to help the client problem solve to develOp a

165

treatment plan suited to the client's life-style. As this
research does not address interventions, the findings
indicate areas important to assess and where the focus of
intervention might be.

Other Findingp: There was a low positive relationship
between perceived comparative seriousness scores and total
stated compliance. This finding is in agreement with study
result reported by Cummings et a1. (1982) who examined
patient perceptions of hypertension in relation to
compliance with treatment. The results showed that
participants who considered their hypertension more severe
were slightly more likely to comply with treatment than
those who considered hypertension as less severe. This is
an unexpected finding since two-thirds of the sample were
over 20% overweight, thereby not complying with diet. In
addition, the sample blood pressures were above l40/95mm Hg
out of control. One may want to examine the types of
treatment prescribed for the subjects as treatment may mean
taking medications only and not following diet or exercise
regimen. Finally, there was a low, positive relationship
between total perceived illness severity scores and stated
compliance with exercise scores found in this study. This
finding may be attributed to individuals being more aware
of the benefits of exercise, and providers suggesting
exercise as a treatment.

The implications for nursing derived from these

findings indicate that the nurse may want to assess how the

166

client perceives diet and exercise as being a beneficial
treatment. The observed correlation between perceived
illness severity and compliance with exercise scores
emphasizes the value of assessing the benefit of exercise.
As the nurse may want to emphasize exercise as part of the
treatment plan for the client.

In sum, hypotheses regarding perceived comparative
seriousness of hypertension in relation to stated
compliance with medication, and stated compliance with
exercise; perceived psychosocial effects and stated
compliance with diet and stated compliance with exercise;
and perceived illness severity with barriers to treatment
in relation to compliance, were found to be statistically
significant. Other findings related to perceived
comparative seriousness and total compliance, and total
perceived illness severity with stated compliance were also
found to be statistically significant. Other hypothesized
relationships between study variables were not found to be

statistically significant.
Implication for NursingPractice

The results of this study have identified a number of
significiant relationships that may be applied to nursing
practice with the hypertensive client in primary care and
advanced practice. Implications for nursing practice are
discussed within King's framework of goal attainment. The

goal of determining individual's perception of illness

167
severity in relation to compliance is linked to the
assessment phase of the nursing process. Study findings
which have relevance in the assessment of hypertensive
clients include the following.

There is a low positive relationship between clients'
perceived comparative seriousness of hypertension clients,
and stated compliance with medication. Based on this
finding nurses would be aware that hypertensive clients
need assistance in complying with treatment. The nurse is
in a key role to educate clients on the seriousness of
hypertension and long term care. This would facilitate
clients' compliance, and help maintain their health
status. In advance practice nurses are qualified to
monitor chronic illness, evaluate prescribed treatment and
provide psychosocial support and health education. In
primary care the nurse can provide longitudinal follow-up
and coordinate care with other health care discipline.

The nurse clinician has knowledge and skills in
history interview and assessment. During the assessment
phase, the nurse would assess the client's perception about
the effects of hypertension and its treatment on his/her
health status. The client's perceived severity of illness
in relation to compliance with medication, side effects of
medications, and complexity of regimen would be assessed to
identify clients who are having difficulty following
treatment or clients at risk for noncompliance. According

to King (1981) in assessment the nurse acts, reacts, and

168

interacts with clients to reach transaction. Awareness by
the nurse of the client's perception of hypertension
compared to other worries, problems, and conditions would
reveal inappropriate health beliefs or misperceptions of
illness. Whether the client perceives the illness as
severe, and whether the illness is severe can be assessed.
This would help determine if perceived seriousness is
accurate. The nurse can then help the client to focus on
those areas to correct misperceptions.

Other findings of this study indicated there was a low
positive relationship between comparative seriousness and
stated compliance with exercise. This would provide a base

that clients may need assessment on an ongoing basis and

follow—up regarding the client's perception of illness in
relation to exercise compliance. In addition, the client's
awareness of the relationship of exercise to blood pressure
control is also .significant. The prescribed exercise
regimen may need to be given to clients written as a
prescription with follow-up on diary keeping and
counseling. In primary care the nurse can provide
continuity through follow-up. The nurse possesses
nurse/client interaction skills, expanded clinical
judgment, and ability to assess psychosocial needs.
According to King (1981) the nurse seeks to understand the
social system of the clients. During the interaction
process the nurse would assess social problems or concerns,

gather and interpret information thus helping the client

169

set goals which would lead to compliance and blood pressure
control.

The observed correlation between perceived
psychosocial effects scores and stated compliance with diet
and exercise scores should emphasize the value of assessing
the client's perceived psychosocial effects on diet and
exercise.

Some areas the nurse clinician could assess are: how
exercise and diet intefere with the client's life-style,
also the complexity of the regimen. Are there barriers
such as food cost, and preparation time, and whether the
client is able to carry out the exercise regimen, or
experiencing side effects from the treatment. The impact
of the treatment plan on the client's health, and the
effect of therapy upon the control of hypertension is
important. Other areas such as social support, resources
available, stressors and relationships with family members
and friends can be explored. The nurse could collect data
and from assessment of data can assist the client to comply
with the treatment. In addition, the nurse can provide
continuity and coordination of care through follow-up and
referral as needed.

In advanced practice the nurse is responsible and
accountable to the client, and can provide a broader sc0pe
of the therapeutic plan. Through consultative and
collaborative strategies, the nurse/client mutually

determine goals for desired behaviors to achieve

170

transaction. As King (1981) cited when transactions are
made between nurses and clients, goals are attained, this
leads to compliance with the regimen and blood subsequent
pressure control.

Since no relationships were found between the
following hypotheses: Total perceived illness severity and
compliance; comparative seriousness and compliance with
diet; perceived psychosocial effects of hypertension and
compliance with medication; perceived impact of
hypertension on work and compliance with diet and exercise
should emphasize the need for nurses to make continuing
reassessment of clients' perception of their illness in
relation to compliance with the therapeutic regimen, and to
determine accuracy of information being collected. Since
this data was collected at one point in time, there still
may be changes in perception of illness over time. The
nurse may still want to assess some clients' perception of
their illness on an ongoing basis. Continual reassessment
can be done at different intervals on a long term basis to
act as a guide in subsequent interviews. The data
collected would be utilized to help the client formulate an
individual plan to help increase compliance. It would
appear unwise to assume, based on these findings, that the
hypertensive client's perceptions of illness severity does
not influence compliance with treatment.

The positive correlations found between comparative

seriousness and exercise, medications and total barriers as

 

171

illustrated in Table 3 indicates that those are significant
areas to focus on for assessment with the hypertensive
client. Findings such as these clearly indicate that
assessment is crucial to help the hypertensive client
develop plans to increase compliance.

According to King (1980), goal attainment is derived
from interpersonal systems whereby the nurse and client
represents one type of interpersonal system. Human
interaction between nurse and client take place, goals are
set, ways to achieve them are explored, which provides a
basis for interventions. The findings in this study
supports King's theory of goal attainment. The nurse
interacts with the client to make an assessment of the
client's perceptions of illness severity and barriers to
treatment in relation to compliance. Data collected from
the assessment could provide a basis for nursing
interventions to provide a mutual and effective plan of
care for the hypertensive client, which would lead to

commpliance and blood pressure control.

Implication for Nursingducation

Implication for nursing education may be based on the
study findings and should be included in continuing
education, undergraduate and graduate education for
nurses. Since nurses have more contact with clients than.

any other health care providers, nurses have more

172

opportunities to influence clients' health behavior. The
health belief model should be incorporated in nursing
education. The model can be used as .a health assessment
tool to assess its theory and its applicability for
clinical practice. The model can serve as a framework for
assessment and evaluation of outcome of client care.

Study findings of client's perception of illness
severity in relation to compliance with treatment have
shown that positive relationships exist. Among the
implications of these findings it is recommended that
assessment using the health belief model be incorporated in
the curriculum to enhance nurses understanding of client's
perceptions of their illness and how it affects their
willingness to Carry out the therapeutic regimen.
According to Given and Given (1983) it is the client's
perceptions of their illness rather than the illness itself
that will influence their behavior. In an in—service
program an assessment tool formulated from the health
belief model could be introduced to nurses to use for
assessment and evaluation of clients. This would increase
nurses understanding of hypertensive clients with whom they
interact. Perceived illness severity should be
incorporated into nursing diagnostic categories and perhaps
dichotomized as "realistic" and "unrealistic" perceived
illness severity and presented for clinical testing.
Tested interventions based on diagnostic labels could aid

in identifying clients at risk for noncompliance.

173

According to Gordon (1982) nursing diagnoses are used
as a basis for planning interventions and evaluating
outcomes. Outcome of care for clients could be evaluated

and documented for cost-effectiveness and third-party
reimbursement. This would be crucial to nurses working in
expanded roles to document what they really do and the
cost-effectiveness of the nurse clinician. Since nurses
provide care to a large number of hypertensive clients in
ambulatory care setting, nursing diagnoses would serve as
guidelines to organize care for clients. The U.S.
Department of Health, Education, and Welfare (1980) has
written goals for detecting hypertension. Their primary
goal is early detection, and their secondary goals are:
increased knowledge of consumer, screening all clients who
have sought health care, setting up methods to screen
outside the health care system, and referral and follow-up
on all persons with hypertension. The nurse could be
instrumental in helping to achieve these goals.

Study findings, as well as pertinent literature,
support the view that perception of illness severity,
barriers to treatment and compliance are influenced by a
number of factors. The findings in this study contribute
to nursing education by indicating there is a need for
nurses to assess the hypertensive's client perceived
illness severity, barriers to treatment in relation to
compliance so that interventions can be implemented.

Additionally, it is recommended that future research

174

be conducted in graduate education regarding nursing
interventions to increase compliance and control
hypertension. This would add to the knowledge base of

nursing practice, and future theory development.

Recommendations for Future Research

A number of recommendations for future research are
suggested from this study. The suggestions for
improvements of the design include the following:

’Replication of the study with samples from a variety
of health care sites, such as Health Maintenance
Organizations, internal medicine and private physicians to
determine how those individuals perceive the severity of
hypertension and relationship to compliance behavior. In
addition using random sampling thereby allowing every
subject to have an equal chance of being assigned to any
group, this would increase the generalization of the
findings, and enhance the possibilities of obtaining
statistically significiant correlations.

The sample subjects in this study had hypertension
considered out of control (diastolic/3: 95mm Hg) a comparison
of subjects with controlled hypertensibn (blood pressure
within normal limits) could be included to determine their
perception of the severity of their illness in relation to
compliance, and how it compares to perceptions and

compliance for individuals out of control.

175

Replication of the study using samples with other
chronic illnesses, such as diabetes, obesity, asthma or
chronic obstructive lung disease, to determine their
perceptions of illness severity. Other illness such as
chronic obstructive lung disease may have more dramatic
effect on the client since the symptoms are progressive.
One would be able to evaluate the client's perception of
the severity of the illness in relation to compliance. In
addition, to determine linear progression of illness in
relation to perceived severity, data could be collected at
different points over time, three year, and five year
intervals. This would provide insight into client's
perception of illness as it becomes more pronounced in
relation to compliance with treatment.

A study should be conducted to compare a sample of
obese and nonobese hypertensives to determine if there is a
difference in their perception of illness severity in
relation to compliance to treatment. In addition, one
could assess how the compliant individual personality
differs from the noncomplier. Since obesity is a chronic
illness that poses a threat to one's health, and is linked
to other conditions appropriate action to lose weight may
be taken for other reasons than health such as body image,
and social acceptance. Also obesity may not be perceived
as an "illness" in sense of the term to some individuals.
Data collected on such a sample would be useful to nurses

to use as guidelines for nursing interventions of the obese

176

and hypertensive clients.

Summary

In sum, the overall value of this study emphasizes
that there still remains a large number of hypertensive
clients who are noncompliant to treatment. The nurse is in
a key position to manage this chronic illness. Findings
from this study indicate that there is a need for nurses to
assess the client perceived illness severity, barriers to
treatment, in relation to compliance. The data received
would provide a basis for nursing interventions. Through
research, the validity of study results are documented.
This would contribute to the testing of nursing theory
which could be integrated with past research and utilized
for future theory development. Therefore, nursing
management of hypertensive clients through research based

practice would be documented.

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APPENDICES

 

APPENDIX A

CONTACT LETTER

To improve the care we give patients with
hypertension, our medical and nursing staffs are working
with researchers at Michigan State University to help
patients better manage their hypertension. We are asking
many patients, including you, for help in this effort.

Your assistance is important and we hOpe you will
agree to participate in this important project. Your
participation will involve responding to a
questionnaire--administered by a research interviewer from
the University--at your next visit and at two other visits
during the next fifteen months. In addition, you may be
asked to meet with a staff nurse during the next six months
to talk with her about your hypertension and its
treatment. We hope you will meet with them.

The information you give about yourself and {your
personal identity will, of course, remain strictly
confidential. Should the results of the study be
published, you will remain anonymous. You are free to
discontinue your participation in this study at any time.

If you do not agree to participate, or should you
withdraw from the study after originally agreeing to
participate, the amount and quality of service we provide
you, naturally, will not change. However, by agreeing to
participate, you will help yourself and us to provide
better care for all our patients.

To indicate your willingness to participate in this
study, please return the enclosed postcard so we can

arrange a day and time that it will be convenient for you
to meet and talk with an interviewer.

Sincerely,

. 188

 

 

APPENDIX B

CONSENT FORM

CONSENT FORM

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 and permitting
University researchers to review your past and future
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
and the College

 

of Nursing and the Department of Community Health
Science of the Colleges of Human and Osteopathic
Medicine 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 serivce 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

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

Signed

 

(Signature of Patient)

Date (

 

. 189

APPENDIX C

INSTRUMENTS
BELIEFS ABOUT HIGH BLOOD PRESSURE
EFFECTS OF HIGH BLOOD PRESSURE
HYPERTENSION PATIENT INTERVIEW
HYRERTENSION INTAKE INFORMATION MEDICAL RECORD AUDIT
SOCIO-DEMOGRAPHIC

 

 

 

BELIEFS ABOUT HIGH BLOOD PRESSURE

EVERYONE HAS CERTAIN BELIEFS ABOUT HIGH BLOOD PRESSURE AND
WHAT HELPS THEM TO FEEL BETTER. BELOW IS A LIST OF
STATEMENTS THAT SOME PEOPLE BELIEVE ABOUT HIGH BLOOD
PRESSURE AND THE BENEFITS OF TREATMENT. SINCE WE ARE TRYING
TO GET YOUR FEELINGS OR BELIEFS, PLEASE INDICATE THE EXTENT
OF YOUR AGREEMENT WITH EACH STATEMENT. THERE ARE NO RIGHT
OR WRONG ANSWERS.

PLEASE ANSWER ALL QUESTIONS IN THE FOLLOWING WAY.

IF YOU STRONGLY AGREE WITH THE STATMENT, THEN CIRCLE
STRONGLY AGREE. IF YOU AGREE WITH THE STATEMENT, THEN
CIRCLE AGREE. IF YOU ARE UNDECIDED ABOUT THE STATEMENT,
THEN CIRCLE UNDECIDED. IF YOU DISAGREE WITH THE STATEMENT,
THEN CIRCLE DISAGREE. IF YOU STRONGLY AGREE WITH THE
STATMENT, THEN CIRCLE STRONGLEY DISAGREE.

Comparative Seriousness

1. High blood pressure is much less serious than
pneumonia.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

2. My high blood pressure will go away when I don't have
so many other problems.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

3. High blood pressure is not as serious as some people
say.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

4. Right now I have more important things to worry about
than my high blood pressure.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

190

10.

11.

12.

13.

14.

191

High blood pressure is much less serious than diabetes.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

Since my high blood pressure isn't serious I don't
have to worry so much.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

Barriers to following diet

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

Strongly Agree Undecided Disagree Strongly
Agree Disagree

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.

15.

16.

17.

18.

19.

20.

21.

22.

192

Strongly Agree Undecided Disagree Strongly
Agree Disagree

Barriers to taking medication

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

iv

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

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

 

 

193

Efficacy of Treatment

23. In general, the doctor has helped my high blood
pressure.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

24. So many doctors have talked to me I don't know what
to do for my high blood pressure.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

25. The treatment that has been prescribed isn't exactly
right for me.

Strongly Agree' Undecided Disagree Strongly
Agree Disagree

26. Taking care of my blood pressure is worth the effort it
requires.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

27. A person could do everything he/she is supposed to do
to control high blood pressure but it won't help much.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

Job Therapy Conflict

PLEASE INDICATE THE EXTENT OF YOUR AGREEMENT WITH EACH OF
THE FOLLOWING STATEMENTS THAT DESCRIBE BELIEFS SOME PEOPLE
HAVE ABOUT WORKING AND THEIR ILLNESS. CIRCLE ONE CHOICE FOR
EACH STATEMENT.

28. If I changed jobs it would be easier to take my
medications.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

29. My job does not interfere with taking my medications.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

30.

31.

32.

33.

34.

. 194

I worry so much about my job that I can't take my
medications.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

If I changed jobs it would be easier to follow my diet.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

My work makes me so tired it is hard to follow my diet.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

I could control my weight if the pressures of my job
weren't so great.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

It has been difficult to follow the work habits
prescribed.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

 

EFFECTS OF HIGH BLOOD PRESSURE

EVERYONE HAS CERTAIN THINGS THEY USUALLY DO IN CARRYING ON
THEIR LIVES. SOMETIMES BECAUSE OF YOUR HIGH BLOOD PRESSURE
YOU DON'T DO THINGS IN THE USUAL WAY: YOU CUT OUT
SOMETHING; YOU DO OTHER THINGS FOR SHORTER LENGTHS OF TIME;
OR YOU DO THINGS IN DIFFERENT WAYS. WE ARE INTERESTED IN
CHANGES IN YOUR USUAL ACTIVITIES DUE TO YOUR HIGH BLOOD
PRESSURE.

PLEASE ANSWER ALL THE STATEMENTS AS HONESTLY AS YOU CAN.
WORK QUICKLY, NOT SPENDING TOO MUCH TIME ON ANY ONE
QUESTION. THERE ARE NO RIGHT OR WORNG ANSWERS.

PLEASE ANSWER ALL QUESTIONS IN THE FOLLOWING WAY.

IF YOU STRONGLY AGREE WITH THE STATEMENT, THEN CIRCLE
STRONGLY AGREE. IF YOU AGREE WITH THE STATEMENT, THEN
CIRCLE AGREE. IF YOU ARE UNDECIDED ABOUT THE STATEMENT,
THEN CIRCLE UNDECIDED. IF YOU DISAGREE WITH THE STATEMENT,
THEN CIRCLE DISAGREE. IF YOU STRONGLY DISAGREE WITH THE
STATEMENT, THEN CIRCLE STRONGLY DISAGREE.

REMEMBER WE ARE INTERESTED IN HOW YOUR HIGH BLOOD PRESSURE
AFFECTS YOU.

Psychosocial Effects

1. Because of my high blood pressure I do not go out for
entertainment often.

Strongly Agree Undecided Disagree Strongly
Agree . Disagree

2. Because of my high blood pressure I am doing less of
the shopping (errands) than I usually do.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

3. I am able to do my usual social activities.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

195

 

10.

11.

12.

196

I am doing my usual community activities.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

I am doing my usual physical recreational activities.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

Because of my high blood pressure I stay home most of
the time.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

My high blood pressure has disrupted my friendships.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

Because of my high blood pressure I isolate myself
from the rest of my family.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

My high blood pressure does not interfere with the
regular daily work around the house that I usually
do (for example, yard work, repairs, cooking,
cleaning).

Strongly Agree Undecided Disagree Strongly
Agree Disagree

Because of my high blood pressure I stay away from
home only for brief periods of time.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

My high blood pressure does not interfere with the
length of visits with my friends.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

My high blood pressure does not interefere with my
usual recreational activities.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

13.

14.

15.

16.

17.

18.

19.

20.

21.

197

I am asking others to do my usual household work
because of my high blood pressure.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

My high blood pressure does not interfere with the
things I do to take care of my children or family.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

Because of my high blood pressure I am more nervous
or restless.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

I act irritable and impatient with myself (for example,
talk badly about myself, swear at myself, or blame
myself for things that happen).

Strongly Agree Undecided Disagree Strongly
Agree Disagree

My high blood pressure causes me to do inactive
recreation (for example, watch TV, play cards, read).

Strongly Agree Undecided Disagree Strongly
Agree Disagree

My high blood pressure interferes with my sleep (for
example, I wake up early, can't fall asleep, awaken
frequently).

Strongly Agree Undecided Disagree Strongly
Agree Disagree

I feel as if my family has become more disorganized
since I was told I have high blood pressure.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

Because of my high blood pressure I don't walk if I
can avoid it.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

Because of my high blood pressure I often act irritably
toward family members (for example, snap at them,
criticize them, pick fights).

 

22.

23.

24.

25.

26.

27.

28.

198

Strongly Agree Undecided Disagree Strongly
Agree Disagree

Impact of Hypertension on Work

I believe that my high blood pressure makes my job
difficult.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

Because of my high blood pressure I am doing a
different kind of work.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

I am absent from work often because of my high blood
pressure.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

I do my job as carefully and accurately as I can.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

Because of my high blood pressure I have to make an
extra effort to get started at work.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

Because of my high blood pressure, I act irritably
toward my work associates (for example, snap at them,
give sharp answers, criticize easily).

Strongly Agree Undecided Disagree Strongly
Agree Disagree

My high blood pressure interferes with my work so that
I work more slowly at my job.

Strongly Agree Undecided Disagree Strongly
Agree Disagree

HYPERTENSION PATIENT INTERVIEW

Now I'm going to ask you some questions about the medicines

your doctor has

he/she may have given you.

1.

Compliance with Medications

A B C
Med. Med. Med.
No. No. No.

 

 

 

l 2 3
Do you take
(name-med)
(READ CATEGORIES. CIRCLE
ANSWER IN QPPROPRIATE COL.)
1. All the time, 1 l 1
2. More than half the
time, 2 2 2
3. Half the time, 3 3 3
4. Less than half the
time, or 4 4 4
5. None of the time? 5 5 5
In the past two weeks
have you taken the
prescribed dosagg
of
(name-med)
(READ CATEGORIES. CIRCLE
ANSWER IN QPPROPRIATE COL.)
1. All the time, 1 1 1
2. More than half the
time, 2 2 2
3. Half the time, 3 3 3
4. Less than half the
time, or 4 4 4
5. None of the time? 5 5 5

199

D
Med.
No.

4

UTA (JON

|-‘

LII-b (JON

prescribed for you about some suggestions

E
Med.
No.

5

H

UNI} LION

U'lb LON

200

3. In the past two weeks
have you taken
at
(name-med)
recommended time of day

 

(READ CATEGORIES. CIRCLE
ANSWER IN QPPROPRIATE COL.)

All the time,

More than half the
time,

Half the time,
Less than half the
time, or

. None of the time?

U1 Aw NH
O. .0
ma LON H

1 1 1 1
2 2 2 2
3 3 3 3
4 4 4 4
5 5 5 5

Compliance with Diet

4. Would you say you follow the diet suggested

(READ CATEGORIES)

1. All the time
2. More than half the time,
3. Half the time,

4. Less than half the
time, or
5. None of the time?

5. When you're away from home, have you followed the diet

prescribed (READ CATEGORIES)

1. All the time
2. More than half the time,
3. Half the time,

4. Less than half the

time, or
5. None of the time?

Compliance with Exercise

6. Would you say you follow the exercise recommended

(READ CATEGORIES)

1. All the time
2. More than half the time,
3. Half the time,

4. Less than half the

time, or
5. None of the time?

7. When you're away from home, do you follow the exercise

prescribed (READ CATEGORIES)

1. All the time
2. More than half the time,
3. Half the time,

4. Less than half the

time, or
5. None of the time?

HYPERTENSION INTAKE INFORMATION MEDICAL RECORD AUDIT

How many years has the patient had hypertension?
(write in) .

What was the Patient's highest blood pressure during

the past six months? (write in and specify position).

Was the patient overweight at the visit at which a
definitive diagnosis of hypertension was made?

1. Normal 2. Twenty percent over
ideal body weight

9. Weight not 3. Less than 20% over
recorded ideal body weight

201

 

SOCIO-DEMOGRAPHIC

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: (WRITE IN)

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

1. White.___

2 . Black _

3. Mexican-American
4. American Indian
5. Oriental ___

6. Other (Specify)

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

1. Married ____

2. Single, never married
3. Separated'___

4. Divorced ___

5. Widowed ____

5. Taking all sources of money into consideration, what was
your family's total income before taxes and other
deductions for the past 12 months? (CHECK ONE)

00. Below $5,000 05. $13,000-$14,999
01. $5,000-$6,999 06. $15,000-$16,999
02. $7,000-$8,999 O7. $17,000-$19,999
03. $9,000-$10,999 08. $20,000-$24,999
04. $11,000-$12,999__ 09. $25,000 or over

202

APPENDIX D
TABLE 4
TABLE 5
TABLE 6

TABLE 4. THE RELATIONSHIP BETWEEN AGE, INCOME, DURATION OF
HYPERTENSION AND STUDY VARIABLES (USING PEARSON
PRODUCT MOMENT CORRELATIONS)

 

Duration of

Age Income Hypertension
Medication
Compliance .2303** .0780 .0463
Dietary
Compliance .1253 .0542 .0547
Exercise
Compliance .1223 .1036 .1527
Comparative
Seriousness -.0335 .0139 .0946
Psychosocial
Effects -.0711 .1563* .0041
Job-Related
Severity -.0695 .0165 .1613
Medication
Barriers -.0883 .1170 .0303
Diet Barriers -.2240** .0520 .1103
Efficacy
Barriers -.1060 .1311 .1054
Job-Related
Barriers -.0664 .0710 .0714

*<:.05 significance

**<:.Ol

 

203

TABLE 5. THE RELATIONSHIP BETWEEN SYSTOLIC AND DIASTOLIC
BLOOD PRESSURE AND STUDY VARIABLES (USING PEARSON
PRODUCT MOMENT CORRELATIONS)

 

Systolic Diastolic

Blood Pressure Blood Pressure
Medication
Compliance .0506 -.0506
Dietary
Compliance .1381 .0946
Exercise
Compliance .0420 -.0821
Comparative
Seriousness .0506 .0337
Psychosocial
Effects .0270 .0080
Job-Related
Severity .0541 .1197
Medication
Barriers .0950 .1187
Diet
Barriers .0903 .0298
Efficacy
Barriers .0050 .0454
Job-Related
Barriers .1024 .1891*

*<;.05 significance

 

204

TABLE 6. THE RELATIONSHIP BETWEEN SEX, MARITAL STATUS, RACE
OVERWEIGHT AND STUDY.VARIABLES (USING POINT

BI-SERIAL CORRELATIONS)

 

Marital

Sex Status Race Z Overweight
Medication
Compliance -.0437 .0959 .1165 -.0360
Dietary
Compliance -.0559 .0368 .0703 -.2205**
Exercise
Compliance -.2718* .0570 .1745 -.2243
Comparative
Seriousness .1229 .0521 .0339 -.0885
Psychosocial
Effects -.0332 .0093 .1504* .1612*
Job-Related
Severity -.0941 .0428 .0369 .0357
Medication
Barriers -.0160 .0315 .1066 .1550*
Diet
Barriers -.0030 .1068 .0099 .2989***
Efficacy
Barriers .0677 .0540 .0721 .2193**
Job-Related
Barriers -.1409 .0456 .0595 .1269

* <2 .05 Significance

** <1 .01
*** <: .001

 

205

 

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