IV1ESI_J RETURNING MATERIALS: Place in book drop to LJBRARJES remove this checkout from .—:—. your record. FINES_ will ‘ be charged if book is returned after the date stamped be10w. ' THE PERCEIVEO MEDICATION, DIETARY, AND JOB BARRIERS TO FOLLOWING A THERAPEUTIC REGIMEN TO CONTROL HYPERTENSION AS IOENTIFIEO BY HYPERTENSIVE PATIENTS IN PRIMARY CARE By Jean Glasser Yudin A THESIS Submitted to Michigan State University in partial FulFillment 0F the requirements For the degree 0F MASTER OF SCIENCE IN NURSING College 0F Nursing 1984 ABSTRACT THE PERCEIVED MEDICATION, DIETARY, AND JOB BARRIERS TD FOLLOWING A THERAPEUTIC REGIMEN TD CDNTRDL HYPERTENSIDN As IDENTIFIED BY HYPERTENSIVE PATIENTS IN PRIMARY CARE By Jean Glasser Yudin A descriptive study oF hypertensive men and women was conducted to identiFy perceived barriers to Following recom- mended health regimens For controlling hypertension and per— ceived job barriers to Following the health regimens. Data were collected From 158 hypertensive men and women, aged 24 to 65, by means oF a selF-administered questionnaire. Data were analyzed using Pearson Product Moment Correlations and descriptive statistics. There were signiFicant relation- ships between belier about diet and age, belier about medi- cations and educational status, belier about medications and systolic blood pressure, and belier about impact oF job on eFFicacy oF treatment and systolic blood pressure. Hunger, dependence on medications and diFFiculty Following work habits were some barriers identiFied by this sample population. Nurses must assess barriers as Factors which aFFect the ability oF hypertensive individuals to Follow health regimens and how the role oF job may also aFFect the ability to Follow health regimens. ACKNOWLEDGEMENTS I would like to thank Barbara and Bill Given For the use oF the data From their research study "Patient Contribu— tions to Care-~Link to Process and Outcome." I would like to thank my committee members: Barb Given, chairperson, Patty Peek, Carol Garlinghouse, and Sue Budd For their expertise, support, and guidance. The assistance oF Rob Hymes and Brian Coyle in analyzing the data was appreciated. I would like to thank my parents For their support and encouragement and For the chance to receive a nursing education. A very special thank you to my husband, Joel, For his support, encouragement, and patience throughout my graduate education. ii CHAPTER. I. II. III. TABLE OF CONTENTS THE PROBLEM . . . . . Introduction . . . . Purpose oF the Study Statement oF the Problem DeFinition oF Concepts Assumptions 0 o o 0 Limitations . . . . Overview . . . . . . CONCEPTUAL FRAMEWORK . Introduction . . . . Conceptual Framework Health BelieF Model Individual Perceptions Relationship oF Nursing to Variables . . . . . SelF Care . . . . Nursing System . . Nursing Process . Summary 0 o o o o 0 LITERATURE REVIEw‘ . . Introduction . . . . Hypertension . . . . Non-Pharmacologic Treatment For Hypertension Health BelieF Model iii Page H (D\l\lr‘ IO 12 l3 13 IS 15 20 28 28 29 3O 33 34 34 34 38 49 CHAPTER III. IV. (Continued) Perceived Barriers . . . . . . . . . . . . Hypertensive Subjects' Perceived Barriers to Following Therapy . . . . . . . . . . Perceived Barriers to Taking Antihypertensive Medications . . . . . Perceived Barriers to Following Dietary Regimens o o o o o o I o o o o o a o o Perceived Job Barriers to Following Antihypertensive Therapy . . . . . . . Nursing Interventions . . . . . . . . . . METHODOLOGY AND PROCEDURE . . . . . . . . . Overview . . . . . . . . . . . . . . . . . Sample . . . . . . . . . . . . . . . . . . Setting . . . . . . . . . . . . . . . . . Instruments . . . . . . . . . . . . . . . Development oF the Instrument to Measure Subjects' Belier About Hypertension . . Scciodemographic Questionnaire . . . . . . Data Collection Procedure . . . . . . . . Operational OeFinitions oF the Study Variables o o o o o o o o o o o o o o I I Perceived Barriers to Commitment to Oiet Perceived Barriers to Commitment to Madications o a I o o o o o o o o o o o Perceived Barriers to Impact oF Job on FOllDWing Therapy 0 o o o I o o o o o o ModiFying Variables . . . . . . . . . . . Reliability oF the Instrument . . . . . . Validity oF the Instrument . . . . . . . . Scoring. . . . . . . . . . . . . . . . . . Procedure For Data Analysis . . . . . . . Human Rights Protection . . . . . . . . . summary I I I I I I I I I I I I I I I I I iv Page 53 55 58 SS 58 73 B3 83 84 85 86 87 88 SO 92 92 92 93 S4 94 SS 97 SS ' SS 99 CHAPTER V. DATA PRESENTATION AND ANALYSIS Descriptive Findings oF the Study Sample ModiFying Factors . . . Demographic Variables Sociopsychological Variables ModiFiers SpeciFic to Hypertension Summary I I I I I I I I Data Presentation For Research Research Question #1 . Research Question #2 . Research Question #3 . Reliability oF the Scales Relationships Among the Scales ModiFying Variables . . Summary I' I I I I I I I VI. SUMMARY INTERPRETATIONS AND RECOMMENDATIONS IntFOdUCtion I I I I I I Summary and Interpretation ModiFying Variables . . Research Question #1 . . Nursing Implications . Research Question #2 . . Nursing Implications . Research Question #3 . . Nursing Implications . Limitations oF the Study Implications For Nursing Implications For Nursing Questions Practice . Education . Implications For Future Nursing Research Page 100 101 101 101 102 108 109 110 110 113 114 118 120 120 123 125 125 125 128 131 135 135 141 143 147 14B 150 158 152 CHAPTER V. DATA PRESENTATION AND ANALYSIS Descriptive Findings oF the Study Sample ModiFying Factors . . . Demographic Variables Sociopsychological Variables ModiFiers SpeciFic to Hypertension Summary . . . . . . . . Data Presentation For Research Research Question #1 . Research Question #2 . Research Question #3 . . . . Reliability oF the Scales Relationships Among.the Scales ModiFying Variables . . Summary I- I I I I I I I VI. SUMMARY INTERPRETATIONS AND RECOMMENDATIONS Introduction . . . . . . Summary and Interpretation ModiFying Variables . . Research Question #1 . . Nursing Implications . Research Question #2 . . Nursing Implications . Research Question #3 . . Nursing Implications . Limitations oF the Study Implications For Nursing Implications For Nursing Questions Practice Education Implications For Future Nursing Research Page 100 101 101 101 102 108 109 110 110 113 114 118 120 120 123 125 125 125 128 131 135 135 141 143 147 145 150 158 152 APPENDIX Page A. BELIEFS ABOUT HYPERTENSION INSTRUMENT . . . . 157 B. SOCIODEMOGRAPHIC QUESTIONNAIRE . . . . . . . 174 C. PARTICIPATION LETTER . . . . . . . . . . . . 178 D. CONSENT FORM . . . . . . . . . . . . . . . . 180 E. FREQUENCY DISTRIBUTION BELIEFS ABOUT DIET SUBSCALE I I I I I I I I I I I I I I I I I I 181 F. FREQUENCY DISTRIBUTION BELIEFS ABOUT MEDICATION SUBSCALE . . .1. . . . . . . . . . 182 G. FREQUENCY DISTRIBUTION BELIEFS ABOUT IMPACT OF JOB ON EFFICACY OF TREATMENT SUBSCALE . . 183 H. CORRELATION MATRIX: MODIFYING VARIABLES AND MAJOR STUDY VARIABLES USING PRODUCT MOMENT CORRELATION I I I I I I I I I I I I I I I I I 184 LIST OF REFERENCES . . . . . . . . . . . . . . . . . . 185 Vi LIST OF TABLES Table Page 1. Hypothesized and Final Scales For Belier About Medications, Belier About Diet, Belier About Impact oF Job on Therapy . . . . . .-. . . . . . . 89 2. Distribution and Percentage oF Subjects by Demographic Variables and ModiFiers SpeciFic to Hypertension I I I I I I I I I I I I I I I I I 103 3. Distribution and Percentage oF Subjects by Marital Status and Living Arrangement (n = 158) . 107 4. Distribution and Percentage oF Subjects by Perceived Barriers to Following a Prescribed Diet For Controlling Hypertension . . . . . . . . 112 5. Distribution and Percentage oF Subjects by Perceived Barriers to Taking Prescribed Medications For Controlling Hypertension . . . . . 115 5. Distribution and Percentage oF Subjects by Perceived Job Barriers Impacting EFFicacy oF Treatment For Controlling Hypertension . . . . . . 117 7. Frequency Distribution Belich About Diet SUbsca 18 I I I I I I I v. I ' I g . g . g . . . . . . 181. 8. Frequency Distribution Belier About Medication SUbSCale I I I I I I I I I I I I . I I I I I I I I I 182 B. Frequency Distribution Belier About Impact oF Job on EFFicacy oF Treatment Subscale . . . . . . 183 10. Correlation Matrix: ModiFying Variables and Major Study Variables Using Product Moment Correlation . . . . . . . . . . . . . . . . . . . 184 vii LIST OF FIGURES Figure ' Page 1. The Preventive Health BelieF Model (Becker, 1974) I I I I I I I I I I I I I I I I I I I I I I 19 2. The Health BelieF Model speciFic to hypertension . . . . . . . . . . . . . . . . . . 22 3. Orem's Model oF Supportive-Educative Nursing System (1980) I I I I I I I I I I I I I I I I I I 3]- viii CHAPTER I THE PROBLEM Ihtroduction In the United States nearly 35 million people are esti— mated to have deFinite hypertension (high blood pressure), and about 25 million additional people are estimated to have borderline high blood pressure (Glanz, Kirscht, and Rosenstock, 1981). According to the report For the National Institute oF Health (1980), hypertension occurs in 20 to 30% 0F the adult population. Cardiovascular disease accounts For more than one—halF oF the deaths in the United States, and high blood pressure is a major determinant oF such deaths (1980 Report oF the Joint National Committee on Detection, Evaluation, and Treatment oF High Blood Pressure). Hypertension's crippling and Fatal eFFects include stroke, heart attack, congestive heart Failure, and renal Failure. This chronic disease is oF great concern since (1) the compli- cations oF hypertension are oFten severe or Fatal, and (2) hypertension is usually asymptomatic and the regimen For controlling hypertension permanent (Sackett and Hayes, 1975). Treatment may include taking daily medications, reducing stress, weight reduction and modiFying liFestyles. Although there have been notable increases in the propor- tion oF hypertensive patients who are aware oF their problems and who are receiving care, the majority oF hypertensive patients' blood pressure remains uncontrolled (Podell, 1975). The in- creasing importance oF chronic conditions has placed a greater emphasis on individual responsibility For health maintenance and care (Carson and Strauss, 1975). One major reason hyperten- sive patients remain uncontrolled is the diFFiculty people have in deciding whether to adhere to a Frequently complex health regimen and then maintaining it For a 1iFetime. For many years, health care providers have stressed patient education as a way oF insuring compliance with prescribed regimens. However, it has been shown in literature on compliance that Factual knowledge and inFormation do little to contribute to positive health behaviors (Sackett, et a1., 1975). Also, patients' belier about their health and the severity oF the disease, the ratio between beneFits and barriers oF the treat- ment, Family stability and behavioral changes have all been positively related to compliance behavior (Haynes, Sackett and Gibson, 1975). With the increasing Frequency oF chronic condi- tions has come a greater emphasis on the individual's responsi- bility For health maintenance and care. This, in turn, has increased the need to understand and modiFy personal health behaviors (Maiman and Becker, 1974). One patient centered approach, the Health BelieF Model, is a psychosocial Formulation developed to explain personal health behavior at the level oF individual decision-making. The Health BelieF Model was developed by Hochbaum, Kegeles, Levanthal, and Rosenstock in the 1950's. The Health BelieF Model is based on the psychological theory oF Lewin who hypoth- esized that behavior depends on two variables: (1) the value oF an outcome to an individual, and (2) the individual’s esti- mate oF the probability that a given action will result in that outcome (Mikhail, 1981). The Health BelieF Model is based on the likelihood that a person will take a recommended health action determined by the individual's state oF readiness and by the perceived beneFits oF the action weighed against the perceived barriers (Becker, 1974). The individual's psychological state oF readiness to take action is determined by the perceived susceptibility to a certain health condition and the perceived severity oF the consequences oF not Following an action to reduce the perceived susceptibility. Perceived beneFits are weighed against perceived barriers to implementing therapy. Thus, the extent to which beneFits outweigh barriers will inFluence the patient's actual compliance behavior with the recommended health regimen (Becker, et al., 1972). It is also proposed that an internal or external cue to action must occur to trigger the appropriate action. Finally, a group oF modiFying Factors will aFFect the individual's perceptions oF susceptibility, severity, and beneFits to taking action. The basis oF the Health BelieF Model is the assumption that behavior is determined by subjective rather than objective thoughts. Thus, health behavior will be determined by an individual's own belier about his health and the suggested health regimen. The results oF research studies have led researchers to stress the importance oF determining patients' belier about their health and suggested health regimens in attempting to increase compliance with a hypertensive regimen. Nelson, et a1. (1978), used the Health BelieF Model approach to explain compliance with a hypertensive regimen. The hypothesis was that a subject's readiness to comply was conceived as the outcome oF certain core perceptions concerning health and hypertension. The researchers predicted that hypertension posed a serious threat that could be avoided by Following a therapeutic regimen. Using the interview technique, the researchers Found that an individual's experience with anti- hypertensive treatment, his/her attitude toward antihypertensive treatment, and a belieF that blood pressure would be higher iF suggested health regimens were not Followed all inFluenced compliance. Nelson also reported that individuals who were noncompliant believed their medications caused side eFFects and believed hypertension disrupted their liFestyle. In a similar study, Caplan, et a1. (1978) Found that the presence oF somatic complaints and the perceptions that consequences oF nonadherence would be serious, contributed to compliance. The Focus oF both studies was on patient char- acteristics and attitudes and the researchers Found that patient attitudes toward hypertension and its treatment were important determinants oF compliance. Glanz, et a1. (1981) examined initial knowledge and attitudes as predictors oF intervention eFFectiveness. One question these researchers asked was, "Do interventions have diFFerent eFFects on individuals who diFFer with respect to initial attitudes and knowledge?" Findings showed that reminders and selF monitoring by nurses improved drug adherence For those with initially lower perceived beneFits. Solomon (1981) developed an approach to the treatment oF hypertension directed at increasing the likelihood a client will comply based on how the client views his chronic disease. Solomon examined such areas as expected beneFits oF treatment, perceived severity oF illness, treatment regimen, side eFFects and cost. Finally, Given (1978) discussed elderly compliance with antihypertensive medication. The First phase oF this research examined the relationships among clients' knowledge, belier about beneFits and barriers, compliance and the eFFects oF the disease upon their psychosocial health. Preliminary evidence suggested that clients' lack oF knowledge oF disease and medi- cations was positively related to negative belier about treat- ment and medication barriers. The evidence also suggested that clients' lack oF knowledge oF disease and medications was negatively related to medication beneFits, belier about the disease, and eFFects oF the disease. Control oF hypertension requires that the client enter and continue in a treatment program and adhere to a prescribed regimen. As noted previously, the Health BelieF Model has been developed to explain health behaviors that are based on an individual's subjective belier. ThereFore, it is neces- sary to examine an individual's subjective perceptions oF barriers to Following suggested health regimens. IF an action is seen as painFul, inaccessible, or inconvenient, the individ— ual may be less likely to Follow the regimen. Individuals who doubt the saFety oF a regimen, believe the side eFFects to be worse than the symptoms, or have to Follow a complex regimen may also be less likely to Follow recommended health actions. ‘ In order to determine a subject's likelihood oF action in Following a prescribed regimen, the beneFit—barrier ratio must be assessed. It is important to determine iF subjects do perceive barriers to Following prescribed regimens, because only when the beneFits outweigh the barriers will the subject consider Following his/her regimen. Purpgse oF the Study The importance cF understanding a hypertensive subject's perception oF barriers to his/her health regimen provided impetus For this study. It has been emphasized in research literature that it is necessary to identiFy perceived barriers to determine what constitutes barriers, and how they inFluence health regimens (Mikhail, 1981). The purpose oF this study was to determine what hypertensive subjects perceived as barriers to recommended health regimens by analyzing barriers to commit- ment to medications, commitment to diet and the impact oF job barriers on Following health regimens. The data For this study were collected as part oF a Federally-Funded research project "Patient Contributions to Care . . . Link to Process and Outcome" Grant #5R01N000552-01,02,03, 8. Given and C. W. Given, co-principal investigators. Statement oF the Problem In this study, the researcher addressed the Following questions: 1. What did hypertensive subjects perceive as barriers to Following a diet For controlling hypertension? 2. What did hypertensive subjects perceive as barriers to taking prescribed medications For controlling hypertension? 3. What did hypertensive subjects perceive as job barriers to Following a prescribed diet or taking prescribed medications For controlling hypertension? DeFinition oF Concepts In this study, the researcher deFined the Following concepts: 1. Hypertensive subjects. Hypertension is a sustained elevation oF blood pressure above the accepted normals 0F 90 mm Hg diastolic or 140 mm Hg systolic (Price and Wilson, 1978). In this study, hypertensive subjects were individuals between the ages 0F 18 and 55 who had medical records that contained two blood pressure readings on separate days, indicating diastolic pressure above 90 mm Hg and/or a systolic pressure above 140 mm Hg. Barriers. An individual may believe that a given I action will be eFFective in reducing the threat oF disease, but at the same time, see the action itselF as being inconvenient, expensive, unpleasant, painFul, or upsetting. Perceived barriers were identiFied as the expressed belier and attitudes oF the subject concerning barriers to implementing aspects oF the therapeutic regimen. Two dimensions oF barriers to implementing elements oF the therapeutic regimen were examined: (a) cost, in- convenience, or change in liFestyle; and (b) side eFFects and discomFort associated with therapy. Dimensions oF the therapeutic regimen. The dimen- sions oF the therapeutic regimen that were analyzed in this study included medications, diet, and impact oF job on adherence to therapy. a. Medication. Medications are prescribed to lower blood pressure to within acceptable ranges Follow- ing the protocol For hypertensive stepped care. Step 1 would include diuretics. Among diuretics used are thiazide and thiazide derivatives, nonthiazide diuretics, and/or potassium~sparing drugs. Step 2 would include beta-adrenergic in- hibitors or beta blockers. Propranolol, Methyldopa, and Reserpine are examples oF beta blockers that are used to treat hypertension. Step 3 would include vasodilators. Vasodilators are oFten added to Steps 1 and 2 drugs and include hydralazine HCL, Clonidine, and Prazosin. Step 4 would include adding or substituting the sym- patholytic drug, Guanethidine sulFate to Steps 1, 2, and 3 drugs (Wiener and Pepper, 1979). b. 2333. This would include weight reduction diet, low sodium diet, dietary potassium supplement 10 or any other diet prescribed For lowering and keeping blood pressure to within acceptable ranges I c. impact oF job on therapy. Social stressors and the individual's social situation may aFFect health belier and health behaviors. One social situation or role with deFined goals is job or work role. The importance a subject places on his/her job or the diFFiculty in carrying out this social role obligation may aFFect the priority the subject places on perForming recommended health behaviors. The values a subject places on perForming health behaviors will be related to the belier the subject has on how these health behaviors aFFect ability to perForm a job. The value the subject places on Following recommended health behaviors could be altered by concern about a job and to what degree the recommended therapeutic regimen interFeres with the job. Assumptions In this study, the researcher made the Following assump- tions: 1. It was assumed that perceived barriers were distinct concepts that could be measured. 2. It was assumed that the subject's perceived barriers The 11 could be adequately measured by means oF a question- naire. It was assumed that the subject’s answers to the questions were real and honest. It was assumed that the subject could read and under- stand the questionnaire. Limitations limitations oF the study were: The subjects who agreed to participate in the study may be diFFerent From subjects who reFused to parti- cipate in the study. ThereFore, the research Findings may not be representative oF all patients with hyper- tension. The subjects in the study were not controlled For severity oF hypertension or duration oF the disease. Patients who received care From Family Practice Physician Residents may have diFFered From patients who received care From Internists. Due to the small sample size used in this study, the Findings may not be generally applicable to a larger population. An individual's perceptions oF barriers in this study may change over time. ThereFore, the Findings in this study may not reFlect the perceptions oF 12 the same participants at another point in time. Overview The study is presented in six chapters. Chapter I in- cluded the introduction to the problem, purpose oF the study, statement oF the problem, deFinition oF concepts, and assump- tions and limitations oF the study. Included in Chapter II are the conceptual Framework and Focuses on the Health BelieF Model and how these concepts relate to nursing. In Chapter III, a review oF the literature that is pertinent to this research is presented and critiqued. In Chapter IV, the research design, methodology, and procedures utilized in this study are described. In Chapter V, the description oF the data and other analyses are given and discussed. In Chapter VI, a summary interpretihg the research Findings, conclusions, recommendations, and nursing implications oF the study are presented. CHAPTER II CONCEPTUAL FRAMEWORK Introduction Proponents oF the Health BelieF Model believe that an individual's perception oF barriers to aspects oF prescribed therapy aFFect the likelihood oF Following a recommended health action. Orem believes nurses can help individuals maintain or change conditions within themselves or their environment. IF nurses can help hypertensive persons identiFy perceived barriers to Following prescribed regimens, then hypertensive subjects and health care providers can work together to decrease perceived barriers and possibly improve adherence to therapy. In Chapter II the conceptual Framework For this study will be discussed. The Health BelieF Model and Orem's selF- care model will be analyzed. Variables From each model will be conceptually deFined and their relationship to each other and the study questions will be discussed. Greater emphasis on the individual's responsibility For health maintenance and care is seen as an important Factor in decreasing the impact oF chronic conditions on morbidity and mortality. This, in turn, has heightened the need For health proFessionals to understand and be able to modiFy health 13 l4 behaviors. It has long been known that people's belier, values, and traditions may hinder their seeking health services, even when the services are accessible and eFFective. It is also known that many people do not enter the health-care system until they are conFronted with disabling symptoms (Haaner and Kirscht, 1970). It is important to remember that care must be directed not only to persuading potential patients to enter the health- care system beFore symptoms appear, but also to educate patients to adopt certain health practices which they believe will reduce or prevent serious illness (Haaner, 1970). For these reasons, it is important to understand why people Follow the health practices they do and to examine methods For modiFying these health behaviors. Hypertension is a major public health problem in the United States. Control oF hypertension requires entering in a treatment program and adhering to a prescribed regimen. Medical regimens For blood pressure control can include drug therapy, weight reduction, sodium restriction and stress re- duction (Glanz, et al., 1981). Nonadherence to a medical regimen is a major problem to eFFective control oF high blood pressure. Adherence to recommendations For management cF hypertension is oFten diFFi- cult because: (1) the hypertensive condition is oFten asymptomatic; (2) a patient may experience undesirable side 15 eFFects From medication; (3) the regimen may be complicated and demanding requiring periodic medical observation; and, (4) the therapy may have to be continued indeFinitely to main- tain blood pressure control (Glanz, et al., 1981). In addition, the individual may be expected to change behavior or habits that are well-engrained into his/her liFestyle. In the past twenty years, numerous research reports have been published reFlecting the desire to discover and understand the determinants oF health-related actions. In recent years, a psychosocial view For explaining personal health behaviors has received much attention. The basis oF the Health BelieF Model is that the likelihood oF undertaking a health action is a Function oF the individual's belieF that the individual is personally susceptible to a disease, that the occurrence oF the disease would have moderate severity or seriousness on some part oF his/her liFe, and that by taking speciFic action an individual can reduce susceptibility to the disease and overcome barriers (Rosenstock, 1974). One area that is oF particular interest is the view oF possible psychological and other costs or barriers (Becker, 1974). The primary purpose oF this study was to determine what barriers hypertensive subjects perceive to Following recommended health regimens speciFically in the areas oF taking medication, Fol— lowing a prescribed diet and the impact oF a job on Following .therapy. 15 Conceptual Framework An adaptation oF Rosenstock's Health BelieF Model by Becker and Maiman (1975) and Orem's (1980) model oF nursing were utilized to develOp the conceptual Framework For this study. Becker and Maiman's Framework is based on the pre- dictive relatibnship between health perceptions and health behaviors. Orem's nursing theory supports the supportive~ educative role oF the nurse. For a patient to increase his/her likelihood oF action, the beneFit-barrier ratio oF Following a recommended health regimen must be analyzed. SpeciFically, the barriers to Following therapy that the individual perceives must be identiFied. IF the patient’s perceived barriers out- weigh the perceived beneFits, it is more unlikely that the patient will Follow the prescribed regimen. Health-care pro- viders and patients must work together to identiFy patients’ perceived barriers and learn to overcome these barriers. Health BelieF Model The theoretical Framework chosen For this study is the Health BelieF Model. The Health BelieF Model has evolved over 29 years oF research and was originally Formulated by Hockbaum, Kegalas, Levanthal, and Rosenstock in the public health service (Rosenstock, 1974). The Health BelieF Model attempts to account For the predictive relationship between 17 health perceptions and health behaviors. The model was' originally developed to account For preventive health action taken in the absence oF symptoms; it has now been reFormulated to include a dimension oF general health motivation based on measures oF concerns and practices that are seen as rela- tively non-speciFic and stable across situations (Becker, 1974). This motivating Force results From a combination oF perceptions and is modiFied by Factors such as demographic characteristics and incidents that trigger behavior (Nelson, 1978). The core dimensions oF the Health BelieF Model are derived From a well established body oF psychological and behavioral theory, particularly the work oF Lewin. Lewin (1938) was interested in a study oF human motivation in relation to per- ceptions. Lewin thought the net aFFect oF simultaneous psycho- logical Forces operating in a psychological liFe space oF an individual brought about a reorganization oF that Field, and thereby provided the basis For psychological behavior. The basis oF the Health BelieF Model is that a decision to undertake a health action will not be made unless the in- dividual is psychologically ready to take action relative to a particular threat or cue (Rosenstock, 1974). The model has a phenomenological orientation. The health care provider- individual relationship is the subjective perception oF the individual rather than the objective environment. The 18 individual can only act on what he/she believes to exist though the health care provider may believe another behavior may be more beneFicial For the individual. Readiness to act is deFined by the extent to which (1) the individual Feels suscepti- ble to the condition in question and the extent to which its possible occurrence is viewed as having serious consequences, -(2) the individual believes that there are actions which would be beneFicial in reducing his/her susceptibility to and/or severity oF the condition should it occur, and (3) the individ- ual believes that the psychological costs associated with taking the health action are outweighed by the beneFits to be derived (Cummings et al., 1978). As noted beFore, the original Formulation was oriented solely toward the desire to avoid a speciFic threat and that this approach has been reFormulated and expanded to include the dimension oF general health motivation (Cummings, et al., 1978). The basic concepts oF the revised Health BelieF Model include motivation, perception oF the severity oF the disease, and perceptions oF beneFits and barriers associated with actions that can be taken to prevent the disease. These perceptions are aFFected by demographic, sociopsychological, and struc- tural variables. A "cue" or triggering mechanism is also necessary For initiating appropriate action (Figure 1). This Framework has been used as a predictor oF preventive health behavior, but there would seem to be no reason why the same 19 .fiwnms .meommc Ammo: Lmflamm guano: m>apco>mtd mt» .H mcsmsu manautm MCHNmmms Lo Lmumumzmz Ucmem Lo LUDEME haasmm mo mmmCHHH EmewmALQ EDLm mULmUpmou LDDCaEmI mLm£uo EDLm mUw>U< mcmamQEmu maUmE mmmz amLDpUmm Hmcoaum>apozv CDePU< on mmju h :x: mmmmmfio to mhuaLm>mmV E0w90< LpammI :x: mmmmman Du , mmmCmJOwme D0>HDULml ummLLu Dm>am0me v>wpcm>MLu DmncmEEOUML . :x: mmmmmeo Du maxmp to UDDLwHQXMJ - a, . mpfiawnwuamumjm Dm>meme . mmmnmatm> HmLJuUJLum. H A . 0pm. - T .ijmmmLu QJDLm mucmLDCML Dcm mea .mmmHo awauom .xpwamcomLmau mmanm awLw> Hmuflmoaonuxmmowoom caspum m>aucm>mLQ op mLmMLLmD Dm>meme mJCaE . n.0um .hufi mcoflpum m>aucm>mLa to IUHCme .mOmL .xmm .mmmw mpwmmcmn Dm>am0me mmHDMaLm> UsLQflLmdemD Eofiuu< to UODLwHDXMJ mLovumutmcdxmeoz mCDeummULom HNDUH>wUEH 20 type oF Formulation could not apply to action taken by individ- uals who know they are ill, especially iF the concept oF susceptibility is broadened to mean the probability oF pro- gressive eFFects oF the disease or a recurrence oF the disease. The modiFied Health BelieF Model which includes the concepts oF motivation, perceived susceptibility, perceived seriousness, perceived beneFits, perceived barriers, cues to action and modiFying variables is the theoretical Framework which was used in this study. In the next section, these variables will be conceptually deFined. Individual Perceptions In the Following section, individual perceptions will be discussed: 1. Motivation. Motivation has been deFined as (a) con- cern about health matters in general, (b) willingness to seek and accept medical direction, (c) intention to comply, and (d) positive health activities (Becker, et al., 1977). An individual, once motivated, will engage in health seeking behavior depending on the amount oF threat perceived by the individual and the value oF the action to be taken. IF an individual perceives many barriers to Following a health regimen and iF these barriers outweigh the perceived beneFits, motivation to comply with suggested health activities may be decreased. 21 Perceived susceptibility. It is believed that individuals vary widely in their perception oF personal susceptibility to a condition (Rosenstock, 1974). At one and DF the scale may be the individual who denies any possibility oF his contracting a disease. In the middle cF this spectrum may be the person who admits to the possibility oF contract- ing a disease, but also the possibility that it won’t happen. At the opposite end oF this spectrum is the individual who believes he/she is in real danger oF contracting the disease. Rosenstock deFines perceived susceptibility as the subjective risks oF contracting a condition (Figure 1). In this study, a diagnosis oF hypertension has been made so the individual's Feelings oF susceptibility to the complications oF hypertension will be diFFer- ent than an individual who is concerned he may develop hypertension (Figure 2). The health belier oF an individual who is diagnosed with hypertension must be modiFied in a planned way. By helping the hypertensive person identiFy his/her perceived barriers to Following a prescribed regimen, the individual may develop a realistic set oF belier ‘about his/her susceptibility to the complications oF hypertension. 22 .CoamchLmux£ HDLPCO CDwmcmmea>£ Lou Emsamm umHU "CmemmL EofiumUaDm mcszoaaou to noctssmxs op ostsomum ammo: tmasmm Epsom: ms» .N mLJmfim Enamcmmeaxz Lo PmmLLP Dm>amUme T a » cmemML LuammL Dmummmmj Giazoaaom on mLmflLLm Dm>wm0me to LmnEJ WDCME EMEamML LuammL Dmpmmmmz vLoaajm Hmfiuom Jumflflmmmluamm maLDHHmk ucmEmULomCamm mLmzuo EOLL mUH>U< CprU< on mmDU Enamcmu ILmu>£ mo mCDHHMUHHQEDU mo mmmcmjoflme Dm>amULml EnamcmPLmnxi mo mcoeumUaHquu on Newawnwpamumjm Dm>meme mCeonHom DP mnemmcmn Dm>am0me mo LmDEJZ a . fivmeoz quJmmMLQ UDDHD Uwaopmmev .mLJmmMLQ DDDHD Uflaoumxm .cowm IcmuLma>£ to CowumLDUu EnamcmumeNI op Dawsommm nmEDU ate .mjpmpm XLo; .mjpmpm Hmcoapm03um .PcmEmmCMLLm ma>aH .mjpmum HmuMLMEV b DLDU Lpammn pamuuw Dcm xmmm op mmmcmc«aaaz Enamcmp ILmQ>£ on maCmeLma mmePmE Luammi pjonm CLMUCCU "caspm>auoz HNmeoHOLUhmmoauom fimDmL .xmm .mmmv UMLQNLmoEmD coapu< to noozasman mLopUmm unafluwnoz mcowpamULmL HNJUH>HUCH 23 Perceived seriousness. Perceptions concerning the seriousness oF a given health problem also vary From person to person. The degree oF serious- ness may be judged by the degree oF emotional arousal created by the thought oF a disease as well as by the kinds oF diFFiculties the individual believes a given health condition will create For him (Robbins, 1952). An individual may perceive seriousness in terms oF a medical problem. Perceived seriousness may also include implications oF the eFFects oF the disease on an individual's job, Family liFe, and social relationships (Rosenstock, 1974). Susceptibility and seriousness are viewed as the threat component (Figure 1). Even iF individuals recognize personal susceptibility, they will not act unless they believe becoming ill will bring serious physical or social repercussions. Again it is important to note that these are the subjective perceptions oF the individual and are not related to the objective estimates oF a health proFessional (Becker, 1974). Perceived beneFits and barriers. An individual's acceptance oF susceptibility to a disease believed to be serious will provide a Force leading to action. The direction this action takes is inFluenced by 24 the belier regarding the eFFectiveness oF alterna— tives in reducing the disease threat the individual Feels (Figure 1). An alternative is seen as bene- Ficial iF it relates subjectively to reducing the susceptibility or seriousness oF an illness. An individual may believe that a certain action will be eFFective in reducing the threat oF disease, but, at the same time see the action as inconvenient, expensive, unpleasant, painFul, or upsetting. These negative aspects act as barriers and arouse conFlicting motives oF avoidance (Rosenstock, 1974). The hypertensive individual may know the eFFects oF hypertension and know that he/she should Follow a prescribed regimen, but, iF he/she doesn't under- stand the regimen or has side eFFects to the medica— tions he/she may not Follow the prescribed health regimen to control hypertension. The perceived beneFits oF the regimen to control hypertension are evaluated by the patient For their ability to reduce the threat component and then weighed against the perceived barriers oF the regimen. IF the positive aspects oF Following the suggested health regimen are strong and the negative aspects are weak, the hypertensive individual will probably Follow the suggested health regimen. IF the negative 25 aspects oF Following the suggested health regimen are strong and the positive aspects are weak, the hypertensive individual will probably not Follow the suggested health regimen (Figure 2). The interrela- tionship is explained by Maiman and Becker (1974), "An individual's estimate oF a prescribed health ac- tion's 'beneFits' oF reducing perceived susceptibility and/or seriousness is weighed against his/her per- ception oF psychological and other 'barriers' to the suggested action." It is necessary to help a patient identiFy his/her perceived barriers and at- tempt to overcome these barriers beFore a patient can be expected to Follow suggested health regimens. Cues to action. A Factor that serves as a cue to appropriate action is necessary. The combined levels oF susceptibility and seriousness provide the energy to act and the perceptions oF the beneFits or bar- riers provide a path oF action. An event is needed to set this process in motion. These events or cues may be internal (perception oF bodily states) or ex- ternal (interpersonal, interaction with health care provider, social supports, media). The required in- tensity oF the cue to start behavior varies with the diFFerences in the levels oF perceived susceptibility and seriousness. Maiman, et a1. (1977) states that the cues make the individual consciously 25 aware oF his/her perceptions about his/her condition. These stimuli or "cues to action" are labeled moti- vational Factors (Figure 1) by Becker (1974). ModiFyingfiFactors. ModiFying Factors which can inFluence behavior include demographic variables (age, sex, race, ethnicity, etc.), sociopsychological variables (personality, social status, peer and reFerence group pressure, income, etc.) and structural variables (such as prior knowledge about problems, prior experience with the problem, and perceived health) (Figure 1). These variables have been used in research and appear to aFFect compliance. Re- searchers have Found that there is low compliance among the very young and the very old (Blackwell, 1973). Mikhail (1981), Becker (1974), and Haaner and Kirscht (1970), proposed that modiFying Factors might inFluence individual perceptions oF suscepti- bility, seriousness and beneFits oF taking action. To summarize, proponents oF the Health BelieF Model assume that an individual will Follow a speciFic health behavior iF the individual possesses minimal levels oF relevent health motivation and knowledge, Feels potentially vulnerable, be- lieves the eFFicacy oF the health behavior and believes that beneFits to Following the health behavior outweigh barriers. The probability that an individual with hypertension 27 will Follow a suggested health regimen regarding diet and/or taking medication is aFFected by the individual's perceived susceptibility to the complications oF hypertension and per- ceived seriousness oF the complications oF hypertension, willingness to seek and accept health care and the individual's concern about health matters pertaining to hypertension (Figure 2). The individual’s cues to action which include advice From others, reinForcement, tailoring, selF Feedback, and social support will aFFect the beneFit/barrier ratio which will in turn aFFect the probability oF Following a recommended health regimen (Figure 2). ModiFying Factors which include demographics (age, sex, race), sociopsychological Factors (marital status, living arrangements, educational level, work status, and income), and variables speciFic to hyperten- sion (duration oF hypertension, systolic blood pressure, diastolic blood pressure and weight) will aFFect the individual's motivation and beneFit/barrier ratio (Figure 2). Health behaviors are inFluenced by several elements. The researcher was interested in what barriers subjects perceived to Follow- ing prescribed regimens concerning diet and taking medication For controlling hypertension. The researcher was also inter- ested in the impact oF job on Following the health regimens. The health-care provider can play an important role in helping the hypertensive individual deFine and change 28 perceived barriers to Following recommended health regimens. Variables oF Orem's selF-care model and their relationship to the study questions will be discussed in the Following section. Relationship oF Nursing to the Study Variables “Orem (1980) believes that nursing is based on the prin- ciple that individuals should be helped in their immediate distress and assisted to attain or regain responsibility within their existing capacities. rNurses' major goal, then, is to help individuals or groups under their care to maintain or change conditions in themselves or their environments. Nursing's special concern that diFFerentiates it From other health services is "the individual's need For selF-care action and the provision and management oF it on a continuous basis in order to sustain liFe and health, recover From disease or injury and cope with their eFFects" (Orem, 1980, p. 55)- Candidates For nursing intervention are those with deFicit or potential deFicit relationships between (1) their current or projected capability For providing selF-care or dependent care, and (2) the qualitative and quantitative demand For care (Orem, 1980). SelF Care Orem states that selF care, the practice oF activities that individuals initiate and perForm on their own behalF 29 in maintaining liFe, health, and well being is a requirement oF every person. Orem categorizes three types oF selF-care requirements: universal, developmental, and health deviation selF care. Universal selF-care requisites are associated with liFe processes and with the maintenance oF the structural and Functional integrity oF the human being. Universal selF- care requisites are common to all persons throughout the liFe cycle adjusted to age, developmental state, and environ- mental Factors. Developmental selF-care requisites are associ- ated with developmental processes and liFe cycle events. Health deviation selF-care requisites are concerned with genetic, constitutional, and structural, and Functional deFicits and with their eFFects, diagnosis and treatment. Nursing System Orem has developed three nurSing systems: the wholly compensatory nursing system, the partly compensatory nursing system, and the supportative-educative nursing system based on whether the nurse, the patient, or both can act to meet the patient's selF-care requisites. This third system is For situations where the patient can and should learn to perForm the required selF—care actions but cannot do so without assistance. In this system, the nurse uses techniques such as support, teaching, and guidance. In this system, the patient's need For assistance is related to decision-making, behavior control and acquiring knowledge and skills. There 30 are a variety oF ways nurses can work in this system. The nurse may oFFer guidance and support to a patient who can perForm selF—care activities or teaching and periodic guidance to the patient who is competent in selF care (Figure 3). NursingpProcess Nursing is more than simply a combination oF all the activities a nurse can perForm in behalF oF a person under nursing care. Nurses can determine when a person needs nursing, design a system oF assistance and provide the delivery oF assistance. The process is reFerred to as the nursing process (Orem, 1980). From this nursing process, a system is developed that will be most beneFicial to the ihdividual. Nursing activities are designed through the nursing process and include diagnosis and treatment, design and plan, and production and management (Figure 3). The nurse's perspective oF the health-care situation will be inFluenced by the hypertensive subject's perception oF his/her health situation (Figure 3). The hypertensive subject's perspective oF his/her health situation stems From the variables in the Health BelieF Model. Motivation, including a willingness to seek health care and concern about health matters pertaining to hypertension, perceived susceptibility and perceived seriousness oF the complications oF hypertension, the perceived beneFit-barrier ratio to Following a suggested pcmwmz .mLJmmmLa UDDHQ Uwaovmmfin .ijmmmLQ DDDHD Ofiaopmxm “Enamcmutmuxn op uflmwumuw fimEOUCw .mJPmpm XLOZ .mjpmum Hmcoflpmojuw .pcmE ImmcmLLm mCM>H~ .mjpmum amp IHLmEv Hmofimoaozuzmuowoom mmUML .xmm .mmmv mLopumflVURLQNLmDEmO mcmEHWML Lpamm£ Dmvmmmmjm mCMSOHHom Du mLmHLLmn Um>meme mJC«E Umpmmmmjm mcflzoaaou Du muwmmcmn Um>flm0me :1 .§ EnamcmuLmaxL Du mmmcmjoflme UM>MUULUE 31 CDHmEmPLmQ>L Du hufiaflnavamummm Dm>fimUme mLmU LPHMML pumuum UCm xmmm on mmmcmcfiaafiz CDwm IcmPLmQ>£ 0p mCflCmmuLma mmeumE Ludmmfi Pjonm CLmUCOU "Coflpm>fipoz .CoflmcvamQ>£ mo COMPmLJD mEmEflmmL Lpammfi w>avaJUMIm>HpLOQu3m L0 Hmnoz m.EwLD .nommag EMpmzm mCMmLJZ .m mLJmam EmEHmmL LpammL DmUCMEEDUML zoaaom 9 mmMLum nofi UEm mCDHmeaUME .pUHU GCMCLMUCOU Etafiummu Dcm .pLDDQJm .wucmveju "Cofipcm>LmuCH mcamLJE Hmcofipmojum mLmoluHmm a, a, PCUE lUWWCWE DEN .LD MPUJUDLE Ewan UCm Emame [prmnufim LPHmNL mo mjuou mCMmLDZ pCmEPmmLh UCm mwmocmmfio TI 9 CoflPNJPHw mLmU Lvammfi mmmUoLm COMPU< pumeJW mafimmw >Ucm m mLmolmHmm Lo mLmOIEHmm to Pcmsuoam>mn PEmEQDHm>mU Dcm mmHUwam 0:9 umHJmmm UCm mmMUmem mLD mumaammm COMPU< mmLJZ Empmhm w>flumUJUMIm>fipLouujm smnmxm mcdmLJZ 32 health regimen including taking medications and Following a diet and demographic variables all inFluence the hypertensive subject's perspective oF his/her health situation. Nurses must assess the hypertensive subject's perspective oF his/her health situation. By determining what Factors inFluence the hypertensive subject's behavior, speciFically his/her perceived barriers toward health care, nurses can also gain a perspective oF the healthecare situation. A plan can be Formulated in which the patient and nurse can work to decrease the patient's perceived barriers (Figure 3). Since selF care is deFined as the practice oF activities that individuals initiate and perForm in order to maintain liFe, health, and well being, selF care is seen as an action, where the patient seeks actions and results (Orem, 1980). Nurses can help the hypertensive individual decrease the number oF perceived barriers by supplying knowledge about the disease entity, the medical regimen needed to control hypertension and the liFestyle changes necessary to decrease the eFFects oF the complications oF hypertension. The nurse can guide the hypertensive subject in making choices to Fit a certain liFestyle and provide support to the subject as he/she makes these changes. By deciding iF a patient perceives barriers to his health regimen and by identiFying the perceived barriers and the beneFit/barrier ratio, the nurse and patient can work together From the patient's perspective to decrease 33 barriers and increase the likelihood oF taking recommended health actions. Summary The theoretical Framework, the Health BelieF Model and the nursing Framework, Orem's SelF-Care Model were intro— duced in Chapter II. Pertinent variables were conceptually deFined and their relationship to each other and the study questions were analyzed. In Chapter III, a review oF the literature on which this study was based will be critiqued. CHAPTER III LITERATURE REVIEW Introduction In this chapter, relevant literature pertaining to the study variables oF perceived barriers to taking medications to control hypertension, perceived barriers to Following diet to control hypertension and perceived job barriers will be re- viewed. The review will also include literature on hyperten— sion, the health belieF model, and nursing interventions For improving health behaviors. Research Findings and opinions applicable to these concepts will be presented. This chapter will be divided into the Following sections: hypertension, the health belieF model, barriers to taking prescribed medica— _tions, barriers to Following a prescribed diet, job barriers, and nursing strategies For caring For hypertensive individuals. Chapter III is a review oF the literature which complements the problem statement and conceptual Framework. Hypertension The deFinition oF hypertension is somewhat arbitrary. In adults, blood pressure greater than 140/90 mm Hg is con- sidered abnormal. Data reported by the National Health Survey 34 35 (1982), showed that only 24% 0F deFinite hypertensives ( 150/95 mm Hg) are in control; 24% are aware oF their illness, but not on treatment; and 20% are on inadequate treatment. The remain- ing 32% 0F hypertensive individuals are not even aware oF their illness. Hypertension is a major public health problem. It has been shown to reduce the liFe span and is a risk Factor For stroke, heart attack, congestive heart Failure, and renal Failure. Treatment For hypertension includes drug therapy and diet therapy. Much oF the literature about treating hyper- tension aims at using drug therapy. More than twenty years ago, treating malignant hyperten- sion with drugs was shown to prolong an individual's liFe. Bjork, et a1. (1951), Leishman (1953), and Hamilton, et a1. (1954), proved that treating hypertension with medication reduced the morbidity and mortality in individuals with less severe Forms oF hypertension. A controlled study done by the Veterans Administration From 1987 to 1972 (Borhani, 1981) conFirmed these observations in men with diastolic blood pressures greater than 115 mm Hg. BeneFits oF drug therapy were also noted in individuals with diastolic blood pressures oF 105-114 mm Hg. This study was a prospective, randomized, double-blind study including 523 males From Veteran Administration hospitals. The participants had well documented hypertension and were randomly assigned to 35 placebo or active treatment groups. Results showed the eFFi- cacy oF drug therapy in reducing congestive heart Failure, myocardial inFarction and stroke. A Five-year study done by the Hypertension Detection and Follow-Up Program Cooperative Group (1982) proved the eFFicacy oF antihypertensive drug therapy in reducing the possibility oF stroke. Ten thousand, nine hundred Forty individuals with a diastolic blood pressure oF 90 mm Hg or higher Participated in the study. The participants were randomly assigned to two groups. One group received stepped care and were Followed in the Hypertension Detection and Follow-Up Program clinic, while the other group received reFerred care and were Followed in the community by physicians. Interviews, blood pressure monitoring and mortality sur- veys were done yearly in both the stepped care and reFerred care groups. Findings showed a 15.9% reduction in all causes oF mortality among the stepped care group compared to the re- Ferrad care group. Findings For the stepped care group also. showed (1) a reduction in incidence oF stroke For all ranges oF diastolic blood pressure, and (2) a 27% reduction oF stroke incidence among subjects aged 30 to 89. The Framingham study (Kannal, 1978) demonstrated the eFFicacy oF treating hypertension in 5,184 individuals aged 30 to 52. All participants were Free oF stroke when they entered the program and were Followed bi-annually For more 37 than twenty years. Results oF this study showed hypertensive persons had twice as much occlusive peripheral arterial dis- ease, three times as much coronary artery disease, Four times as much congestive heart Failure and seven times as many brain inFarctions as did participants with normal blood pressure. Interestingly, morbidity rates For individuals with their hypertension in control were approximately the same as normo- tensive participants. The Framingham study supported the pram- ise that hypertension is a powerFul precursor to stroke. The eFFicacy oF treating mild hypertension (diastolic oF 95-110 mm Hg) was demonstrated in an Australian study (1980). Three thousand Four hundred twenty—seven men and women, aged 30 to 59, with diastolic blood pressures oF 95-110 mm Hg participated in the study. Each person was assigned to a placebo or active treatment group and then Followed For Four years. The results showed a signiFicant decrease in mortality From cardiovascular disease and stroke in the active treatment group. Stamler, et a1. (1980) has questioned the long term use oF drug therapy in mild, asymptomatic hypertensive individuals (dia- stolic blood pressure 90-104 mm Hg). The MRFIT research group (Cohen, 1981) showed the importance oF using antihypertensive medications For those individuals with diastolic blood pressures greater than 100 mm Hg, but Felt a more conservative approach to blood pressure control be used For individuals with diastolic 38 blood pressures oF 90-100 mm Hg (1982). The Australian Thera- peutic Trial Found less complications occurred when diastolic blood pressure was brought below 100 mm Hg without using drugs. Kaplan (1983) suggested using weight reduction For obese individuals, moderate sodium restriction For all and behavior modiFication approaches For individuals with hypertension who would use them. Non-Pharmacologic Treatment For Hypertension A review oF literature provides evidence concerning the importance oF non-pharmacologic treatment For hypertension. There is interest in using weight reduction and sodium restric- tion as a means For controlling blood pressure in hypertensive individuals. These approaches are oF particular importance to persons with mild hypertension, who may be able to control their hypertension without drugs, but are also useFul in persons with more severe hypertension who must use antihypertensive medications to control blood presSure. Epidemiological studies by LangFord (1981) and Fries (1975) show correlations between blood pressure and body weight and blood pressure and sodium restriction. The 1984 report oF the Joint National Committee (1984) stated that weight reduction should be an integral part oF therapy For obese individuals with hypertension. Patients with essential hyper- tension should be counseled concerning moderate sodium restric- tion. 39 Stamler, Stamler, Riedlinger, Algora and Roberts (1978) reported Findings related to weight and blood pressure during a screening oF 1,000,000 hypertensive persons. The researchers were interested in the association oF estimated weight and the prevalence oF elevated blood pressure in persons aged 20 to 54 years. A singular blood pressure was taken by health proFes- sionals and weight was estimated as underweight, normal weight or overweight by the participants. Hypertension was deFined as a diastolic blood pressure 0F 95 mm Hg or above or the current use oF medication to control blood pressure. In overweight persons, aged 20 to 39, the rate oF hyper- tension was double that oF normal weight persons and triple the rate oF underweight persons. In the age group 40 to 54 years, the rate oF hypertension was greater than 50% in over- weight compared to normal weight individuals and almost 100% greater in overweight individuals compared to underweight persons. Stamler, et a1. thus concluded that the association between overweight and high blood pressure may be causative. IF this is valid, then weight control could be used to lower elevated blood pressure. There has been some canusion as to whether a decrease in blood pressure is due to sodium re- striction, weight loss, or a combination oF both. Reisen, et a1. (1978) studied the eFFect oF weight loss on blood pressure with no reduction in sodium intake using hypertensive individuals in Israel. One hundred and seven 40 patients were enrolled in the study. Criteria For admission included: (1) at least two blood pressure readings oF greater than 140 mm Hg systolic and/or 90 mm Hg diastolic; (2) excess weight oF more than 10% above ideal body weight; and (3) no antihypertensive drug therapy or inadequate control oF blood pressure using antihypertensive medications. OF the 107 parti- cipants, 24 were on no drugs and 83 were receiving inadequate drug therapy. The 24 participants receiving no drug therapy and 57 randomly selected patients receiving inadequate drug therapy were placed on a weight reduction program. Males who were 10% above ideal weight reseived 1200 calories daily while Females 10% above ideal weight received 1000 calories each day. Men greater than 20% overweight were placed on a 1000 calorie diet and women were placed on an 800 calorie diet. All participants were encouraged to eat salty Foods. All participants visited the clinic every two weeks and were seen by the dietician and physician. AFter six months, all subjects on the dietary regimen lost at least three Kg (mean 10.5 Kg). Seventy-Five percent oF individuals who were on the weight loss regimen and not receiving antihypertensive medications and 51% oF individuals who were dieting and taking antihypertensive medications achieved normotensive levels. The normotensive blood pressure levels represent a signiFicant (p = .001) and direct association between weight loss and blood pressure. The group who Followed no weight loss diet 41 did not attain normotensive levels in blood pressure. Reisen and associates believed that weight loss had a direct eFFect on reducing blood pressure and that weight loss could be used to control hypertension in overweight individuals. The results also indicate that it is not necessary to reach ideal body weight to decrease blood pressure to normotensive levels. The researchers believed weight control through dietary measures was an eFFicient, low-cost way to control blood pressure. Limitations to the Findings in the Reisen study could be patient non-compliance with a dietary regimen For an extended period and a health-care provider's inability to individualize an appropriate weight loss program to a hyper- tensive patient's tastes and economic level. Tuck, Sowers, DornFeld, Kledzik and Maxwell (1981) also studied the eFFect oF weight reduction oF blood pressure in 25 obese individuals. Subjects were 30 to 182% overweight and 12 subjects had elevated blood pressures above 140/95. All subjects were placed on a 320 Kcal diet. FiFteen subjects (Group A) received 120 mmol oF sodium daily and 10 subjects (Group 8) received 40 mmol oF sodium daily. The subjects were monitored For 12 weeks. There was a signiFicant weight loss in both groups correlating positively with signiFicant and equal decreases in mean arterial blood pressures (r = 0.58, p = .05). There was also a decrease in urinary sodium excretion which would indicate a decreased sodium intake. 42 Tuck, et a1. monitored plasma renin activity (PRA) and aldosterone levels and Felt that blood pressure reductions in obese patients may depend to some degree on PRA and aldosterone reductions. PRA and aldosterone levels were shown to be inde- pendent oF sodium intake. The results oF this study indicate that a 10 to 30% weight reduction can be signiFicant to lower blood pressure to a normotensive range and that individuals do not need to reach ideal body weight to note signiFicant de- creases in blood pressure. Many researchers believe salt ingestion inFluences blood pressure levels. On a physiological level, hypertension may be a homeostatic response to increased extracellular Fluid which results From increased sodium intake. Freis (1975) Found that a reduction oF sodium in the diet to less than two grams/day did lower blood pressure. A study by Brown, Brown and Stephens (1982) assessed die- tary Factors related to elevated blood pressure among Harlem residents. One hundred seven volunteer subjects, aged 5 to 70 years participated in the study. The systolic blood pressure was 80-180 mm Hg and the diastolic pressure was 40-115 mm Hg with a mean blood pressure oF 120/78. This normotensive mean reFlects the Fact that 54.7% oF subjects were under 30. Forty percent oF the subjects had blood pressures above the normal range For their age. Subjects who reported using salt For cooking and at the table showed a signiFicant elevation oF both systolic and diastolic pressures (r = .05 - .001). 43 Brown, et al. reported that subjects who stated they ate salty Foods (potato chips, soFt drinks) had signiFicant correlations between ingested Foods and systolic blood pres- sures (r = .05). OF the subjects who reported eating pork, there was a signiFicant correlation between elevated systolic (r = .05) and diastolic pressure (r = .001). It is important to note that socioeconomic Factors may aFFect blood pressure in this volunteer group. At the same time, it is important to note that the level oF sodium ingestion did correlate with an elevated blood pressure. MacGregor, et a1. (1982) reported a double-blind random- ized crossover trial oF moderate sodium restriction in essential hypertensives. Nineteen individuals, aged 30 to 55 with systolic pressures From 135 to 185 mm Hg and diastolic pres- sures oF 90 to 110 mm Hg (average pressure 155/98 mm Hg) parti- cipated in the lO-week study. All subjects were placed on a no-added salt diet and avoidance oF Foods with high sodium content. Subjects were instructed on how to Follow these restrictions. For one month the subjects received 10 mmol slow sodium tablets. Each subject took the number oF tablets necessary to restore his/her sodium intake to the usual amount ingested. The number oF tablets varied From 7 to 12. The alternate month the subjects received the same number oF placebo tablets. Findings showed a 7.1 mm Hg decrease in mean blood pressure during the month subjects were receiving placebos as compared to the month subjects received slow sodium tablets. 44 MacGregor Found the decrease in blood pressure was the same as that obtained using a diuretic or beta blocker. The researchers suggested that For many patients with mild to moderate essential hypertension, sodium restriction (no added salt, avoidance oF salty Foods) should be the First treatment. MacGregor, et a1. did recognize the diFFiculty oF long-term compliance to a sodium restricted diet and the diFFiculty in approximating sodium content in Foods. Morgan, et a1. (1978) also researched treating hyperten- sion by sodium restriction. The researchers Followed patients For two years rather than short-term as in the MacGregor study. Thirty-one Australian subjects with diastolic blood pressures between 95 and 109 mm Hg were treated with a mild sodium restric- tion regimen. The subjects were instructed to avoid salty Foods and not to add salt at the table. This group was com- pared to a control group who received no treatment (n = 33) and a group treated with antihypertensive medication (n = 52). Compliance was measured through blood pressure and weight readings and 24-hour urine samples. Diastolic pressure in the diet controlled group Fell a mean oF 7.3 mm Hg compared to the control group whose diastolic pressure rose 1.8 mm Hg. The group receiving antihypertensive medications also had signiFicant decreases in diastolic as well as systolic pressures. The decrease in blood pressure in the diet controlled group was not as great as subjects receiving antihypertensive 45 medications, but the decrease was enough to put many individuals in the normotensive range. The subjects in the diet controlled group did signiFicantly reduce their sodium intake, but not to the level desired by the researchers and were still able to de- crease their blood pressure to normotensive ranges. Morgan, et a1. concluded by noting they do not advocate sodium restriction to 100 mmol/day as a suitable treatment For patients with established hypertension, but that hypertension could be prevented iF sodium intake was reduced to70 to 100 mmol/day. The researchers recognized the "high sodium content oF many prepared Foods in Australia makes it diFFicult to reduce intake below 100 mmol/day." Ram, Garrett and Kaplan (1981) studied the eFFect oF moderate sodium restriction and diuretics For the eFFect oF potassium wasting and blood pressure control in 12 patients aged 28 to 52, diagnosed with mild hypertension (average blood pressure 148/100). The subjects were randomly assigned a high or low sodium diet and various diuretics. The diuretics used in this study included chlorthalidone, hydrochlorothiazide, and Furosimide. Each diuretic was given at Four-week intervals. HalF oF the subjects were on either a low sodium (less than 100 mEq oF sodium) or high sodium (greater than 150 mEq oF sodium) diet. One-third were taking each oF the diuretics during each study period. There was a mean Fall in blood pressure oF 9.1 mm Hg in the group on the high sodium diet compared to a mean 45 Fall oF 13.9 mm Hg in the group on the low sodium diet. Potas- sium levels Fell 225 mEq in the low sodium diet group compared to 455 mEq in the high sodium diet group (p = .05) documenting that in this study moderate sodium restriction and diuretics produced less potassium loss than high sodium diets and diuret- ics. Ram, et a1. supported the use oF sodium restriction (Four gram sodium diet) through dietary measures For individuals with minimal elevation in blood pressure and sodium restriction with a single morning dose oF a diuretic with intermediate action For people who cannot reduce elevated blood pressure by sodium restriction alone. Many researchers have Found dietary patterns, speciFically sodium intake, to be a major contributor to the continued prevalence oF high blood pressure in individuals. Research Findings From the Morgan study (1978) indicate sodium restric- tion should be tried beFore drugs to control hypertension in persons whose diastolic blood pressure is 90-105 mm Hg. MacGregor, et a1. (1982) believe that avoiding sodium-rich Foods should be part oF the management oF hypertension and Ram, et a1. (1981) believe moderate sodium restriction should be used in conjunction with diuretics to treat hypertension. In contrast, McCarron, et a1. (1984) suggest that diets low in sodium are associated with higher blood pressures, while high sodium diets are associated with lower blood pressures. 47 A study by McCarron, Morris, Henry and Stanton (1984) analyzed epidemiologic data For the association between diet and blood pressure in the United States. Ten thousand, three hundred and seventy-two individuals aged 18 to 74 participated in this study. Data concerning health and nutrition oF the participants were obtained through interviews and examinations. McCarron, et a1. Found that increased consumption oF sodium and potassium were negatively associated with elevated systolic blood pressure (-O.279 and -0.451, respectively). Other Findings included deFiciencies rather than excesses in nutrients characterize the hypertensive individual; reduced consumption oF calcium and potassium are nutritional markers oF hypertension and as stated previously, diets low in sodium are associated with higher blood pressures. Though these correlations cannot be accepted as causative oF hypertension, the researchers believe they have implications For the associ- ation oF diet with hypertension. The value oF weight control in hypertension management has been shown. There remains controversy as to whether sodium' restriction should be used to control hypertension. A review oF the previous studies have shown a positive correlation between diet control and blood pressure control in many studies. The eFFectiveness oF diet in controlling blood pressure depends on the hypertensive patient's ability to adapt to the changes. In summary, it has been shown that hypertension is a 48 major risk Factor For several health problems. Studies have shown that drug therapy and non-drug therapy are eFFective in lowering elevated blood pressure, thus reducing the morbidity and mortality oF hypertensive individuals. The Veterans Admin- istration studies and reports From the Hypertension Detection and Follow-Up Program indicate that drug therapy is clearly beneFicial For individuals with severe and moderate hyperten- sion. Other researchers have questioned the use oF antihyper- tensive medications For persons with mild hypertension, thus renewing the interest in using diet modiFication For treatment oF blood pressure. Yet, there are still a large number oF persons who don't know they have hypertension, are being inade- quately treated or are not Following suggested regimens. Hypertension remains a widespread disease and although detection oF hypertension is important, emphasis must also be placed on assisting hypertensive individuals to adhere to regimens and maintain long-term blood pressure control. Nurses must use educational and counseling strategies to help individuals understand and accept hypertension and therapeutic regimens. The Health BelieF Model has been widely studied and used to describe why people do or do not Follow antihypertensive regi- mens. One condition oF the Health BelieF Model is that individ- uals must believe that beneFits oF therapy outweigh barriers. In the next section, the Health BelieF Model and particularly barriers to care will be discussed. 49 Health BelieF Model The Health BelieF Model postulates that the likelihood an individual will undertake a recommended action is dependent on the individual's subjective belier concerning the threat oF the illness (perceived susceptibility and severity), the eFFicacy oF the recommended action, and the barriers to be- ginning or continuing the action. The Health BelieF Model was originally Formulated to explain preventive health behavior, but researchers have expanded the model to explain other types oF behavior. Kirscht (1974) applied the model to illness behavior. Kirscht indicated that symptoms oF an illness were important as they may represent a threat to the individual and may arouse health motivation or act as a cue to taking action. Becker (1974) used the model to explain sick-role behavior taken by those who consider themselves ill, For the purpose oF getting well. Kasl (1974) Further redeFined the Health BelieF Model so that behavior taken by individuals with chronic illnesses could be explained. Kasl suggested that chronic illness be- havior deserved special attention because the individual has to stay in treatment even though he/she may not Feel sick, take medications although he/she could perceive no changes in health status, Follow a regimen For an indeFinite period oF time, and do these with minimal social or institutionalized support. 50 Finally, Baric (1959) identiFied an "at risk" role. Baric stated that this role diFFered From sick role behavior in that an individual in a sick role has certain rights and obligations, whereas the "at risk" role is not Formally recog- nized or reinForced by society, has no time limit, and the individual in the "at risk" role is held responsible For this role. Studies utilizing the Health BelieF Model provide evi- dence oF the model's useFulness in predicting health behavior associated with screening tests For tuberculosis and cervical cancer; preventive actions againstrdental disease, polio, inFluenza; use oF health services in the presence oF symptoms; and adherence to therapeutic regimens while under treatment (Becker, 1974, 1975, 1977; Cummings, 1979). Mikhail (1981) reviewed Health BelieF Model research literature published From 1959 to 1979. Mikhail critiqued studies that addressed various health belieF model indices. Perceived susceptibility and perceived severity were Found to be related to preventive health actions, sick role actions, and chronic illness behaviors in 15 studies. Eight studies showed that iF people believed in the eFFectiveness oF treatment, they were more likely to Follow suggested health regimens. In two studies it was shown that iF perceived severity was high but ways to cope with the problem were not available to the individual, an appropriate health action was not taken. 51 Mikhail reviewed studies that addressed barriers to care and Found that monetary cost oF a regimen was described as a barrier in studies done by Larson, et a1. (1979) and Radius, et a1. (1978). Other perceived barriers included pain, inac- cessibility, inconvenience (Kegalas, 1953; Becker, 1977; Kirscht and Rosenstock, 1977) doubting the saFety oF a regimen or side eFFects oF a regimen (Haaner, 1970; Haynes, et al., (1975). Andreoli (1981) analyzed selF concept and health belier between compliant and non-compliant hypertensive individuals and used the Health BelieF Model as the conceptual Framework. Seventy-one male patients enrolled in a hypertension clinic in a Veterans Administration Medical Center participated in the study. Forty-one subjects were labeled compliers and 30 were non-compliers. The subjects were categorized as compliers or non-compliers based on a clinical record oF their diastolic blood pressure and the nurse’s interpretation oF their status oF compliance. Andreoli measured the Health BelieF Model in- dices oF severity oF hypertension, susceptibility to hyperten- sion, and the beneFits oF complying with therapy. The subjects also completed a selF-concept questionnaire. The means oF the scores on the two scales were compared using a two-tailed t- test. The analyses showed there was no signiFicant diFFerence in scores on the two questionnaires between compliers and non- compliersy. The author concluded there was no diFFerence in 52 selF concept and health belier between compliers and non-com- pliers, and recommended Further research to identiFy character- istics that would diFFerentiate compliers with non-compliers. As has been noted, the Health BelieF Model has been utilized to predict a wide range oF health behaviors From be- haviors associated with screening tests to behaviors associated with chronic illnesses. Maiman, et a1. (1977) tested the reli- ability oF health belieF model dimensions as part oF a prospec- tive study oF mothers' adherence to a diet regimen prescribed For their obese children. The investigators constructed in- dices to measure each major component oF the Health BelieF Model and Found substantial reliability. There was also some interrelatedness among the constructed indices that might ques- tion the independence oF the belier measured in the study. Cummings, Jette and Rosenstock (1978), using a multi- trait-multimethod design attempted to determine the construct validity oF the Health BelieF Model. The researchers measured respondents' perceptions oF various dimensions oF the Health BelieF Model. Each perception was measured by three methods. Results determined that the dimensions could be measured with a substantial amount oF convergent validity using a Likert or multiple choice questionnaire items. Finally, Jette, et a1. (1981) developed a questionnaire to measure the perception oF seven belieF dimensions. The ques- tions were taken From questionnaires used in previous studies 53 and original wording was used where possible. The researchers also used two independent samples oF adults'in their study. Their Findings supported the assumptions that the Health BelieF Model dimensions are distinct and diFFerent and that reliable indices that measure health belier can be developed and repli- cated. Thus, the Health BelieF Model has been used to measure perceptions oF health behaviors in a wide spectrum oF studies. This has caused concern about the reliability and validity oF the various model dimensions, but recent studies have shown the dimensions to be reliable and Valid. Perceived barriers is one component oF the Health BelieF Model that impacts health behavior. Perceived barriers have been operationally deFined as access to care, convenience, cost, side eFFects, complexity oF regimen, duration oF regimen, and how much the regimen interFeres with liFestyle. In the next section, a review oF literature oF perceived barriers will be presented. Perceived Barriers Perceived barriers have been identiFied as the expressed belier and attitudes oF an individual concerning barriers to implementing aspects oF a suggested regimen (Becker, 1974). Two dimensions oF barriers analyzed in the present study were: cost, convenience, or change in liFestyle; and side eFFects and discomFort associated with therapy. 54 Several studies have been done to identiFy individuals' perceptions oF barriers to Following recommended therapies. IF an individual believes that a certain action is inconven- ient, expensive, unpleasant, painFul or upsetting, the negative aspects may act as barriers to Following a prescribed regimen. The monetary cost oF a service has been Found to be negatively associated with obtaining a service (Larson, et al., 1979; Radius, 1978; Kegalas, 1953; Becker, 1977). Kirscht and Rosen- stock (1977) Found that iF indiViduals perceived a recommended action as painFul, inaccessible, or inconvenient, the action was not likely to be Followed. Individuals who doubted the saFety oF a regimen or thought the regimen had side eFFects were also not likely to Follow the suggested regimen (Becker, et al., 1977; Kirscht and Rosenstock, 1977; Taylor, 1979). Finally, the complexity and long duration oF a regimen were perceived by individuals as barriers (Haaner, 1970; Haynes, at al., 1975). The Health BelieF Model has been used to predict health behaviors associated with screening tests, acute illnesses, and chronic illnesses. Perceived barriers to adhering to suggested health regimens have included cost, pain, inconven- ience, and concern about saFety oF the regimen. IF individuals perceive diFFiculty in Following suggested health regimens For health maintenance or acute problems, health care providers must recognize individuals' perceived barriers to Following regimens For chronic conditions that require liFe-long changes. 55 IF barriers to Following regimens can be identiFied, health- care providers and patients can work together to develop strategies For overcoming barriers. In the next section hy- pertensive individuals' perceptions oF barriers will be dis- cussed. Hypertensive Subjects' Perceived Barriers to Following Therapy The problem oF patients' adhering to medical regimens is complex. It is known that hypertensive patients who Fail to remain in continuous medical care or who are unwilling to Follow a prescribed medical regimen may have diFFiculty successFully controlling their hypertension. It becomes neces- sary to ask why patients do not Follow recommended regimens or what barriers hypertensive patients perceive to Following suggested regimens. A study was done by Caldwell, Cobb, Dowling, and DeJongh (1970) to assess why patients drop out oF treatment For hyper- tension. Using the interview method, stated reasons For not Following treatment included poor instruction, side eFFects oF medications, Financial need, lack oF Family support, and dissatisFaction with the suggested program For controlling hypertension. The researchers believed that several Factors including socioeconomic status, education regarding the disease and the patients' belier about the severity oF hypertension and the value oF staying in treatment aFFected adherence to therapy. 55 Kirscht and Rosenstock (1977) collected data From 132 hypertensive patients oF private physicians in order to identiFy Factors that were related to adherence to a therapeutic regimen. These researchers used the Health BelieF Model as the basis For their research to determine that hypertensive individuals will Follow prescribed regimens based on their Feelings about the condition, their vulnerability to the sequalae, the side eFFects and the beneFits or barriers oF Following the regimen. Results showed that patients who Felt susceptible to the sequalae oF hypertension, who Felt the consequences were seri- ous and who Felt the intervention was eFFective were more likely to Follow regimens For controlling hypertension. The perceived barriers to Following regimens included side eFFects oF medications and diFFiculty in Following a physician's advice. Finnerty, Shaw, and Himmelsbach (1973) studied hyperten- sive individuals who dropped out oF therapy with an emphasis on perceived barriers to care. Subjects who had stopped Follow- ing regimens were interviewed. Reasons For stopping treatment or perceived barriers, included inconvenient clinic hours, lengthy waits beFore seeing the physician, and insuFFicient time with the health-care proFessional. A study by Gillum, Neutra, Stason, and Solomon (1979) identiFied similar barriers to Following regimens For the control oF hypertension. The basis oF the study was to determine the likelihood that persons being treated For hypertension 57 would drOp out oF programs and why these individuals would stop therapy. The clinical courses oF patients were Followed through their medical records and individuals who stopped therapy were interviewed. Barriers to continuing therapy perceived by individuals included the perceived severity oF the illness, the lack oF enthusiasm on the part oF the health- care providers in treating the mildly hypertensive person, the cost oF care and the inconvenience oF care. One Finding in this study showed that patients with less severe hyperten- sion with no symptoms and without other ailments were more likely to stop therapy. There were several Factors that aFFected the results oF these studies. One important aspect was the socioeconomic status oF participants. A second variable was lack oF agree- ment among researchers deFining the terms nonadherence or "dropping out" oF therapy. DeFinitions used in these studies included pill Counts, prescription reFills, number oF Follow- up appointments, and/or blood pressure levels. Taking these aspects into consideration, it is still possible to see that hypertensive individuals do perceive barriers to Following prescribed regimens For controlling blood pressure. In summary, hypertensive subjects did perceive barriers to Following therapeutic regimens which may have included antihypertensive medications and/or dietary measures. Perceived barriers included side eFFects oF medications, lack oF support, 58 cost, and dissatisFaction with the health-care proFessional. In the next section perceived barriers to taking antihyperten- sive medications will be discussed. Perceived Barriers to Taking Antihypertensive Medications Hershey, Morton, Davis and Reichgott (1980) used an expanded version oF the Health BelieF Model and analyzed compli- ance behavior oF 132 individuals with hypertension. The parti- cipants were randomly selected From a hypertension program and all were taking at least one antihypertensive medication. Health BelieF Model indices measured included perceived sus- ceptibility, perceived severity, perceived beneFits, concern about health matters, vulnerability to illness, dependence on providers and control over health matters. 0F these percep- tions only increased control over health matters and increased dependence on providers were positively signiFicant in relation- ship to compliance. Hershey and associates Found the sociodemographic variables oF age, sex, education, work status, and income had no signiFi- cant eFFect on compliance. Perceived barriers included side eFFects, disruption in liFestyle, and duration oF treatment. These barriers had a signiFicant negative relationship to taking prescribed medications. In 1970 Caldwell, et a1. examined the dropout problem in antihypertensive drug therapy. Forty-two individuals who 59 were diagnosed with hypertension but had stopped therapy, were compared with a control group oF 24 patients who remained in treatment For hypertension. The authors wanted to determine why patients drop out oF therapy. Caldwell, et a1. interviewed individuals who had developed hypertensive emergencies aFter stopping treatment. These individuals were interviewed twice: once in the emergency room and at another point during the hospitalization. The control group was interviewed during an outpatient appointment. Perceived barriers included poor or inadequate instruction From health-care personnel (N = 42, 35%); lack oF income (N = 42, 33%); lack oF Family support (N = 42, 14%); dissatisFaction (N = 42, 10%); and side eFFects oF medications and discourage- ment (N = 42, 7%). An interesting statistic was that 39%.' (N = 42) oF individuals stopped treatment because they Felt well. It could be assumed that they had not been educated to the Fact that Feeling well is not the same as being well. In a later study, Caldwell (1983) assessed psychosocial Factors that inFluence the control oF moderate or severe hyper- tension. One hundred FiFty individuals diagnosed with moderate or severe hypertension and were under treatment participated in the study. All patients had been treated For at least one year and were taking two or more medications. 'ClassiFied by the step care regimen: 1% oF the participants were in Step 1; 43% were at Step 2; 43% were at Step 3; and 5% were 50 at Step 4. Eight percent were taking other combinations oF medications. Data were gathered using the interview and chart review methods. Barriers to Following recommended regimens included number oF medications taken daily, keeping all scheduled appoint- ments, and complexity oF the stepped care regimen. There was a signiFicant positive relationship among the socioeconomic variables oF age and marital status and compliance indicating older persons and married persons were more compliant than younger persons or unmarried persons. There was a signiFicant negative relationship between income and compliance. The authors also calculated a LiFe Events score modiFied From the Holmes and Rahe Social Readjustment Scale. The scores on this liFe event scale also had a negative relationship to compliance. The authors concluded by noting that psycho- social and socioeconomic Factors could be used to predict which individuals may be less likely to control their blood pressure. Cummings, Kirscht, Binder and Godley (1982) in a cross- sectional study examined aspects oF the Health BelieF Model including the relationship oF health belier, knowledge about hypertension, barriers to receiving medical care, and personal characteristics to drug treatment maintenance in a group oF 205 hypertensive individuals. A person was said to be hyper- tensive iF his average diastolic pressure was greater than ' 51 95 mm Hg or iF the diastolic pressure was less than 95 mm Hg, but the person was under a physician's care For hypertension. Compliance was deFined as taking antihypertensive medications as ordered aFter a diagnosis oF hypertension. Interviews and blood pressures were done on each patient. Cummings identi- Fied Four separate measures oF barriers. The First measure pertained to diFFiculty Following physician's advice. The second measure dealt with access to medical care. The third measure was source oF medical Care and the Fourth measure .dealt with Finances. Forty-three oF Cummings' study participants stated they had stopped treatment on their own. Perceived barriers included side eFFects 7%, cost oF treatment 11.5%, prescription not reFilled 20.9%, inconvenience 4.7%, and lack oF knowledge concerning medications 2.3%. Again, 39.5% Felt Fine without the medication which could be a result oF inadequate education concerning hypertension or treatment procedures. Another possible reason For stopping medications because the individual Felt Fine without medication could be low perceived severity and/or lack oF enthusiasm From the health-care provider to treat uncomplicated hypertension. The authors concluded that health-care providers must educate their patients to the im- portance oF taking medications even when asymptommatic. The authors also believed that more provider supervision and/or better Follow-up may help to decrease perceived barriers. 52 Brand, Smith and Brand (1977) conducted a descriptive study to determine the eFFect oF economic barriers to Following prescribed antihypertensive treatments. Two hundred twenty- Five patients were involved in the study. These individuals were classiFied by the socioeconomic Factors oF age, education, income, marital status, and severity oF disease. Barriers were deFined as income status, the number oF drugs prescribed For hypertension, and the dose Frequency. The socioeconomic Factors that aFFected adherence were age (the youngest and oldest groups had diFFiculty Following regimens); marital status (single and widowed were less adherent), which suggest that Family support plays an important role in therapy, educa- tion (those individuals with less than six years education were less adherent, and income. Barriers to not taking prescribed medications in the Brand study included the cost oF drugs, the patient's attitude, misunderstanding oF physicians' advice, lack oF communication between physicians and patients and the number oF medications to be taken. To overcome the monetary barriers, Brand, et a1. suggested: (1) increase cOOperation between physicians and pharmacists when prescribing, (2) establishing an education program to reduce unnecessary use oF drugs, (3) provide prescrip- tion drugs Free oF charge to people over 50 years oF age who are Financially needy. A study by Nelson, Stason, Neutra, Solomon, and McArdle 53 (1978) Found a signiFicant relationship between side eFFects and adherence with antihypertensive medication. One hundred Forty-two patients participated in the study. Adherence was measured in terms oF blood pressure, selF-reports, and appoint- ment keeping. Perceived barriers to treatment included per- ceived time costs and convenience, side eFFects oF medications and impact oF treatment on liFestyle. Blood pressure control was associated with eFFicacy oF treatment, taking medications For other chronic problems, and a higher education level. Better appointment keeping was done by older individuals and employed individuals. Results oF the study Found that improved blood pressure control was aFFected by the eFFectiveness oF treatment and the potential diFFiculties associated with having high blood pressure. To summarize, perceived barriers have been operationally deFined in many ways. Medication side eFFects is one way barriers have been Frequently deFined and the results oF studies have shown that side eFFects oF medications do negatively aFFect compliance. Kirscht and Rosenstock (1977), Baile and Gross (1979), Hershey, et a1. (1980), Nelson, et a1. (1978), Caldwell, et a1. (1970), and Cummings, et a1. (1982) Found no signiFicant relationship. The monetary cost oF antihypertensive treatment usually negatively aFFected adherence (Brand, et a1. 1977, Caldwell, 1970; Kirscht and Rosenstock, 1977). A study done by Cummings, 54 et a1. (1982), though, Found no signiFicant negative relation- ship between cost and adherence. Complexity oF the regimen (Brand, et al., 1977; Caldwell, et al., 1983) and duration oF treatment (Hershey, et al., 1980) were shown to have a negative eFFect on treatment. Access to treatment was a barrier to care in studies done by Caldwell, et a1. (1983) and Cummings, at al. (1982). A study by Logan, et a1. (1979) did report a positive relationship between access to care and compliance. Finally, in studies where the operational deFinition oF barriers was "treatment impact on liFestyle" a negative relationship between treatment and compliance was Found (Kirscht and Rosenstock, 1977; Levine, et al., 1979; Nelson, et al., 1978; Hershey, et al., 1980), Caldwell, et 81-, 1970)- The diFFerence in conceptual deFinitions oF barriers complicates a review oF research studies. Perceived barriers have been studied as part oF the Health BelieF Model or studied singularly as a determinant oF compliance. The research vari- able "barrier" may be termed "barrier" in one study and "modi- Fier" in another. Barriers have also been measured by client perception (selF-report) and by researchers (cost, accessibil- ity). The outcome variable to be measured in studies also makes it diFFicult to identiFy perceived barriers. Following a prescribed diet, taking medications, blood pressure, and pill counts have all been identiFied as outcome variables in studies. This wide variety oF deFinitions is seen as a 55 strength by some researchers and as a weakness by others. Researchers must continue to study perceived barriers in a variety oF settings to provide a basis For the design and implementation oF health-care interventions. In summary, research studies have been done that have shown that hypertensive subjects do perceive barriers to taking antihypertensive medications. Perceived barriers include side eFFects oF medications, the cost oF the medications, and the complexity oF the prescribed drug regimens. In the next section, barriers to Following dietary regimens will be discussed. - Perceived Barriers to Following Dietarijegimens Following dietary regimens to control hypertension appears to be more diFFicult than taking antihypertensive medications. This may become more oF a problem iF health-care providers rely on sodium modiFied diet as the therapeutic regimen For controlling hypertension. Glanz (1979) suggested that dietary regimens possessed characteristics that Foster barriers. Imposing a sodium modi- Fied diet is restrictive, Forcing liFestyle changes, is oFten oF liFe-long duration and may be only one oF many changes suggested to the hypertensive individual. Another problem is that the patient may adhere to his/her diet, but not take antihypertensive medications or exercise 55 regularly which will decrease the eFFectiveness oF the diet. This may increase the patient's Frustration with his entire therapeutic regimen.l Glanz (1979) suggested possible barriers to dietary regimens would include cost oF the Food, diet-inter- Ference with Family habits, access to the proper Foods and the skill, time, and eFFort necessary to prepare the Food. These concepts were not analyzed as possible barriers in the research analysis. In a 1980 report, Glanz deFined certain characteristics oF dietary regimens that may be possible barriers to the patient; dietary regimens are usually restrictive while other regimens are additive; diets are used as a method oF control rather than cure; the duration oF the diet is oFten liFelong; lack oF support From Family, work coherts or health-care providers. Becker, Maiman, Kirscht, Haaner, and Orachman (1977) in a prospective experimental design, attempted to predict and explain mothers' adherence to a diet prescribed For their obese children. One hundred eighty-two persons claiming to be responsible For the newly diagnosed obese child's daily care participated in the study. The age range was 17 to 52 years. The interview technique was used to gather inFormation. Barriers identiFied were perceived saFety oF the diet, diFFi- culty implementing the diet, Family problems and diFFiculty getting through the day. \ The operational deFinitions oF barriers to diet has 57 varied among studies. MacGregor, et a1. (1982) suggested bar- riers to Following speciFied diets might include inadequate Food labelling oF sodium content, lack oF support From Family or health-care providers and diFFiculty controlling sodium intake when dining out or travelling. These potential barriers were not addressed in the study. Morgan, et a1. (1978) suggested that high sodium content in prepared Foods may act as a barrier to Following recommended diets but did not pursue this possible relationship in their study.) Knapp (1978) investigated diet compliance in obesity. One hundred new patients in a clinic were randomly assigned to one oF Five diets. Forty-six percent oF the subjects had been told by physicians to lose weight For health reasons. Four oF the diets were outlined with speciFic meals to Follow. The FiFth diet plan listed Foods and their caloric intake. All diets were approximately 1000 calories. Knapp Found that more subjects Followed the diet that required modiFications or restriction. This diet was high in carbohydrates and Fats which may be similar to the diets normally consumed by these subjects. Barriers For not remaining in this program were not discussed by the researchers although non-compliance in this study was 37 to 95%. In summary, researchers have shown that weight loss and/or sodium restriction are beneFicial in reducing elevated blood pressure. Researchers have hypothesized that it is 58 more diFFicult For hypertensive individuals to Follow low sodium or weight reduction diets than it is to take antihyper- tensive medications (Glanz, 1979) and patient with dietary regimens is generally assumed to be poorer than with medica- tion regimens. Dietary regimens are oFten more diFFicult to Follow because they tend to be restrictive, require changes in liFestyle behaviors, are oF liFelong duration, and may be one oF many aspects oF a health regimen (Glanz, 1979). One problem in several studies is that possible barriers to Following dietary regimens have been suggested, but actual perceived barriers to Following dietary regimens have not been identiFied. Needed are studies oF perceived barriers to Following dietary regimens For controlling hypertension which can be used by health-care providers to design appropriate interventions to improve compliance. Perceived Job Barriers_to Following Antihypertensive Therapy Hypertensive patients' social situations may aFFect their belier about Following recommended health regimens. Work status or job is one signiFicant social role obligation that may impinge on a person's ability to Follow a prescribed diet or take prescribed antihypertensive medications. Social stressors have been deFined as those circumstances that an individual considers to be problematic or undesirable. As has been discussed, Following a health regimen to 59 control hypertension oFten requires changes in liFestyle pat— terns. Individuals may already be Facing stressors associated with work and Find it diFFicult to Follow recommended health regimens. In other words, the role obligations oF work status or job may produce enough stress or obligation and the hyper- tensive individual may be devoting more attention and energy to carrying out job obligations that there is no energy leFt to Follow health regimens (Given, 1982). A review oF the literature Failed to show how a job may aFFect an individual's ability to Follow a therapeutic regimen. However, studies have shown that the chronic disease, hypertension, does aFFect an individual’s job. Charlson, Alderman, and Melcher (1982) studied a work-site population in an eFFort to determine whether patients newly labelled as having hypertension experienced increased absenteeism due to illness. Charlson studied absenteeism days in 259 hyperten- sive subjects For one year aFter they were screened and labelled hypertensive. Criteria For being labelled hypertensive included a blood pressure equal or greater than 150/90 on two separate occasions For those 30 years oF age or less and a blood pres- sure equal or greater than 150/95 For those individuals 30 years or more and/or taking antihypertensive medications. OF the 259 subjects, 211 were previously aware they were hyper- tensive and 48 were previously unaware. Findings showed that 7O beFore screening, the unaware subjects had signiFicantly less absenteeism than did the aware subjects and that aFter screening absenteeism in the unaware group rose signiFicantly but stayed the same in the aware group. It is interesting to hypothesize that the unaware subjects adopted sick role behavior aFter being diagnosed as hypertensive, especially iF sick role be- havior is identiFied as the "activity undertaken by those who consider themselves ill, For the purpose oF getting well" (Kasl, 1955, p. 245). One oF the "rights" oF an individual who has assumed sick role behavior is to be excused From social roles or obligations, which would include work. Findings also showed that younger subjects and high risk subjects showed increased absenteeism aFter screening. A very interesting Finding in the Charlson study was that newly labelled individuals who received active Follow-up and treatment with antihyperten- sive medication had minimal increases in absenteeism. In contrast those subjects who received active Follow-up but 22 medication or those who received sporadic Follow-up had signiFicantly greater increases in absenteeism. This would lead one to hypothesize that newly diagnosed hypertensive individuals might Feel he/she was "getting better" iF a medica- tion was prescribed. Charlson concluded by stating that cau- tion should be used when labeling an individual as hypertensive, especially iF no antihypertensive medication is given to the perSon. 71 In contrast, Haynes, Sackett, Taylor, Gibson and Johnson (1978) showed that labeling oF an individual as hypertensive did increase absenteeism, but initiation oF therapy For a newly diagnosed hypertensive individual did not eFFect absentee— ism. Two hundred eight men participated in the study. The unaware group (those who had never been told they had hyperten- sion) consisted oF 138 men and 70 men were in the aware group. As in the Charlson study, Findings in the Haynes study showed that aware participants had twice as much absenteeism as the unaware group beFore screening, and in the year aFter the screening, the previously unaware subjects tripled their ab- senteeism rate, while the aware group showed only a small non-signiFicant rise in absenteeism rate. The Haynes group initiated a program to promote compliance which included education about hypertension, increased super- vision, and home blood pressure monitoring. Findings showed that neither the initiation oF therapy or the instructional program inFluenced absenteeism rates. Haynes suggested that based on the study's Findings, discretion should be used when labeling individuals as hypertensive and that detection should only be carried out in settings where therapy and Follow—up can be done. Alderman and Miller (1978) Found that access to therapy and Follow-up did not aFFect hypertensive individuals' adherence to therapeutic regimens or their blood pressure control. 72 Alderman and Miller compared a group oF workers who received their health care at a union health center with workers who received their care at the work site. A total oF 952 subjects participated in the study. Alderman and Miller concluded that success can be obtained when using a systematic approach to treating a large population group. These researchers Found that accessibility to care was not the Factor responsible For improved blood pressure control but, rather, the workers' social cohesion and the health-care team concept. The research- ers did believe that on-site treatment centers were valuable For hypertensive employees. Finally, McInnes and MacDonald (1981) stated that occupa- tional health-care providers are in a unique position to identiFy hypertensive patients, detect risk Factors and assist in the treatment and management oF hypertensive workers. The researchers believed that health-care providers would watch For side eFFects oF medications realizing that some side eFFects could endanger a person who was working with machinery or in high places. The nurse could improve adherence by tailoring therapy to meet job requirements, ad—‘ ministering doses to coincide with shiFt-working, decrease the number oF drugs, and simpliFy drug regimens. Although the present study is assessing the perceived job barriers to Following regimens and not the eFFect oF the regimen on the hypertensive individual's job, these studies 73 have implications For Future job barriers. IF an individual misses work Frequently, suFFers From side eFFects or is incon- venienced by his/her-health regimen, the job may become diFFicult to perForm, thus producing job barriers. In summary, there is no literature that discusses the eFFects oF job barriers on Following a therapeutic regimen. Health-care providers must be aware oF the eFFects oF health regimens on job perFormance and the potential these eFFects have on producing job barriers. In the next section, nursing interventions will be dis- cussed. Nursing Interventions Nurses play an important role in helping hypertensive patients Follow recommended pharmacological and nonpharma- cological methods For controlling hypertension (Heine, 1981). The report oF the 1984 Joint National Committee on Detection, Evaluation and Treatment oF High Blood Pressure states that as soon as the diagnosis oF essential hypertension is made, patients and health-care proFessionals must work together to control hypertension. As stated in this report, one role nurses should assume is to identiFy adherence problems, suggest solutions, educate patients and monitor progress toward normal blood pressure. Heine (1981) states that nurses have demonstrated their 74 eFFectiveness in working with hypertensive individuals in a variety oF settings including community health projects, public health clinics, and hypertension programs. Heine re- ports there are several ways nurses can assist an individual to learn to cope with their selF-care deFicit (Orem, 1980). One strategy is to develop a therapeutic alliance by establish- ing good rapport with open communication. Another strategy is guidance whereby the nurse assists the patient in making decisions and learning skills appropriate For therapy. In- volving the Family in counseling and education and teaching the patient and Family about misconceptions associated with the disease including the asymptomatic nature oF hypertension, the need For continuing therapy and the selF-monitoring oF blood pressure is a Final method. Dunbar (1980) reviewed studies that utilized several behavioral strategies that can be used by nurses to assist patients with their health regimens. Reminders, tailoring, contracting, selF-monitoring, reinForcement, and Family and peer support were various suggested strategies. Dunbar re- ported that the eFFect oF using these strategies was not dramatic in most studies, but that each strategy did improve patients' adherence to health regimens. Dunbar, et a1. (1979) Felt that individualized programs were most useFul in helping patients adhere to regimens. Harper (1984) applied Orem's constructs to selF-care 75 medication behavior 0F 50 volunteer black, elderly, hyperten- sive women. Harper's hypothesis was that women who participated in a medication selF-care program compared with women who participated in a teaching program about hypertension would have higher scores on a test about medications, Fewer medication errors and lower systolic and diastolic blood pressures. All participants had problems with taking medications. The patients were randomly assigned to one oF two treatment programs: the medication selF-care program (n = 30) or the teaching program about hypertension (n = 30). Patients in the selF- care program received Four interventions about the purpose, side eFFects, dosage, schedule and saFety Factors concerning medications. Patients in the teaching program received Four interventions about hypertension. The selF-care groups initi- ally show an increased knowledge base concerning medications, perceived control over their health and selF-care behaviors as compared to the control group, but this knowledge decreased over time. One possible reason was the program's positive behavioral approach motivated people to learn and practice selF-care behaviors. Similar results were reported in a study by Wilbur and Barrow (1959) in a Georgia community. Two hundred twenty individuals diagnosed with hypertension participated in this study. Participants assigned themselves to groups that would or would not receive visits From a Public Health Nurse at 75 regular intervals. The Public Health Nurse monitored blood pressure, encouraged medical Follow-up and adherence to medica- tions. This experimental group received reinForcement For two years. Hypertension control increased From 15% to 80% in the experimental group. Two years aFter the visits stopped, hypertension control in the experimental group dropped to 29%. It was hypothesized that long-term supervision was the reason the nursing intervention was eFFective. Wilbur and Barrow concluded that any successFul program For high blood pressure control must be liFe-long. Daniels and Kochar (1980) reported their experience in a joint practice relationship with a nationally recognized community hypertension control program, an inner city hyperten- sion clinic, and a work-site hypertension control program. These researchers believed monitoring and Facilitating adherence to therapeutic regimens were the responsibility oF the proFes- sional nurse. These researchers also stressed the importance oF the therapeutic relationship when working with hypertensive patients. The individuals' liFestyle, perception oF hyperten- sion, side eFFects, satisFaction with the program and past adherence to therapeutic regimens were assessed. Therapeutic regimens were individualized to each patient and included medication review, positive and negative Feedback concerning blood pressure levels, and determining patients' satisFaction with the clinic. Services were designed to provide an outreach 77 system For patients who missed appointments, decrease waiting time, reduce expense For medications as possible and provide clear instructions concerning side eFFects. A study by JeFFrey, et a1. (1983) was done to compare the eFFectiveness oF group and individual counseling on over- weight men with labile hypertension. Ninety-three males parti- cipated in a 20-week dietary intervention program aimed at a 10% body weight reduction and a sodium intake 0F 70 mEq each day. The study was conducted over two years. The parti- cipants were randomly assigned to a group who received written handouts about weight reduction or'written handouts about sodium restriction. At the end oF the study, both groups had signiFicant reductions in blood pressure, weight, and sodium excretion. Changes in knowledge concerning weight control and sodium restriction were also signiFicant For both groups. The researchers concluded by stating that both strate- gies were successFul in the short term, but that maintenance or behavior change on a long-term basis remains a challenge. A study by Caplan, et a1. (1976) was designed to determine iF patient education and social support provided by nurse clinicians would improve adherence For 70 hypertensive adults. The volunteers were assigned to either a control group who received "usual care"; a lecture group; or a social support group. The lecture group received Four weekly one—hour lectures on the physiology oF hypertension and treatment. The social 78 support group received six, two-hour weekly sessions which provided Factual inFormation and support to improve patients' adherence and motivation. AFter eight weeks, systolic and diastolic pressures had improved in the lecture and social support group compared to the control group. In contrast, a study by Webb (1980) concerning the eF- Fectiveness oF patient education and psychosocial counseling to promote adherence among hypertensive patients showed no eFFectiveness due to interventions by nurses. One hundred twenty-three participants were randomly assigned to one oF three intervention groups: group patient education and regular physician visits (n = 37); individual psychosocial counseling and regular physician visits (n = 31); or only regular physician visits (n = 55). The unequal group sizes did not produce a bias, t-tests between group means showed no signiFicant diFFerences (p = .1). The education intervention included three group education sessions one month apart. The Focus oF these sessions were causes oF hypertension, importance oF compliance, etc. The participants were actively involved in group discussion and group decision-making. The counseling intervention included three individual sessions Focusing on problems identiFied by the patient. Webb reported that neither intervention improved patient adherence or blood pressure. This researcher would question the interventions; iF individual- ized to speciFic patient problems would the outcome be increased adherence? 79 Tagliacozzo, Luskin, Lash and Kenji (1974) reported on the eFFects oF nurse intervention on patients' adherence to therapeutic regimens. One hundred ninety-two patients with hypertension and/or diabetes participated in the study. Patients were randomly assigned to an experimental group who received Four teaching sessions or a control group who did not receive sessions. The results showed that though there were increases in patients' understanding oF their illnesses, the nurse intervention did not inFluence patients' attitudes toward seriousness oF the illness. Higher rates oF compliance were seen in patients who were more knowledgeable oF their disease, had higher education, income, and Felt Favorable toward the clinic. Glanz and Kirscht (1981) analyzed data From a longitudinal study oF 432 hypertensive individuals to determine how patients react to educational interventions and how their reactions are related to changes in their adherence. Patients were randomly assigned to Four sequential intervention experiments. Theseinterventions were written messages, nurse's phone calls, selF-monitoring and social support. Findings showed that participants recalled the interventions they were exposed to several weeks aFter the exposure. The participants also Found the interventions interesting, important, and reassuring. Again, the interventions had some eFFect on behavior, but the eFFect was short-term. 80 Foster and Kousch (1981) reported that several strategies had proven successFul in improving adherence For the time the patients were exposed to the interventions. These research- ers reported that changes in the delivery oF health services (reduced waiting time, postcard reminders), communication techniques (Feedback, reinForcement, explanation), behavioral strategies (contracting, home blood pressure monitoring, using diaries), contributed to improvement in adherence either used alone or in combination (Finnerty, 1973; Foster, 1978; Sackett, et al., 1975; Stamler, et al., 1975; Steckel, et al., 1977). Foster and Kousch (1981) oFFered speciFic strategies to promote adherence when patients identiFy barriers to Follow- ing regimens. Pill taking or appointment keeping strategies were appropriate when identiFied barriers were "environmental," For instance, busy work schedules, transportation problems. Developing a therapeutic relationship with the patient was especially important when perceived barriers were side eFFects oF medications or dietary regimens. Strategies For good com- munication between provider and patient were important when the patients' health belier were in conFlict with the provider's belier. Finally, the researchers reported that in situations where the patient is resistant to all strategies, support, periodic contact and a positive attitude toward the patient were the most eFFective strategies. Logan, Milne, Achber, Campbell and Haynes (1979) addressed 81 the problem oF adherence when access to care was a barrier. Work-site care provided by nurses was compared to regular Family physician care in a randomized controlled study. Four hundred FiFty-seven volunteers participated in the study. Subjects were randomly grouped to receive their care From a nurse during work hours or From a physician outside work time. More work site volunteers were prescribed antihyperten- sive medications (94.7%) and reached their goal in six months (48.5%). Adherence was measured by pill counts and stated compliance and more work site subjects were adherent (57.5%) as compared to oFFsite subjects (49.1%). The researchers stated these improved outcomes were due to access and who delivered the care. As has been noted in several studies, nursing interven- tions do promote increased adherence For a short term. The Working Group to OeFine CritiCal Patient Behaviors in High Blood Pressure Control deFined behaviors critical to hyperten- sive subjects' achieving therapeutic control and assuming active responsibility For their own care. This group Focused on the "achievement and maintenance oF long-term control through drug therapy and concentrated on the patient-physician inter- action as a critical Factor." The objectives oF the group were to deFine the subjects' knowledge base, subjects' attitudes and skills necessary to control hypertension over a liFetime. The Four patient behaviors that were deFined as critical 82 to achievement oF long-term blood pressure control were: (1) make the decision to control their blood pressure; (2) take prescribed medication as scheduled; (3) monitor their progress toward blood pressure control; (4) solve problems that block their achieving normotensive blood pressure levels. The Working Group Further deFined a Framework in which a nurse can use the nursing process as deFined by McCombs, et a1. (1980), assessment, planning, intervention, evaluation, to identiFy hypertensive patients' critical behaviors and work together to achieve blood pressure control. To summarize, nurses have proven themselves to be eFFective in delivering health-care services to the millions oF people diagnosed with hypertension (Finnerty, 1975; Clark, 1975). There still remain many hypertensive individuals who do not adhere to therapy or who are undetected, thus controlled. It has been shown in literature that nursing interventions are successFul in improving adherence For the time the inter- vention is used. Because nurses have counseling and educative skills, it is important For nurses and patients to deFine patients' barriers to Following health regimens and develop speciFic interventions to help the individual adhere to liFe- long therapy. CHAPTER IV METHODOLOGY AND PROCEDURE Overview This research study was designed to determine what bar- riers hypertensive subjects perceive_in Following their thera- peutic regimen. The dimensions analyzed were commitment to taking medications, commitment to Following recommended dietary measures, and the impact oF work on Following therapy. The data For the study were collected as part oF a Feder- ally-Funded research project "Patient Contributions to Care-- Link to Process and Outcome." Grant #5R01N000552-01,02,03, 5. Given and C. W. Given, co-principal investigators. The project was Funded by the Public Health Service, Division oF Nursing. The data were collected in 1980-81, using voluntary participants who answered a selF-administered questionnaire. Data For this thesis were taken From the Intake Phase oF a controlled Field experiment beFore the random assignment oF the subjects to control or experimental groups. A population oF hypertensive subjects From Four sites within the state oF Michigan was used. The instrument was administered to a sample oF 158 hypertensive subjects. The study was descriptive in nature and a combination oF descriptive 83 84 and inFerential statistical techniques was used to analyze the data. Descriptive techniques including Frequency distribu- tions were done on each item comprising a scale. The internal consistency aspect oF reliability was determined For each scale through computation oF coeFFicient alpha. Frequency distributions were done on the sociodemographic data. Finally, correlations among the scales and the sociodemographic measures were determined through Pearson Product Moment correlation. The purpose oF this chapter is to present the methodology, and procedures used in this study.f The areas to be discussed are sample, setting, instruments, data collection procedures, scoring, procedures For data analysis, and human rights protec- tion. Sample The sample selected For this study included consenting hypertensive subjects From Four sites in Michigan. To be eligible For the study, subjects had to meet several criteria. Subjects had to: (1) be between the ages oF 18 and 55 years; (2) have an established diagnosis oF hypertension; (3) be literate; (4) show no evidence oF cancer, and stage renal disease, stroke, blindness, psychosis (or be in present treat- ment For psychiatric problems); (5) not be pregnant or lactating and, (5) be on a prescribed diet or medication regimen For hypertension. 85 The medical records oF the subjects had to include: (1) two elevated blood pressure readings taken at least two months apart. The hypertensive subjects had to have had either a systolic pressure oF 140 mm Hg or above or a diastolic pres- sure oF 95 mm Hg or above on these two occasions; (2) name oF medication(s), dosage, and the date prescribed and/or type oF diet prescribed; and (3) two weight measures taken at least two months apart. The sample For the study was identiFied in two ways. In three Family practice residency sites, a computer-based automated health inFormation system identiFied hypertensive subjects who Fit the criteria. The method used in the private practice setting was to have Four physicians recall appropriate hypertensive subjects. Four hundred and thirty-three hyperten- sive subjects were originally screened. OF these 433 subjects, 177 were excluded because they didn't Fit all the criteria. Based on the screening results, 255 subjects were asked to participate in the study. From these 255 eligible subjects, 158 hypertensive subjects consented and were enrolled in the study. Setting The study was conducted at Four sites in Michigan. Three oF the sites were ambulatory care centers staFFed by medical residents training as Family physicians. These sites 85 were located in large cities in central southern Michigan. The three ambulatory care sites were comparable. All had between 18 and 24 Family practice resident physicians in train- ing. There were equal number oF Family practice resident physicians in the First, second and third year programs. Each site averaged 900 to 1200 patient visits per month. The Fourth site was two private practice oFFices shared by Four internists. The private oFFices were located in a large city in southern Michigan and were staFFed by Four general inter- nists. These internists were all board eligible or board certiFied in general internal medicine. Instruments Two instruments were utilized in this study. One instru- ment was a questionnaire analyzing subjects' belier about hypertension with speciFic questions assessing subjects' be- lier about taking medications, Following a speciFied diet, and the eFFect oF a job on Following recommended regimens. This questionnaire was based on patient belier obtained through pre-study interviews and a review oF the literature. The second instrument was a questionnaire designed to gather sociodemographic inFormation about the study partici- pants. The subjects answered questions concerning age, sex, race, marital status, living arrangements, educational status, work status, income, duration oF diagnosis oF hypertension. 87 These instruments were developed by 5. Given and C. W. Given, the principal co-investigators oF the study: Patient Contribu- tions to Care-~Link to Process and Outcome. Development oF the Instrument to Measure Subjects' Belier About Hypertension This instrument was developed, tested, and retested on three samples oF subjects. These subjects were not part oF the sample oF subjects whose responses were analyzed in this study. The instrument was developed to measure subjects' belier about: (1) the seriousness oF their disease, (2) the eFFicacy oF the therapies prescribed to manage their disease, (3) their personal responsibility For controlling their blood pressure, (4) the beneFits and barriers to undertaking and continuing prescribed therapy, and (5) the impact oF work on Following prescribed therapy (see Appendix A). Statements were developed From a review oF measures oF health belie s and From indepth interviews with 30 people who had hypertension. These hypertensive persons were asked their thoughts about hypertension, the severity oF their disease, the eFFicacy oF prescribed therapeutic regimens, and perceived barriers to Following therapeutic regimens. From these inter- views and review oF the literature, scales were Formed to measure concepts concerning patients' belier about hypertension and therapy. 88 This instrument was administered to 154 subjects who recorded their responses on a Five—point Likert-type scale with responses ranging From "strongly agree" to "strongly disagree." Followihg the initial analysis, several scales describing subjects' belier about the severity oF their disease and the eFFicacy oF treatment had relatively low alpha coeFFi- cients. Additional items were included and the items used to measure these two belier were administered to a second sample oF 45 subjects. For the purpose oF validation, the entire instrument was administered to a third sample 0F 97 hypertensive subjects. Scales that had originally been developed to identiFy belier about beneFits and belier about barriers to taking medications, belier about beneFits and belier about barriers to Following diet and belier about impact oF job on taking medications and Following diet did have ade- quate levels oF internal consistency, but the scales were highly interrelated suggesting the scales were covering similar ideas. Thus, the six scales were combined to three scales: belier about commitment to diet, belier about commitment to medications and impact oF job on Following therapy (see Table 1). Scciodemographic Questionnaire The sociodemographic questionnaire was designed to ga- ther inFormation about variables that may have inFluenced the 89 Table 1 Hypothesized and Final Scales For Belier About Medications, Belier About Diet, Belier About Impact oF Job on Therapy Hypothesized Scales Final Scales Phases I and II l. Barriers to taking medications 2. BeneFits oF taking medications 3. Barriers to Following diet 4. BeneFits oF Following diet 5. Impact oF job on taking medications 5. Impact oF job on Following diet Belier about commitment to medications Belier about commitment to diet Impact oF job on Follow— ing therapy 90 subjects' perception oF barriers to Following diet recommenda- tions, barriers to taking antihypertensive medications and barriers job may impose to Following therapy. This questionnaire was used For gathering data in the research project, "Patient Contributions to Care--Link to Process and Outcome" (see Appendix B). The sociodemographic variables included age, sex, race, marital status, living arrangement, educational status, work status, income, and duration oF diagnosis oF hypertension. Data Collection Procedure Following screening procedures and instrument development 255 hypertensive subjects were eligible For the experimental phase oF the study. Letters asking For participation in the study were sent to the 255 subjects (see Appendix C). The letters described the purpose oF the study, its potential beneFit to the subjects, the length oF time oF the study, the requirements For participation, a disclaimer that reFusal to participate would not aFFect their care, and that they would remain anonymous and their answers conFidential. Subjects who wished to participate were asked to return a postcard and those wishing more inFormation were given the name and number oF a staFF member who could answer their ques- tions. This letter was signed by the medical director oF each residency center and by the physicians in each oF the private practices. 91 Each subject who returned a postcard expressing interest and all subjects who did not return a postcard were contacted by phone. The study was again-described and subjects were asked when it was convenient to meet with the interviewer at the site to complete the questionnaires. From the 255 eligible hypertensive subjects, 158 subjects consented to be a part oF the study. At the time oF the interview, the study was described again, and upon obtaining the subjects' agreement to participate, the subject was taken to a private room. The interviewer brieFly explained the content oF the Five selF-administered instruments, including the one used in this study: the Belier about Hypertension Instrument. AFter obtaining the subjects' written consent (see Appendix D) the subject received the selF-administered instruments. The subject was told the interviewer would be available iF the subjects had any questions. The interviewer periodically checked on the subject's progress. AFter the selF-administered Forms were completed, the interviewer returned to the room and personally adminis- tered the two remaining structured instruments that elicited inFormation about the subjectfs treatment regimen and symptoms and severity oF any symptoms the subject may have had during the two weeks preceding the interview. 92 Operational DeFinitions oF the Study Variables Perceived Barriers to Commitment to Diet ' Perceived barriers to commitment to diet were the ex- pressed belier oF the subject concerning the psychological, physical, Financial, or other costs to Following a recommended diet prescribed by a health—care provider. Barriers to commit- ment to diet were the perceived problems the subject must have overcome beFore he/she could Follow a prescribed dietary regimen. Perceived barriers to commitment to diet were measured using a subscale oF the belier about hypertension instrument. The subscale used was the belier about commitment to diet subscale. The statements were worded to measure perceptions or belier. For example, "I have time to Follow the diet prescribed For me." For items included see Appendix A, items 32, 33, 35, 35, 38, 39, 40. Perceived Barriers to Commitment to Medications Perceived barriers to commitment to medications were the expressed belier oF the subject concerning the psychologi- cal, physical, Financial, or other costs oF taking medications to improve control oF hypertension. Barriers to commitment were the perceived problems the subject must have overcome beFore he/she could take the prescribed medications For hyper- tension. Perceived barriers to commitment to medications 93 were measured using a subscale oF the belier about hyperten~ sion instrument. The subscale used was belier about commit- ment to medications subscale. This instrument was designed to measure the subjects' belier about perceived barriers to taking prescribed antihypertensive medications. The state- ments in the scale were worded to measure perceptions or belier. An example was,"I believe that my medications will control my high blood pressure." For items included see Appendix A, items 22, 23, 24, 25, 25, 28, 29, 30. Perceived Barriers to Impact oF Job on Following Therapy Perceived barriers concerning the impact oF a job on Following health regimens were the expressed belier oF the subject concerning the psychological, physical or other costs the job imposed on Following therapy. The barriers were the perceived problems the subject must have overcome beFore he/she would Follow a prescribed regimen. Perceived barriers concern- ing the impact oF job on Following therapy were measured using a subscale oF the belier about hypertension instrument. The subscale used was the impact oF job on Following therapy subscale. The instrument was designed to measure the subjects' belier about the impact oF job on eFFicacy oF treatment. The statements in the scale were worded to measure perceptions. For instance, "I worry so much about my job that I can't take my medications." For items included see Appendix A, items 45, 4s, 47, 4e, 50, 51. 94 ModiFying Variables ModiFying variables are those variables that may inFluence the results oF the study (Polit and Hungler, 1978). Subjects' values are inFluenced by modiFying variables. The value a subject places on perForming a recommended health action will be related to a subject's belier about his/her health state. Age, sex, race, and socioeconomic status aFFect subject's exposure to certain experiences and learning, thus Formulating and inFluencing health belier. The satisFaction or stresses that evolve with certain role obligations like marital status or work obligations may also inFluence health belier. Data were collected on variables which could aFFect the study ques- tions. These variables included age, sex, marital status, race, living arrangement, educational status, work status, income, and duration oF diagnosis oF hypertension. This inFormation was obtained using the sociodemographic questionnaire (see Ap- pendix B). Other modiFying variables which would aFFect study questions were systolic blood pressure, diastolic blood pressure and weight. InFormation concerning these variables were ob- tained From the subjects' charts. Reliability oF the Instrument IF repeated use oF an instrument under similar condi- tions gives similar results, the instrument is considered reliable. The reliability oF an instrument is the degree 95 0F consistency with which it measures the attribute it is supposed to be measuring (Polit and Hungler, 1978). The higher the degree oF consistency, the greater the reliability oF the instrument. Reliability can be assessed by addressing the stability, consistency, and dependability oF an instrument. An instrument is said to be internally consistent to the extent that all oF the subparts (in this study belier about diet, medications and impact oF job on therapy) are measuring the same characteristics (commitment to diet, commit- ment to medications, impact oF job on therapy). A high degree oF interrelatedness among the subparts indicates a high degree oF internal consistency. Two techniques used to evaluate internal consistency are the split halF reliability method and coeFFicient alpha (or Cronbach's Method as it is also called). The measure used in this study to determine the internal consistency oF the subscales in the belier about hypertension scale was coeFFicient alpha. The reliability coeFFicient For the belier about commitment to medication subscale was .79. The reliability coeFFicient For the belier about commitment to diet subscale was .59, and the reliability coeFFicient For the impact oF job onFollowing therapy was .91. These values all represent an adequate level oF internal consistency. 95 Validity oF the Instrument Validity reFers to the "degree to which an instrument measures what it is supposed to be measuring" (Polit and Hungler, 1978), and can be diFFicult to establish. Problems oF validity relate to the question, "Are we really measuring the attribute we think we are measuring?" (Polit and Hungler, 1978). The types oF validity most important to this study are content and construct validity. Content validity is concerned with the sampling adequacy oF the content area being measured (Polit and Hungler, 1978). Objective methods For assessing adequate content coverage oF an instrument are hard to Find. Subjective methods, experts' analyses oF the items used in the instrument, and the research- er's good judgment to careFully plan the items to be used in the instrument are ways to insure content validity. Content validity can be assessed by examining methods used to develop the questions in the instrument. The belier about hyperten- sion instrument was developed From interviews with hypertensive subjects, From an extensive review oF the literature, by pre- testing the instrument, and From the experience oF the co- principal investigators. Construct validity concerns the attribute being measured. The researcher is concerned with the question, What is the instrument really measuring? and is the concept (in this case, belier) being adequately measured using this instrument? 97 The co-principal investigators evaluated construct validity oF the belier about hypertension instrument by using Factor analysis with varimax rotation. Scoring Data comprising the sociodemographic instrument included inFormation about the age, sex, race, marital status, living arrangements, educational status, work status, income, and duration oF diagnosis oF hypertension oF the participants. Subjects selected the most appropriate response. The response was scored by the corresponding number to each response. Age was recorded and scored as a continuous variable. Ques- tions are noted in Appendix B. The subscales used to measure perceived barriers to diet and medications, and the subscale that measured perceived impact oF job on eFFicacy oF treatment were scored using a Likert Five-point response. Statements were balanced in terms oF positive and negative wording and responses were recorded on a Five-point scale that ranged From (1) strongly agree; (2) agree; (3) undecided; (4) disagree; (5) strongly disagree. Each belieF in each subscale was scored individually. A low score oF one or two on a negatively worded statement would indicate the subject perceived the belieF as a barrier. An example oF a negatively worded statement was, I am conFused by all the medication the doctor has given me. A high score 98 0F Four or Five on a positively worded statement would indicate the subject perceived that belieF as a barrier. An example oF a positively worded statement was, I believe my medications will control my high blood pressure. Scores For each belieF were analyzed to determine how many subjects perceived the belieF as a barrier. Procedure For Data Analysis Both descriptive and inFerential statistical techniques were used in this study. Descriptive techniques used in this study were Frequency distributions including percentages, means, and standard deviation. They were used to describe the potential modiFying variables and to describe the score responses on the barrier to diet subscale, barrier to medica- tion subscale and the impact oF job on eFFicacy oF treatment subscale and to answer the research questions posited. The inFerential statistical technique used in this study was the Pearson Product Moment Correlation. This correlation was used to determine iF a relationship existed between the modiFy- ing variables and the study variables. By determining a corre- lation between the variables, it could be determined iF and to what degree the modiFying variables aFFected the subjects' perception oF barriers. The minimal level oF signiFicance which was acceptable in this study was to the .05 level. 99 Human Rights Protection All subjects were inFormed about the purpose oF the study, the procedures For collecting the data, and the conFiden- tially oF the participants and the results. All subjects were inFormed that they had the right to reFuse to participate, that they had the right to withdraw at any time, and iF they did not participate in the study, their care would not be aFFected. Written consent was obtained From the subjects. Summary The purpose oF Chapter IV was to present the methodology and procedures used in this descriptive study analyzing subjects' perceived barriers to Following a prescribed diet, barriers to taking prescribed antihypertensive medication, and the impact oF a job on Following prescribed regimens. Areas dis- cussed were sample, setting, instruments, data collection procedures, scoring procedures For data analysis, and human rights protection. In Chapter V, the analysis oF the data and a discussion oF the interpretation oF the results will be presented. CHAPTER V DATA PRESENTATION AND ANALYSIS The data presented in this chapter describe the study population and the study population's perceived barriers to Following a recommended health regimen For controlling hyper- tension. Data are also presented to describe the relation- ship among the study variables and the extraneous variables (modiFying variables). Finally, data are presented describing the relationship among the three scales used to assess perceived barriers (barriers to taking medications, barriers to Follow- ing a diet, job barriers). A volunteer sample oF 158 English-speaking men and women, aged 24 to 55 years comprised the study sample. This population participated in the research project: Patient Contributions to Care--Link to Process and Outcome (Given and Given, 1982). In this chapter, a description oF the Findings oF the study and data presentation For the Following questions are included: 1. What do hypertensive subjects perceive as barriers to Following a prescribed diet For controlling hypertension? 2. What do hypertensive subjects perceive as barriers 100 101 to taking prescribed medications For controlling hypertension? 3. What do hypertensive subjects perceive as job barriers to Following a prescribed diet or taking prescribed medications For controlling hypertension? Descriptive Findings oF the Stugy Sample The study population was obtained From three ambulatory care sites and one internal medicine private practice oFFice located in large cities in southern Michigan. ModiFying Factors As presented in the conceptual model in Chapter II, there are several Factors which may modiFy an individual's health belier. In this study, modiFying variables were divided into three groups: demographics, sociopsychological and modiFiers speciFic to hypertensive individuals. In the Following section, the study population will be described within the context oF these variables. Demographic Variables The demographic variables utilized in this study were age, sex, and race: 1. Age. The age oF the study population ranged From 24 to 55 years. The mean age oF the subjects was 102 45.8 years (see Table 2). 2. §E§' The distribution oF males and Females in this study was Fairly even with 50.5% (n = 80) women and 48.4% men (n = 78) participating in the study (see Table 2). 3. Eggs. Race was determined For 155 subjects in the study. One hundred thirty-six (85.5%) subjects were white, 19 (12.1%) subjects were black and 1 subject (0.5%) was Mexican-American (see Table 2). Sociopsychological Variables The sociopsychological variables measured in this study were marital status, living arrangement, education, work status, and income. Marital status. One hundred twenty-Four oF the subjects (78.5%) were married. The remaining 21.5% oF the subjects were single (n 11, 7.0%), separated (n = 5, 3.2%), divorced (n = 10, 5.3%) or widowed (n = 8, 5.1%). The 1980 U.S. census reports the Following percentages oF marital status For persons over 18 years: single, 20.3%; married, 55.5%; widowed, 8.0%; and divorced, 5.2% (see Table 2). The study sample had a lower percentage oF single persons in comparison to the general population, but the remaining statistics are similar. 103 Table 2 Distribution and Percentage oF Subjects by Demographic Variables and ModiFiers SpeciFic to Hypertension Number oF Subjects Percentage 593 (n = 158) 24-35 22 13.9 35-45 45 28.5 45-55 53 33.5 55-55 38 24.1 fig (n = 158) Male 78 49.4 Female 80 50.5 5393 (n = 157) White 135 85.5 Black 19 12.1 Mexican-American 1 .5 Other 1 .5 Marital Status (n = 158) Married 124 78.5 Single 11 7.0 Separated 5 3.2 Divorced 10 5.3 widowed e 5.1 Living Arrangements (n = 158) Living alone 18 11.4 Living with children 7 4.4 Living with other relatives 5 3.8 Living with spouse and children 80 50.5 104 Table 2 (Continued) Number oF Subjects Percentage Living Arrangements (Continued) Living with spouse 39 24.7 Living with spouse, children, relatives 3 1.9 Living with spouse's relatives 2 1.3 Other living arrangements 3 1.9 Educational Status (n = 158) Completed high school 4.4 Junior high school 3.8 Some high school 20 12.7 Graduated high school 54 34.2 Technical, business or trade school 7 4.4 Some college 18 11.4 Postgraduate or ProFessional 15 10.1 Work Status (n = 158) Work at regular job 104 55.8 Unemployed or laid oFF 10 5.3 Retired 9 5.7 Disabled 3.2 HousewiFe 25 15.5 Other 3 1.9 Income (n = 158) Less than $5,000 4 2.5 $ 5,000 - $10,999 21 13.9 $11,000 - $19,999 31 20.5 $20,000 - $24,999 28 18.5 $25,000 or more 57 44.4 105 Table 2 (Continued) ,--—- Number oF Subjects Percentage Duration oF Diagnosed Hypertension (n = 152) Less than 2 years 45 29.5 3-5 years 38 25.0 5-8 years 27 17.8 9-11 years 15 9.9 12-14 years 5 3.3 15 years or more 22 14.5 Systolic Blood Pressure (n = 151) 108 - 140 mm Hg 55 37.1 141 - 155 mm Hg 54 49.0 155 - 190 mm Hg 17 11.3 191 - 210 mm Hg 4 2.5 Diastolic Blood Pressure (n = 151) 70 - 89 mm Hg 22 14.5 90 - 104 mm Hg 103 58.2 105 - 114 mm Hg 23 15.2 115 - 120 mm Hg 3 2.0 Percentage Overweigflt (n = 150) 20% over ideal body weight 101 57.3 Less than 20% over ideal body weight 49 32.7 105 Living arrangements. One-halF oF the subjects (50.5%) were married and living with a spouse and children. Married and living with spouse alone was reported by 39 subjects (24.7%). Seven (4.4%) persons reported they were single and lived with children and 18 subjects (11.4%) reported living alone (see Table 2). Marital status and living arrangement. The marital status and living arrangement oF each participant was obtained. Thus, the majority oF participants were married and lived with a spouse and children. The distribution oF participants by the variables oF marital status and living arrangement can be seen in Table 3. Educational status. The educational status was determined For each participant. FiFty-Four subjects (34.2%) graduated high school, 33 (20.9%) participants did not graduate high school while 37 (23.4%) participants went on to receive some college education. This included trade or business school. Thirty-Four (21.5%) oF the participants were college graduates, postgraduates or proFessionals (see Table 2). Work status. The work status oF 155 participants was obtained. One hundred Four subjects (55.2%) worked at.a regular job. Twenty-six (15.5%) were housewives. Ten participants (5.4%) were unemployed or laid oFF, 9 participants (5.7%) were retired, and 5 (3.2%) participants were disabled (see Table 2). 107 Table 3 Distribution and Percentage oF Subjects by Marital Status and Living Arrangement (n = 158) Marital Status and Number oF Living Arrangement Subjects Percentage Married, living with spouse and children 80 50.5% Married, living with spouse 39 24.7% Unmarried, living alone 18 11.4% Single, living with children 7 4.4% Unmarried, living with other individuals 5 3.8% Married, living with spouse, children, other relatives 3 1.9 Married, living with spouse, relatives 3 1.9% Other living arrangements 2 1.3% 158 100.00% 108 Income. The total Family income on a yearly basis was obtained From 151 participants. Sixty-seven subjects (44.4%) reported a yearly income oF more than $25,000. Four partici- pants (2.5%) earned less than $5,000. Twenty-one participants (13.9%) earned between $5,000 and $10,000/year. Thirty-one participants (20.5%) earned between $11,000 and $19,999 and 28 participants (18.5%) reported yearly incomes between $20,000 and $24,999 (see Table 2). ModiFiers SpeciFic to Hypertension The modiFying variables speciFic to hypertension that were measured in the present study were the duration oF hyper- tension, systolic blood pressure, diastolic blood pressure, and weight. Duration oF diagnosed hypertension. Data concerning the duration oF diagnosed hypertension were obtained From 152 participants. Eighty-three subjects (54.5%) had been diagnosed with hypertension For Five years or less. Twenty- seven subjects (17.8%) had been diagnosed with hypertension For 9 to 11 years while 42 subjects had been diagnosed with hypertension greater than 11 years (see Table 2). Systolic blood pressure. One hundred FiFty-one subjects' systolic blood pressures were recorded. Sixty-Four subjects (49%) had systolic blood pressures ranging From 141—155 mm Hg, 109 37.1% (n = 55) oF subjects'systolic blood pressure was 108-140 mm Hg and 13.9% (n = 2l) oF subjects’systolic blood pressure was 155-210 mm Hg (see Table 2). Diastolic blood pressure. One hundred FiFty-one subjects' diastolic blood pressures were recorded. One hundred three subjects' (58.2%) diastolic blood pressures were classiFied as mild hypertension with ranges From 90-104 mm Hg (1984 Joint National Committee Report). Based on this 1984 Joint Committee Report, 15.2% (n = 23) oF the subjects had moderate hypertension (diastolic blood pressure ranging From 105-114 mm Hg), and 2.0% oF the subjects had severe hypertension (diastolic blood pressure equal to or greater than 115 mm Hg). Fourteen and six-tenths percent oF the sample population had normotensive blood pressures (diastolic blood pressures less than 85 mm Hg) (see Table 2). Weight. Data covering 150 subjects' body weight were collected. Twice as many subjects (57.3%) were 20% over ideal body weight compared to 32.7% subjects who were normal body weight, less than 20% over ideal body weight (see Table 2). Summary The descriptive Findings oF the study population were presented in the previous section. The descriptors oF the study or the modiFying variables were presented by demographic 110 variables, sociopsychologic variables and variables speciFic to hypertension. The results oF the descriptive data indicate that the study population included an even distribution oF men and women ranging in age From 24 to 55. The majority oF the participants were white, middle-class, married and living with a spouse and/or children. The majority oF parti- cipants had a high school education and worked at a regular job. Finally, the mean years diagnosed with hypertension was 3.6 years. Data Presentation For Research Questions In this section, each research question will be presented with its associated data as well as an explanation oF the statistical analyses utilized. Research Question #1 What do hypertensive subjects perceive as barriers to Following a prescribed diet For controlling hypertension? Perceived barriers to Following a prescribed diet. Following are the statistical techniques utilized and the results: 1. Statistical techniques For obtainipgAperceived bar- riers. To obtain descriptive data regarding perceived barriers to Following a prescribed diet, Frequency distributions were calculated. Possible response 111 scores ranged From one to Five. For descriptive purposes, the responses "strongly agree" and "agree" were collapsed into an "agree" category and responses "strongly disagree" and "disagree" were collapsed into 3 "disagree" category. A low score indicated the subject perceived the statement as a barrier. Statements 32, 35, 39, 40 (Appendix A) were positively worded so a high score would indicate the subject perceived the statement as a barrier. Each statement was scored separately. Data are presented as the number oF subjects and percentage oF subjects who did/did not perceive the statement as a barrier, the mean score oF the responses and the standard deviation. The statistical results. The perceived barriers and number oF subjects who perceived the statements as barriers to diet are presented in Table 4. The total Frequency distribution is presented in Appendix E. FiFty-one subjects (33.1%) believed it was diFFi- cult to Follow the prescribed diet For controlling hypertension. Thirty-Four subjects (22.0%) perceived lack oF Family support as a barrier. Hunger when Following the diet (20.7%) and the prescribed diet interFering with personal liFe (21.9%) were perceived barriers For 32 subjects. Less than 10% (n = 15) 112 Table 4 Distribution and Percentage oF Subjects by Perceived Barriers to Following a Prescribed Diet For Controlling Hypertension Subjects Who Perceived BelieF as Barrier Total BelieF N N Percentage Following my diet does not interFere with my normal daily activities 155 18 11.5% I am always hungry when I stick to my diet 155 32 20.7% I dislike the tastes oF ' Foods on my diet 155 19 12.3% It has been diFFicult Following the diet prescribed For me 154 51 33.1% I have time to Follow the diet the doctor ordered For me 154 15 9.7% I can count on my Family when I need help Following my diet 154 34 22.0% My personal liFe does not interFere with my diet 153 32 21.9% 113 oF the subjects believed they did not have time to Follow the prescribed diet. Thus, perceived barriers included lack oF Family support, hunger and diFFiculty making changes in personal liFe. Research Question #2 What do hypertensive subjects perceive. as barriers to taking prescribed medications For controlling hypertension? Perceived barriers to taking prescribed medications. Following are the statistical techniques utilized and the results: 1. Statistical techniques For obtaining perceived bar~ riers. To obtain descriptive data regarding perceived barriers to taking prescribed antihypertensive medi- cations, Frequency distributions were calculated. Possible response scores ranged From one to Five. The response "strongly agree" and "agree" were col— lapsed into the category "agree," while the responses "strongly disagree" and "disagree" were collapsed in the category "disagree." Statements 28, 29, and 30 (Appendix A) were positively worded so a high score would indicate the subjects perceived the statement as a barrier. A low score would indi- cate the subjects perceived the statement as a bar- rier. Data are presented as the number oF subjects 114 responding to each statement, the number and per- centage oF subjects who did/did not perceive the statements as barriers, the mean score oF the re- sponses, and the standard deviation. ’2. The statistical results. The perceived barriers to taking medications and the number oF subjects who perceived the statements as barriers are presented in Table 5. The total Frequency distribution is presented in Appendix F. Thirteen subjects (8.4%) believed they must take medications even iF they didn't believe they would get better. Twelve subjects (7.9%) perceived possible dependence on the medica- tions as a barrier. Other perceived barriers in- cluded conFusion with all the medications prescribed, lack oF interest in taking the medications and inter- Ference with daily activities. Only one subject (0.7%) perceived change in liFestyle as a barrier. Perceived barriers For this study population included conFusion, lack oF interest in taking medications and interFerence with daily activities. Research Question #3 What do hypertensive subjects perceive as job barriers to Following a prescribed diet or taking prescribed medications For controlling hypertension? 115 Table 5 Distribution and Percentage oF Subjects by Perceived Barriers to Taking Prescribed Medications For Controlling Hypertension Subjects Who Perceived BelieF Total as Barrier BelieF N N Percentage I am conFused by all the medications the doctor has given me 154 5 3.2% I would have to change too many habits to take my . medications 153 l .7% IF I take my medications I may become dependent on them 153 12 7.9% I am not interested in taking my medications regularly 154 4 2.5% Taking my medications inter- Fere with my normal daily activities 153 7 4.5% I must take my high blood pressure medications even iF I don't think I'm getting better 154 13 8.4% I believe my medications will control my high blood pressure 153 3 2.0% Taking medications is some- thing a person must do no matter how hard it is 154 3 1.9% 115 Perceived job barriers to Followingpantihypertensive regimens. Following are the statistical techniques utilized and the results: 1. Statistical techniques For obtaining perceived bar- riers. To obtain descriptive data regarding perceived barriers to Following therapeutic regimens, Frequency distributions were calculated. For descriptive purposes, the "strongly agree" and "agree" responses were collapsed into an "agree" category and the "strongly disagree" and "disagree" responses were collapsed into the "disagree" category. Data are presented as the number oF subjects who did/did not perceive the statements as barriers, the mean score oF the responses and the standard deviation. The statistical results. The perceived job barriers to Following prescribed regimens For controlling hypertension and the number oF subjects who perceived Ithe statements as barriers are presented in Table 5. The total Frequency distribution is presented in Appendix G. Eleven subjects (9.8%) perceived their work habits as diFFicult. Eight subjects (7.2%) perceived their job as a barrier to Following a diet. Fewer subjects (n = 2, 1.8%) perceived their job as a barrier to taking prescribed medications. Two subjects (1.8%) perceived their worry about 117 Table 5 Distribution and Percentage oF Subjects by Perceived Job Barriers Impacting EFFicacy oF Treatment For Controlling Hypertension Subjects Who Perceived BelieF as Barrier Total BelieF N N Percentage IF I changed jobs, it would be easier to take my medi- cations 112 2 1.8% I worry so much about my job that I can't take my medications 112 2 1.8% IF I changed jobs, it would , be easier to Follow my diet 111 8 7.2% I could control my weight iF the pressures oF my job weren't so great 113 3 2.7% It has been diFFicult to Follow the work habits prescribed 112 11 9.8% My job does not interFere with taking my medications 112 3 2.7% 118 their job as a barrier to taking their medications. Less than 10% 0F the subjects perceived any oF the statements as barriers to Following a prescribed regimen. Although the majority oF subjects did not perceive job barriers, subjects did perceive barriers. These barriers to Following health regimens included worry about job and the pressure oF the job. In summary, data were presented in this section oF Chapter V describing the perceived barriers to Following a prescribed diet to control hypertension, taking prescribed medications to control hypertension and the perceived job barriers to Following a regimen to control hypertension. In the next section oF Chapter V, the reliability coeF- Ficients oF the scales and the relationship among the scales will be presented. Reliability oF the Scales The reliability oF the scales was measured through the computation oF the coeFFicient alpha. CoeFFicient alpha was computed individually For each oF the scales: belier about commitment to diet, belier about commitment to medication, and belier about impact oF job on therapy. The reliability coeFFicient For belier about commitment to diet subscale was .81. This alpha coeFFicient represented 119 a Fairly high degree oF internal consistency among the belier measured to Following a prescribed diet For controlling hyper- tension. Six items were deleted From the original belier about commitment to diet subscale to obtain this reliability coeFFicient (Appendix A, items 34, 37, 41, 42, 43, 44). The reliability coeFFicient For the belier about commit— ment to medications subscale was .75 which represents a Fairly high internal consistency among the items measuring perceived barriers to taking medications For controlling hypertension. Three items wre deleted From the original subscale to obtain this alpha coeFFicient (Appendix A, items 21, 27, 31). The reliability coeFFicient For the belier about impact oF job on therapy was .88 which represents a Fairly high internal consistency among the items measuring perceived job barriers to Following a prescribed regimen For controlling hypertension. Dne item was deleted From the original subscale to obtain this alpha coeFFicient (Appendix A, item 49). In summary, the alpha coeFFicients computed to measure the reliability oF the subscales in this study were: Belier about commitment to diet .81 Belier about commitment to medications .75 Belier about impact oF job on therapy .88 120 Relationships Among the Scales The degree and direction oF the relationship among the three scales were calculated by means oF Pearson Product Moment Correlation. The correlation (r) between the commitment to medication subscale and commitment to diet subscale was r = .3201 with a signiFicance level oF p = .001. The correlation between the commitment to medication subscale and the belieF about impact oF job on therapy subscale was r = .5450 with a signiFicance level oF p = .001. The correlation between the belier about commitment to diet subscale and the belier about impact oF job on therapy subscale was r = .3304 with a signiFicance level oF p = .001. These Findings indicate there was a signiFicant relationship between the belier about commitment to medications subscale and the belier about impact .oF job on therapy subscale. The relationship among the modiFy- ing variables and belier about barriers to medications, diet, and belier about job barriers will be presented in the next section. ModiFying Variables The degree and direction oF the relationships among the modiFying variables and the subscales, belier about perceived barriers were calculated by means oF Pearson Product Moment Correlation including point biserial correlations when the data were 121 in the Form oF discrete categories rather than con- tinuous scores. The total correlation matrix can be seen in Table 10. modiFying l. 2. S. The Following are the relationships between the variables and the major study variables: 522‘ There was a moderate positive relationship between age and belier about commitment to diet (r = .2330, p = .002), indicating the older the individual the Fewer the perceived barriers. §E§° There were no signiFicant relationships between sex and the subscales. Eggs. There were no signiFicant relationships between race and the subscales. Marital status. There were no signiFicant relation- ships between marital status and the subscales. Living arrangement. There were no signiFicant rela- tionships between living arrangements and the sub- scales. Educational status. There was a moderate positive relationship between educational status and belier about commitment to medications (r = .2253, p = .003), indicating the higher the educational level, the Fewer perceived barriers. Work status. There were no signiFicant relationships between work status and the subscales. 122 8. Income. There were no signiFicant relationships between income and the subscales. 9. Duration oF diagnosed hypertension. There was no signiFicant relationship between duration oF hyper- tension and the subscales. 10. Systolic blood pressure. There was a moderate posi- tive relationship between systolic blood pressure and belier about commitment to medications (r = .1710, p = .028), indicating the higher the systolic blood pressure the Fewer perceived barriers. There was also a moderate positive relationship between systolic blood pressure and belier about impact oF job on eFFicacy oF treatment (r = .2024, p = .023), indi- cating the higher the systolic blood pressure the Fewer the perceived barriers. 11. Diastolic blood pressure. There were no signiFicant relationships between diastolic blood pressure and the subscales. 12. Weight.' There were no signiFicant relationships between weight and the subscales. In summary, the relationship among the modiFying variables and the major study variables oF belier about diet, belier about medications, and belier about job were addressed in this section. There was a moderate positive relationship be- tween educational status and belier about medications 123 indicating the more education the Fewer the perceived barriers. There was a moderate positive relationship between age and belier about diet indicating the older the individual the Fewer the perceived barriers. There was also a moderate posi- tive relationship between systolic blood pressure and belier about medications and belier about impact oF job on eFFicacy oF treatment indicating the higher the systolic blood pressure the Fewer the perceived barriers. Finally, there were no re— lationships among the other modiFying variables and the major study variables. Summary In this chapter, data were presented that described the study sample, the perceived barriers to taking prescribed medi- cations For controlling hypertension, the perceived barriers to Following a prescribed diet For controlling hypertension, and the perceived job barriers to Following therapeutic regi- mens. The Pearson Product Moment Correlation was utilized to identiFy the degree and direction oF relationships among the belier about perceived barriers. The modiFying variables were also correlated with the individual belier and the subscales. Reliability analyses were described concerning the subscales utilized in this study. In Chapter VI, the research study and the data described in Chapter V will be interpreted. Conclusions will be 124 discussed in relation to the research questions. Limitations oF the present study and implications For nursing practice, education and research will be presented. CHAPTER VI SUMMARY INTERPRETATIONS AND RECOMMENDATIONS Introduction In Chapter VI a summary and interpretation oF the research Findings are presented. This summary and interpretation will include a description oF the study sample, results oF the re- search questions, limitations oF the present study, and impli- cations oF this For nursing practice, education and research. Summary and Interpretation A descriptive study was completed to determine what hypertensive subjects perceive as barriers to Following a prescribed diet (weight loss and/or sodium restriction) and taking antihypertensive medications to control hypertension. Perceived job barriers that interFered with subjects' ability to Follow the therapeutic regimen were also assessed. This study consisted oF 158 hypertensive subjects who ranged in age From 24 to 55 years. The sample consisted oF an even distribution oF men and women and included married persons living with either a spouse and/or children. The subjects included persons currently working at a job, home- makers, and a small number oF unemployed, retired, or disabled 125 125 persons. More than one-halF the subjects had a high school education or higher. Duration oF diagnosed hypertension For subjects in this study ranged From less than one year to 15 or more years, with the majority oF persons having hypertension Five years or less. There was a greater proportion oF white subjects than black subjects, but the proportion was similar to that oF the general population. Median Family income For the sample was higher than For the general population. ThereFore, the study population was composed primarily oF white men and women, aged 24 to 55, who worked at regular jobs and lived with a spouse and children. These Findings are consistent with statistics oF the general population. This sample population is similar to sample populations in other studies that assess perceived barriers to therapeutic regimens (Tuck, at al., 1981; Glanz, at al., 1981). One instrument was used in this study and was developed based on expectancy value models and Rosenstock's Health BelieF Model. One instrument was a questionnaire analyzing subjects' belier about hypertension with speciFic questions assessing subjects'belier about taking medications, Following a speci- Fied diet, and the eFFect oF job on Following recommended regimens. This instrument was developed by B. Given and C. W. Given, principal co-investigators oF the study: Patient Con- tributions to Care--Link to Process and Outcome (Appendix A). 127 A questionnaire designed to gather sociodemographic inFormation about the study participants was also used. A combination oF descriptive and inFerential statistical techniques were used to analyze the data. Descriptive tech- niques were done on each item comprising a scale and reliability oF each scale was determined through computation oF coeFFicient alpha. All scales had a moderate to high reliability (Chapter V). The purpose oF the study, as discussed in Chapter I, was to answer the research questions: 1. What do hypertensive subjects perceive as barriers to Following a diet For controlling hypertension? 2. What do hypertensive subjects perceive as barriers to taking prescribed antihypertensive medications For controlling hypertension? 3. What do hypertensive subjects perceive as job barriers to Following a prescribed diet or taking prescribed antihypertensive medications For controlling hyper- tension? In the Following section, the relationship oF sociodemo- graphic variables or modiFying variables to the major study variables will be discussed. 128 ModiFyipg Variables As discussed in the literature review, proponents oF the Health BelieF Model believe that an individual's perception oF barriers to aspects oF prescribed therapy aFFect the like- lihood oF Following a recommended health action (Becker, 1974; Kirscht, 1974). ModiFying variables or sociodemographic vari- ables may also aFFect an individual's perceptions oF barriers to care. For a hypertensive individual, age, sex, race, educa- tion, marital status, income, work status, living arrangement, and duration oF hypertension may aFFect perceptions oF barriers to Following therapeutic regimens (see conceptual Framework). A Pearson Product Moment Correlation was perFormed to determine relationships among the modiFying variables and the major study variables oF barriers to medications, barriers to diet, and job barriers (Table 10, Appendix H). SigniFicant relationships were not Found between sex, race, marital status, living arrangement, work status, income, and duration oF hyper- tension. A positive relationship, albeit moderate, was Found, between educational status and belier about medications, indicating the more education an individual has, the Fewer perceived barriers to taking medications. This is consistent with studies which show correlation between educational level and compliance with medical regimens (Caldwell, et al., 1970; 129 Kirscht and Rosenstock, 1977). However, this is contrary to the Findings oF other researchers who Found no correlation between educational status and compliance with medical regimens (Greene, et al., 1982). This researcher hypothesized that it was possible that the more education an individual had, the 2225 the perceived barriers to taking medications. Individ- uals with more education may be cognizant oF the possible side eFFects oF medications and the liFelong commitment to taking medications, thus perceiving more barriers. Individuals with more education may also be aware oF non-pharmacologic measures For controlling blood pressure; diet and exercise may be viewed as less intrusive and may be a part oF their liFestyle. The Feeling oF dependence on medications also may be viewed as a barrier. Thus, health care providers must include an assessment oF the individual's belier, sociodemographic status including educational level and liFestyle. The individual should be an active partici- pant in establishing a program For controlling hypertension and the programs should be tailored to Fit the individual's liFestyle. This researcher believed that although some conclusions concerning perceptions oF barriers to care and the eFFects oF modiFying variables may be drawn, it is ill-advised to make generalizations concerning the sociodemographic variables oF an individual and his/her perceived barriers to care. 130 In combining the results oF several studies, one may draw False conclusions because studies that have determined perceived barriers to care have analyzed diFFerent medical conditions, patient populations, used varying research designs, ways oF gathering data methods and outcome measures. The inFormation obtained From these studies may provide useFul data to identiFy individuals who may perceive more barriers, but the Findings do not help to account For the many individ- uals who have one or more oF the characteristics and do not perceive barriers to care. ThereFore, sociodemographic or modiFying variables may be called "risk Factors." Health care providers may use these modiFying variables as an aid For identiFying persons who will potentially perceive barri- ers, but these modiFying variables should not be used to cats- gorize persons as perceiving greater barriers to care. Clinical Nurse Specialists (CNS) must be aware oF the modiFying variables that can aFFect an individual’s ability to Follow a therapeutic regimen. Most importantly, the CNS must explore with the individual modiFying variables the individual believes may put him/her "at risk" For noncompliance. In summary, there was a moderate positive relationship between education and perceived barriers to medications indi- cating the more education the Fewer perceived barriers. There were no signiFicant relationships between the modiFying variables oF sex, race, marital status, income, work status, living 131 larrangement, and duration oF hypertension and the major study variables. In the next section, the major study variables and research Findings will be discussed. Research Questions 1. What do hypertensive subjects perceive as barriers to Following a diet For controlling hypertension? Descriptive statistical techniques were used to deter- mine what barriers subjects perceived to Following a diet For controlling hypertension. A percentage ranging From 9.7 to 33.1 oF the subjects perceived barriers to Following a speciFied diet, but the majority oF study participants did not perceive barriers to Following a prescribed diet. Researchers have shown that it is more diFFicult to adhere to a dietary regimen than taking medications For con- trolling hypertension (Glanz, 1980). Glanz reported that dietary regimens are oFten restrictive rather than additive. Medication regimens oFten require changes in liFestyle and are oF long or permanent duration. This researcher also antic- ipated that lack oF social support, cost oF Food, and the taste oF low sodium Foods would be identiFied as barriers. However, this was not Found in this study. It was anticipated that the majority oF subjects would perceive barriers, thus, the Finding oF low perceived barriers to Following a diet was an unexpected one. 132 There are several possible explanations For this Find— ing. Some explanations may be related to the modiFying vari- ables oF the study sample. The age range For people in this study was 41 years (range 24 to 55 years). The broad range 0F 41 years could account For diFFerences in the subjects' perceptions oF barriers. The marital status and living arrangements could also inFluence subjects' perceptions and account For the low per- centage oF perceived barriers. Caldwell, et al. (1983) Found that hypertensive patients who were unmarried had poor blood pressure control. The majority oF the participants in this study were married and living with a spouse and children. Seventy-eight percent Felt they could count on their Family when they needed help Following the diet. Another possible explanation could be that individuals are becoming more aware through the media oF the importance oF low sodium Foods. Family journals, magazines, diet and exercise journals, and newspapers all have articles on the value oF low sodium Foods and no added salt diets. Persons may be decreasing their sodium intake For reasons unrelated to their hypertension; peer pressure or social desirability. As individuals become more aware oF their sodium intake, they may Find more creative ways to prepare their Foods and make Food preparation a part oF their daily activities. These possibilities would substantiate the Findings that only 19 133 subjects (12.3%) disliked the tastes oF their Foods, that 15 subjects (9.7%) did not have time to Follow the prescribed diets and that 155 subjects believed Following the diet recom- mended to them did not interFere with daily activities. Research Findings indicate that longer duration oF a disease and adherence to a regimen are negatively associated (Becker, et al., 1977; Glanz, 1980). Findings indicate that the longer an individual has been diagnosed with hypertension the more perceived barriers to Following a therapeutic diet. The majority oF subjects (54.5%) had been diagnosed with hyper- tension Five years or less and perceived Fewer barriers to diet, thus supporting preVious Findings. At this point, it might be hypothesized that the subjects perceived Few barriers to Following a diet because they had no diFFiculty. IF this were the case, blood pressure and weight should be within normal limits. One hundred one subjects (57.3%) were more than 20% overweight. Systolic blood pressures ranged From 108-210 mm Hg with a mean oF 149.3 mm Hg. (Diastolic blood pressures ranged From 50 to 120 mm Hg with a mean oF 95.7 mm Hg. As discussed in the.literature review, high normal blood pressure should be 140/90 and individuals should be within normal limits For weight (High Blood Pressure Detection and Follow-Up, 1984). ThereFore, the scale used to assess perceived barriers to care may not have tapped the barriers to diet perceived by this sample population. The subjects 134 may not have been Following their diet and the barriers may not have been real to them. Another possibility, though, could be the subjects did perceive themselves as Following their diet (thus perceiving Few barriers), but did not take medications, did not exercise, and continued to Follow poor health practices (smoke, alcohol intake), which could account For elevated blood pressure. It is also possible that the individuals in this study were not Following a prescribed diet For hypertension control. One criteria For inclusion in the study was Following a diet For controlling hypertension and/or taking antihypertensive medications. This researcher did not determine what diets individuals were prescribed or iF they did Follow their diets. Thus, it is possible that individuals were 223 prescribed diets or did not Follow dietary regimens. IF so, then it would be logical that individuals would not perceive barriers to recommended dietary regimens. A Final possibility is that data concerning perceived barriers were collected From a group oF individuals diagnosed with hypertension and being seen by a physician. These people were in no educational or counseling programs to identiFy barriers and/or assist with increasing adherence. Because there were no "incentives" to lose weight or decrease blood pressure; For instance, weekly monitoring, home blood pressure testing, small group counseling, the subjects did not perceive a need to Follow a diet; again, the outcome would be Few 135 perceived barriers to care. IF subjects were in educational or counseling groups and the outcome was weight loss and/or blood pressure reduction, it is possible more barriers would be identiFied. Nursing Implications The rank order oF perceived barriers was presented in Table 4. FiFty—one subjects (33.1%) perceived their recom- mended diet as being diFFicult to Follow. IdentiFied barriers For the diFFiculty in Following recommended diets were lack oF Family support (n = 34, 22.0%), personal liFe interFering with diet (n = 32, 21.9%), although only 18 subjects (11.5%) believed that Following their diet interFered with normal daily activities and hunger when Following the recommended diet (n = 32, 20.7%) was a barrier. Nurses, especially those in advanced practice can assist individuals to Follow recommended diets For controlling hyper- 'tension. Nurses can meet with patients on an individual basis For assessment and patient education. At the initial visit, a nutritional assessment including a dietary history, Food habits, and exercise habits would be done. The individual's liFestyle, Family history, and medical history would also be assessed at this time. The patient would be educated about the basics oF the prescribed diet and barriers to Following the diet as perceived by the patient would be discussed. 135 Simple recommendations or diet diaries may decrease the Feel- ing oF being overwhelmed. At the next visit, the nurse and patient may want to include a signiFicant other or the person involved in Food preparation. At this time, a plan based on the individual's liFestyle, capabilities and the mutually established outcomes would be developed. The patient may be given Food lists or booklets to assist in understanding dietary habits. Evaluation oF progress and oF patient's understanding oF the regimen should be done. Perceived barriers would be reassessed because the patient may perceive diFFerent barriers as therapy is initiated. Depending on the patient's liFestyle and needs, the nurse may take on the role oF counselor, resource person, or support person. DiFFerent techniques to improve adherence to a diet may include tailoring the dietary regimen to Fit the person's liFestyle, contracting with the individual, group sessions or individual reFresher courses (Heine, 1981). 2. What do hypertensive subjects perceive as barriers to taking prescribed antihypertensive medications For con- trolling hypertension? Many studies have been done to assess hypertensive in— dividuals' perceived barriers to Following therapeutic regimens. Cummings, at al. (1982) Found hypertensive patients' perceived lack oF interest (4.7%), and dependence on the medications 137 (2.3%) as barriers to taking medications. Kirscht and Rosen- stock (1977) Found that individuals who had diFFiculty Follow- ing physician's advice had diFFiculty adhering to health regimens. Finally, Caldwell, et a1. (1970) Found hypertensive patients perceived poor instruction (35.0%) and discouragement (7.0%) as barriers to continuing treatment. Because so many hypertensive patients have diFFiculty Following antihypertensive medication regimens, this researcher anticipated that more subjects would perceive barriers. Yet, the percentage oF patients who perceived "lack oF interest," as a barrier was similar in this study and the Cummings' study. It is very diFFicult to make comparisons between studies be- cause the perceived outcomes vary with each study. Adherence to antihypertensive regimens has been measured by blood pres- sure, pill counts, prescription reFills, and appointment keep— ing. Adherence has also been measured on Likert-type scales where the subjects choose always to take medications, some- times to take medications, never to take medications. This wide variety oF deFinitions makes assessing speciFic barriers to taking antihypertensive medications diFFicult. In the present study, there are several possible reasons why Few subjects perceived barriers. The sociodemographic variables may have aFFected the perception oF barriers. It has been shown in reseach studies that the very young and the very old are more likely to perceive 138 barriers to care (Gillum, et al., 1979; Blackwell, 1973). The age range oF the sample in this study was 24 to 55, with no very young or very old participating in the study. There was a moderate positive relationship between educa- tional status and belier about medications (r = .2253, p=; .003) in the present study; the higher the educational status the Fewer the perceived barriers. Almost halF the subjects (43.9%) had at least some college education while 54 subjects (34.2%) had a high school education. These Findings support the results that Few barriers were perceived in this study. Results oF research studies have indicated that persons who are unmarried are less likely to Follow therapeutic regi- mens (Gillum, et al., 1979). In the present study, 124 sub- jects (78.5%) were married. These subjects may perceive their spouses as being supportive and knowledgeable about the thera- peutic regimen. The spouse may help decrease the conFusion and disinterest a hypertensive subject will Feel when adhering to liFelong therapy. A spouse may also help to incorporate medication regimens into the hypertensive subject's daily routine. An interesting Finding in the present study was that 13 subjects (8.4%) Felt they must take their antihypertensive medications even iF they did not Feel they were getting better. The symptoms oF hypertension are oFten asymptomatic and studies have shown that patients oFten stop taking their medications because they "Feel Fine" (Caldwell, et al., 1970). It would 139 be interesting to know why these people didn't Feel they were getting better; was their blood pressure elevated, were they not taking their medications regularly or, because they were told they had to continue medications did they perceive they were not getting better? These subjects may beneFit From a reFresher course about hypertension and the rationale For therapy. Another possible reason Few subjects perceived barriers to taking medications is that subjects were attuned to their health status and realized that taking medications For blood pressure would improve health and possibly lengthen liFespan. The majority oF subjects were proFessionals with some college education. These subjects may be more "health conscious" and be aware oF regimens For controlling hypertension. Hypertension is a major health problem in the United States and more individuals are becoming aware oF this Fact. Many articles have been published discussing the physiology oF hypertension and methods oF treatment. More people are being diagnosed with hypertension due in part to better screen- ing and detection programs (1984 Report oF the Joint National Committee). Hypertensive individuals may Find it "easier" to Follow medication regimens because they know Friends or relatives with hypertension. The sample population may Find other individuals with hypertension are support persons. The criteria For inclusion in this study included taking 140 at least one antihypertensive medication. Data were not ga- thered by this researcher concerning how many medications individual subjects were taking. Some medications For con- trolling blood pressure can be taken once each day.‘ It is possible subjects did not perceive conFusion concerning their medications because they were only taking one medication daily. Persons may also Feel their antihypertensive regimen does not interFere with their liFestylebecause their regimen con- sists oF one medication daily. Another possible reason Few barriers were perceived is that subjects in the present study did not consistently take their medications as directed. A subject may take his/her medications "most oF the time," Feel no adverse eFFects and believe he/she is adhering to the regimen. IF an individual believes he/she can take medications Fairly regularly and maintain blood pressure control, they are not likely to believe their medications interFere with their liFestyle or that they have to change too many habits to take medications. Finally, the sample participants' perceived barriers were measured at one point in time. It is possible subjects were Feeling conFused or disinterested the day data were col- lected For the study. It is also possible the subscale did not tap the barriers to medications perceived by the study sample. There were no items to measure perceived barriers due to cost, side eFFects, or physician—patient relationship. 141 Nursing Implications Descriptive statistical techniques were used to determine what barriers subjects perceived to taking prescribed antihyper- tensive medications to control hypertension. Results oF the analysis showed that 13 subjects Felt they must take their antihypertensive medications even iF they Felt they were not getting better. Twelve subjects (7.9%) perceived dependence on the medications as a barrier. Seven subjects (4.5%) per-‘ ceived disruption in liFestyle as a barrier while Five subjects (3.2%) perceived conFusion about medications as a barrier. Four subjects (2.5%) were not interested in taking the medi- cations on a regular basis. Only three subjects (2.0%) did not believe their medications would control their blood pres- sure. Inability to take antihypertensive medications on a regu- lar basis has been recognized as a major problem in the control oF hypertension. The nurse in an advanced practice role is in a key position to elicit the individual's perceptions about hypertension and assist the individual to develop appropriate belier about hypertension and the treatment regimen. The nurse must assess the individual's needs, status, and priori- ties and answer the questions: "How willing is the patient to begin treatment?" "What does the patient expect From treat- ment?" or "What is a realistic goal For the patient?" The nurse should assess the patient's belier concerning 142 medications. Educational strategies including lecture/discus- sion Format, group sessions, selF-instructional materials, and handouts will provide the patient with appropriate inForma- tion which may decrease perceived dependence or conFusion about medications (Heine, 1981). A treatment regimen must be based on mutual agreement' and responsibilities between the patient and the health care provider. The mutual goal should be a reduction in blood pres— sure to a normotensive level. Patient responsibilities could include: making the decision to control hypertension, Follow- ing prescribed therapeutic regimens, and identiFying possible ' barriers to Following regimens. The health care provider's responsibilities may include: encouraging the patient to take an active role in his/her care, developing a therapeutic rela- 'tionship with the patient and assisting the patient to Find_ ways to incorporate the regimen into his/her liFestyle. Methods to incorporate an individualized medication regimen into a patient's liFestyle include: tailoring the regimen, providing cues to take medications, contracting with the patient, gradually implementing the regimen, iF possible, teaching the patient to selF monitor blood pressure and, Finally, rein- Forcing the patient's progress. It is important For nurses to assess an individual's support system and involve this system in providing social and emotional support to the patient. Finally, health care 143 providers should utilize the team approach in assisting the hypertensive patient to Follow a medication regimen. Pharma- cists, physicians, social workers, and nurses all provide unique services that may beneFit a patient at diFFerent times. In summary, hypertensive patients should be included when designing a therapeutic regimen to control hypertension. By assessing patient's belier and desired outcomes, an individ- ualized plan can be developed that will help reduce perceived barriers. 3. What do hypertensive subjects perceive as job barriers to Following a prescribed diet or taking prescribed medi— cations For controlling hypertension? Fewer subjects responded to the belier in this scale. The number oF subjects who responded ranged From 114 to 123 subjects. One hundred Four subjects stated they were employed at the time the data were collected and 25 subjects indicated they were housewives. Since more subjects responded to the belier than stated they were employed at regular jobs, it can be assumed that housewives believed their occupation was considered a regular job and/or persons who were not currently employed responded to the section regarding job barriers. This may have an eFFect on the type oF barriers perceived by this sample. It may also have an eFFect oF the actual percent- tage oF working persons who perceived the statements as 144 barriers. This researcher would hypothesize that persons who were retired (5.4%) would not perceive their job as aFFecting their ability to Follow therapeutic regimens. Conversely, it is possible that persons who were unemployed or laid oFF (5.4%) were so worried about Finding a job that they had diFFi- culty taking medication. Few persons perceived barriers, but there are reasons why some people did perceive their job as a barrier to Following suggested regimens. Data From studies by Haynes, et a1. (1978) and Charlson, at al. (1982) Found that labeling an individual "hypertensive" does aFFect absentee- ism From work. Haynes, et a1. Found that absenteeism was re- lated to the employee's awareness oF the diagnosis but was 223 aFFected by the institution oF therapy or the success in reducing blood pressure. Charlson, et a1. Found that younger (less than 30) employees were more inclined to miss work aFter. being labeled hypertensive than older (greater than 30) em- ployees. More than one-halF (54.5%) oF the sample population had been diagnosed with hypertension Five years or less. It is possible that the increased absenteeism From work Following the individual being labeled hypertensive was now causing prob- lems at work. Individual's job perFormances may be below ac- ceptable levels due to absenteeism. The employees may have been experiencing greater pressures to improve work or have been told their jobs were in jeopardy. IF this is so, it may have been diFFicult to Follow therapeutic regimens For blood 145 pressure control. Three subjects did perceive their job as interFering with taking their medications. This is an important Finding For persons who prescribe medications. Antihypertensive medica- tions may be taken daily, but depending on the control needed, individuals may have to take combinations oF drugs two or three times each day. Many drugs do cause side eFFects that may aFFect an individual's ability to perForm a job duty. IF an individual's job requires working with machinery or working in high places and the patient is experiencing side eFFects From the medications, the patient may not be able to perForm his/her job. Thus, the individual may believe that changing jobs would make it easier to take medications. Individuals in the sample population may work shiFts that require sleeping through the day or working in the even- ing. It may be diFFicult For these individuals to Follow low sodium diets because they eat alone or prepare their own meals. It may also be diFFicult to take medications three times each day with meals. Thus, these individuals may be- lieve that changing jobs would make it easier to take medica- tions (n = 2) and Follow a diet (n = 8). Few respondents perceived the belier as job barriers and there are several possible reasons For these Findings. One possible reason would be that the individuals' jobs were not causing stress or worry. Almost halF oF the population 145 (44.9%) had received some college education or were college graduates. It is likely these individuals were working in a job oF their choice. There are stresses with all jobs, but iF these individuals were controlling their stresses, it is probable they did not perceive their job as aFFecting their ability to Follow a therapeutic regimen. This is borne out in the analysis oF the data which shows that Few individ- uals believed the pressures oF the job were too great (n = 3) or that worry about job aFFected medication regimens (n = 2). The majority oF subjects were married (78.5%) and living with a spouse and children. These individuals would provide support to the hypertensive individual. Many individuals in this study may have used a spouse as a conFidant to discuss the pressures and worries oF the job situation. The spouse may provide a supportive environment For taking medications and Following a diet by preparing low sodium meals and tailor- ing the patient's medication regimen to his/her liFestyle. Another reason Few individuals perceived these belier as barriers would be that they were not taking their medications or Following their diets regularly. Because subjects were not having diFFiculty taking medications or Following a diet, does not mean they were adhering to the regimen. It is possi- ble that a job would cause barriers to taking medications iF the individual was taking medications as directed. This researcher did not measure individual's level oF adherence 147 to suggested regimens. A Final possibility as to why individuals perceived Few job barriers was that the concept oF barriers was not tapped. One or two questions were used to assess the concepts oF job barriers to taking medication and Following a prescribed diet. It is possible these statements did not correctly assess the sample populations' perception oF job barriers. Nursing Implications Descriptive statistical techniques were used to determine what job barriers hypertensive subjects perceive to Following a recommended health regimen For controlling hypertension. No previous research has analyzed this question and thus no Findings exist to either support or reFute the Findings in this study. Eleven subjects (9.8%) Felt that their work habits were diFFicult to Follow. Eight subjects (7.2%) believed it would be easier to Follow their recommended diet iF they changed jobs and three subjects (2.7%) believed they could control their weight iF job pressures weren't so great. Three subjects (2.7%) believed their job interFered with their medication regimen. Two subjects (1.8%) believed it would be easier to take their medications iF they changed jobs and two subjects (1.8%) Felt they worried so much about their jobs that they could not take their medications. An individual's job or 148 work status must be considered a possible barrier to Follow- ing regimens For controlling hypertension based on these Find- ings. Nurses in advanced practice should include job status in their assessment. Included in this assessment should be data associated with a job that may aFFect a hypertensive individual's ability or desire to Follow a regimen. Type oF work (labor or management), working hours (shiFt work), work conditions (indoors, outdoors, high places, hot, crowded, or noisy work sites, working alone or in groups) and environ- mental stresses (psychological stress, exposure to chemicals or heavy metals) should be assessed For an individual who perceives job as a barrier. The hypertensive individual could be taught stress reduc- tion or anticipatory guidance which would reduce worry and job pressures. Labeling an individual as hypertensive should be done when the diagnosis would be accurate. The nurse should educate the individual concerning hypertension using appropri- ate strategies, but base the diagnosis oF hypertension on correct criteria. Once the therapeutic regimen is initiated, health care providers must collaborate to individualize the regimen. Medication and diet scheduling should be based on the individual's type oF work, work conditions and work hours. The individual's job should be considered when scheduling Follow-up visits. 149 For patients who believe it would be easier to Follow therapeutic regimens iF they changed jobs, the nurse should use anticipatory guidance and assist the individual in suitable job placement. Finally, the nurse in advanced practice in collaboration with other health care providers may design work-site programs to monitor hypertensive patients, provide inFormation about hypertension to employers and co-workers, or develop work-site health promotion programs. Limitations oF the Study In addition to the limitations stated in Chapter I, the Following limitations have been identiFied which may have aFFected the results oF the study. Data For work status was gathered on the sociodemographic instrument, but this researcher did not determine the main occupation oF study participants. The type oF job each partici- pant perFormed may have aFFected perceived job barriers. This researcher did not gather data For level oF career commit- ment or job satisFaction. These variables may also have aF- Fected perceived job barriers. Data For Family yearly income was obtained but this researcher did not correlate income with living arrangement For each subject. This analysis would have been helpFul in determining sociodemographic status oF the subjects. There were no measures oF adherence in the present study. 150 There were measures oF adherence in the parent study by Given and Given (1982), but this researcher did not measure how oFten patients believed they took their medications or how well they Followed their prescribed-diets. These Findings may have aFFected individuals’ perceptions oF barriers. There was no measure oF social support in the present study. This variable may have had an eFFect oF the subjects' perceptions oF barriers related to job and Following thera- peutic regimens. Data were not gathered on other types oF perceived bar- riers including side eFFects, cost oF medications and cost oF low sodium Foods. These belier may have been perceived as barriers by the study population. Implications For Nursipg Practice The implications For nursing practice will be discussed within the context oF the nursing process adapted From Orem (1980). Research has shown that individuals who are unable to Follow therapeutic regimens perceive barriers to care. There are several types oF barriers that aFFect individuals' abilities to Follow regimens and these have been addressed in the present study. IF an individual's perceived barriers prevent him/hen From Following a therapeutic regimen, then the person is un- able to perForm optimal selF care (Orem, 1984). Individuals 151 perceive barriers that are unique to them and are inFluenced by a variety oF Factors including sociodemographic variables. Health regimens that require an individual to change liFelong habits (For instance, weight reduction, sodium restriction, or taking medications on a daily basis) cannot be initiated and oFten will not be successFul iF the individual perceives barriers to Following regimens. Thus, the goal oF nursing is to help individuals perceive and overcome barriers and perForm selF care. In practice, nurses must be aware oF the eFFect oF bar- riers on Following a therapeutic regimen. The nurse must value the importance oF an individual providing his/her own selF care and access the eFFect oF barriers on a person's ability to perForm selF care activities. Nurses must Focus on individuals, and more importantly, the nurse's perspective must encompass the patient's perspective oF his/her health situation and perception oF barriers. The nursing process consists oF assessment, diagnosis, planning, implementation and evaluation. Using this process, the nurse in advanced practice can practice within the sup- portive-educative nursing system and provide guidance, support, and education to help individuals identiFy barriers and assist the individual in learning ways to overcome barriers. During the assessment phase or diagnosis and prescrip- tion phase (Orem, 1984) oF the nursing process, the nurse I 152 must help the individual identiFy barriers that prevent the individual From Following regimens designed to improve the health state. The nurse should assess the individual's socio- demographic status and identiFy "at risk" individuals. The nurse would assess the individual’s perception: oF barriers to medications, diet and job barriers. The assessment tools used in this study could be used For this purpose. The nurse would Form her own perceptions oF the patient's health state and perceived barriers than share these perceptions with the patient; thus, the two would Form a therapeutic relation- ship and base the goals or outcomes oF the relationship on mutually deFined problems (Orem, 1980). During the assessment phase, the nurse must assess the individual's understanding oF the term "barrier." It is possible the individual may not perceive barriers and the nurse may use anticipatory guidance to assist the individ- ual in identiFying real and potential problems. An individual may not identiFy barriers beFore starting a regimen, but once the individual begins treatment or as the regimen becomes more complex, barriers may be identiFied. This is especially possible when a person is asked to alter dietary patterns that require the individual and Family to change liFelong patterns. By assisting the patient to understand the concept oF barriers, how barriers can aFFect adherence to regimens, and how barriers can change over time, the nurse helps the 153 patient identiFy potential problems. At this point, a nursing diagnosis should be developed and used to guide nursing inter- ventions. Based on the Findings oF this study, nurses should be aware that perceived barriers may include hunger when Follow- ing a diet, lack oF Family support, and interFerence with liFestyle. Nurses should be aware that educational status aFFects perceived barriers to taking medications. Nurses should also be aware that an individual's job may cause so many stresses that an individual does not have the resources leFt to Follow therapeutic regimens. Hunger, Family support, and how a regimen eFFects liFe- style are rarely assessed. The nurse in an expanded role must include these aspects in a complete assessment. Thus, the therapeutic regimen will be based on the individual's be- lier and perceptions and individualized to the patient. Findings From this study indicate that individuals will perceive barriers to care, but the peceived barriers are not necessarily the same barriers the nurse perceives; thereFora, the nurse's values or assumptions may not be the same as the pa- tient's values. 'Thus, it is vital to determine the patient's perception oF barriers and base nursing interventions on the patient's perceptions. In planning and implementation, the nurse and patient design a system oF nursing assistance (Orem, 1980), which 154 includes guidance, support, and education. Together, the nurse and patient mutually agree on priorities and set real- istic goals For overcoming barriers. These goals may include providing the patient with inFormation about the various alternatives For treating hypertension and guiding the patient to Fit these alternatives into his/her liFestyle. The nurse may instruct the patient on various strategies that could be incorporated into the plan to help patients overcome bar— riers. These strategies include tailoring, medication record- ing, pill dispensers, use oF community resources, contracting and educating patients about medications, diet, exercise, stress reduction, and smoking and alcohol use. Nurses should provide support to the patient and Family or signiFicant other support systems. Nurses and patients need to understand the stages oF adaptation to a chronic disease and liFelong therapy and understand that once the patient acknowledges and accepts hypertension as a liFelong situation, educational interventions can take place. Nurses in advanced roles should assist individuals to examine liFe- style including the individual's job status. These areas may need to be altered to make a therapeutic regimen success- Ful. These areas are oFten diFFicult to change even when recognized as barriers and assisting the individual to use stress reduction and anticipatory guidance is an important nursing Function. 155 The nurse may want to involve the Family in counseling and educating the patient. This social and emotional support may increase the patient's selF conFidence in his/her ability to overcome barriers and lower psychological stress. Educating the patient about hypertension and its treat- ment is another method to decrease barriers. Individualized educational strategies can help the patient appreciate the reasons For liFelong treatment and recognize the importance oF taking medications even iF there are no symptoms oF disease. The nurse must assess the patient's ability and desire to learn and individualize educational approaches. The nurse must also encourage the patient to continue to learn as changes occur or regimens become more complex. At the same time, educational strategies should be combined with other strategies. Individual educational sessions can prove successFul For conveying support and inFormation. The sessions can be individualized For each patient and can progress at the patient's rate oF learning. Group sessions could also be successFul because they allow For peer support and the patients can share problems and solutions. For example, by discussing barriers to taking medications, a group may come up with several suggestions or ways to remember to take medications. The group may also provide support and education concerning side eFFects and cost. Another educational strategy is selF instruction. By providing the patient and support system 155 with an audiovisual about hypertension, pamphlets or books, the individuals can learn on their own and at their own speed. SelF-instructional materials are also halpFul to the patient when he/she needs a reFresher course concerning some aspect oF therapy. Because the materials are selF taught, the patient is most likely to use them when he/she is motivated to learn, thus enhancing education. The nurse may provide anticipatory guidance to the patient concerning perceived barriers and strategies For overcoming barriers. The patient may not perceive barriers as he/she begins the health care program, but as the patient continues the program, barriers may develop or become recognized. The nurse may help the patient develop problem-solving strategies and coping strategies relative to overcoming bar- riers. Nursing interventions could include stress reduction and blood pressure monitoring by the patient and Family with a goal being the patient taking an active role and determining the eFFects oF his/her selF care. In the production and management phase (Orem, 1980), or evaluation phase, progress toward the goals and change in the system as necessary is assessed. Progress would be based on behavioral outcomes; decrease in barriers to taking medications, decrease in barriers to Following diet, increase in ability to control job-related stress, and increased ability to Follow health regimens and health outcomes; decreased 157 blood pressure and weight. In summary, the clinical nurse specialist must encourage the hypertensive individual to take an active role in develop- ing his/her therapeutic regimen For controlling hypertension. The patient must be encouraged to base the rationale For decisions on appropriate belier and attitudes. The nursing process; assessment, diagnosis, plan, intervention and evalu— ation should guide the nurse's role in assisting the individual. The nurse may take on the roles oF counselor, resource person, educator, patient advocate, and use behavioral and educative strategies, when assisting the individual. The nursing pro- Fession should collaborate and consult with other health care providers and work employers to educate and develop individualized and appropriate therapeutic regimens For hyper- tensive individuals. The nursing proFession must become assertive in assisting hypertensive individuals to perForm selF care. Nurses should develop innovative nursing programs to assist individuals to recognize and overcome barriers. This means nurses must become politically aware and active and support policy changes that would recognize nursing assistance Financially. Finally, nurses must become knowledgeable about community resources that are available to assist hypertensive individuals and develop networks oF resource people For consultation and collaboration. 158 Implications For Nursing Education The recommendations For nursing education apply to undergraduate, graduate and continuing education programs For nurses.v Nursing education programs should include the Health BelieF Model as a theoretical Framework For predicting and understanding health related behaviors. Nurses should be educated to all variables in the Health BelieF Model but special emphasis should be on perception oF barriers. Nurses should be educated to the eFFect barriers have on individuals' abilities to Follow therapeutic regimens. Nurses should be educated to the diverse behaviors the Health BelieF Model has been used to describe; From preventive to sick role be- haviors to chronic illness behaviors. At the same time, nursing education should Focus on the "at risk" role as described by Baric (1959). The present study has introduced three potential variables that may inFluence individuals' ability For Following therapeutic regimens, barriers to diet, barriers to medication and job barriers. Educational programs For nurses should include the concept oF the therapeutic regimen. Nurses should know there are oFten several correct and eFFective ways to treat a problem based on health care providers' preFerences, success with interventions, and latest scientiFic Findings. Nurses must also be educated to the nursing management plan and to the 159 use oF nursing diagnoses when developing a plan oF care For an individual. It is important that educational programs include the concept oF barriers and how barriers aFFect the ability to Follow therapeutic regimens. An individual's perception oF barriers to Following recommended therapies must be taken into consideration when developing a nursing management plan. Nurses must know that 525p individual will have his/her own perception oF barriers and that nursing management plans must be unique and individualized based on perceived barriers. Nurses must also be educated to the Fact that an individ- ual's perceived barriers may be diFFerent based on what is expected in the therapeutic regimen. Thus, an individual may perceive certain barriers to taking medications, but these barriers may be diFFerent than perceived barriers to Following a low sodium diet. Nurses must become aware oF the many types oF perceived barriers and how important it is to overcome barriers to beneFit From therapeutic regimens. At the same time, nurses must learn how diFFicult it is For individuals to change liFelong perceptions and barriers. The concept oF role barriers, particularly the barriers that may come about due to an individual's job must be a part oF nursing education. People oFten do not receive as much support or recognition For the eFFects oF a job on 150 Following a therapeutic regimen. Nurses must recognize the eFFect a job has on producing barriers to Following regimens. The nurse may be the one to identiFy job as producing barriers to an individual and his Family. Nursing education programs must include the eFFect oF a chronic illness on an individual and his Family. A person with a chronic illness has certain "rights" and "roles" that are diFFerent From a person with a terminal illness or an acute illness. The rights and roles oF an individual with a chronic illness are oFten more ambiguous and oF longer duration. Individuals and support’persons oFten need to be educated to these rights and roles, and be taught ways to work within the "rules." Nurses must also be educated to the aspects oF diFFerent chronic diseases and recognize that the rights and roles associated with hypertension diFFer From those associated with diabetes or renal Failure. I Nursing education programs should also include the eFFects oF sociodemographic variables on individuals' percep- tions oF barriers. Although the present study showed the sociodemographic variables had minimal eFFect on the major study variables, it is valuable to be aware oF an individual's ethnicity, living arrangement, Financial status, and educa- -tional level when developing nursing management plans. Nurses must also be educated to the many nursing inter- ventions that can be used to decrease an individual's perceived 151 barriers to Following therapeutic regimens. Nurses must be aware oF the diFFerent educative strategies: individual and group sessions, behavior modiFication, tailoring, cueing, when working with an individual to increase his/her percep- tions oF barriers. Nurses must also be taught to provide anticipatory guidance, especially to individuals who perceive job and changes in liFestyle as barriers. IF the nurse can provide anticipatory guidance and discuss potential barriers with the patient, noncompliance may be reduced. Nurses must be educated to understand they can help individuals change belier by re-educating the patient. Noncompliance is recognized as a major problem For hypertensive individuals. Nursing education should include Factors associated with noncompliance and the role perception oF barriers has in the concept oF compliance. Finally, nursing education programs should include the importance oF using nursing diagnoses when developing nursing management plans. A nursing diagnosis describing the perceived barriers an individual has to Following a thera- peutic regimen would be invaluable when developing strategies to increase a hypertensive individual's adherence to a medical regimen. Diagnoses related to barriers to medications, bar- riers to diet, and job barriers could be included in the Health Perception-Health Management Pattern category. 152 Implications For Future Nursing Research Many research studies have been carried out to examine individuals' perceived barriers to Following therapeutic regimens. Perceived barriers to taking medications and Follow- ing specialized diets have been addressed, but the eFFect oF the social role oF job as producing barriers to Following therapeutic regimens has not been studied in previous research. Thus, the present study should be replicated to Further test the research question oF perceived job barriers to Following therapeutic regimens. Recommendations For Future research would include assess- ing how the type oF job, work hours, job description, and job satisFaction aFFect perceptions oF job barriers. Another recommendation would be to use the interview method and open- ended questions to gather inFormation about how hypertensive individuals perceive their job. The eFFect oF job on taking antihypertensive medications verses Following a recommended diet would provide an interesting study. The limitations oF this study should be considered when designing the method- ology For Future study. The study should be replicated using diFFerent types oF sample populations: all men or all women or individuals who make up socioeconomic extremes. Men and women may perceive diFFerent barriers and a comparison oF the diFFerences could be done. Studies could be done using individuals in speciFic 153 age groups; For instance, young adults or old adults. A very interesting study would be a cross sectional study to compare or diFFerentiate the types oF barriers perceived by individuals in diFFerent developmental stages. A longitudinal study analyzing how perceptions oF barriers change over time as individuals go From one developmental stage to the next would be an interesting Focus. The eFFect oF the duration oF a chronic illness on perceived barriers would also provide an interesting study. An individual newly diagnosed with hypertension may perceive diFFerent barriers than an individual who has had hypertension For ten years. The eFFect oF the duration and/or complexity oF the regimen on perception oF barriers is also a recommendation For Future research. This study should be replicated using diFFerent socio- demographic variables; For instance, the economic status - oF the individual. Another study should be done to determine common sociodemographic characteristics oF a group oF hyper- tensive individuals who perceive a high percentage oF barriers than compare and/or contrast the variables with a group oF individuals who perceive a low percentage oF barriers. From this research, it may be possible to develop "at risk" para- meters. This study should also be replicated using subjects with diFFerent chronic diseases. Using similar sociodemographic 154 variables, it would be interesting to compare or contrast barriers perceived by hypertensive individuals with those perceived by diabetic individuals or individuals with chronic obstructive pulmonary disease. The subscales oF belier about medications, belier about diet, and belier about job barriers could be expanded. Each subscale was comprised oF Five to seven belier. By increasing the number oF belier, more perceived barriers may have been tapped. It is possible individuals did not perceive the same barriers as proposed by the researchers. Development oF an open-ended questionnaire to identiFy per- ceived barriers to regimens would be another method For tapping barriers. Another method For tapping barriers would be to present patients with a list oF potential barriers and have them rank the perceived barriers From perceived as barriers to not perceived as barriers. This study should be replicated using diFFerent parts oF the Health BelieF Model and the eFFects oF perception oF barriers. Nursing research could include development oF nursing interventions to help individuals decrease their perceptions oF barriers. These interventions would be based on individual barriers identiFied by subjects. In the present study, perceived barriers were analyzed once; beFore a nursing intervention was initiated. A very interesting study would be to assess individuals' perceived barriers at two points 155 in time; beFore the nursing intervention then again halF way through the nursing intervention as was done in the parent study. The number and type oF perceived barriers at the two points in time may prove to be diFFerent. Another recommendation For Further research would be to assess how social support eFFects an individual's percep- tion oF barriers. Assessing the perceived roles oF the patient and identiFied social support and how these roles may support or hinder a hypertensive individual's ability to Follow a regimen could provide enlightening results. Therapeutic regimens For controlling hypertension incor- porate several treatment plans. An assessment oF barriers by individuals who are Following diFFerent regimens would make an interesting study. Finally, by deFining perceived barriers as being determined based on an individual’s selF concept, perception oF health, or locus oF control would provide For several interesting studies. The Findings oF this study have implications not only For nursing practice, but For other disciplines as well. Nurses and other proFessionals such as nutritionists, psycholo— gists, pharmacists, and physicians must be aware oF the bar— riers individuals perceive to Following diets or taking medi- cations. There is a need For increased awareness oF the Factors which may aFFect adherence to regimens designed to control hypertension. The perspective oF several disciplines 155 is needed to develop strategies that would be helpFul to hypertensive patients to reduce their perception oF barriers. Thus, recommendations For Future research would include: 1. In Assess how the social role, job, aFFects or creates barriers to Following therapeutic regimens. Assess how individuals with diFFerent sociodemographic Factors perceive barriers to Following therapeutic regimens. Assess how perceived barriers may change based on the duration or complexity oF a regimen, the introduction oF a nursing intervention, or a change in sociodemographic variables. Assess how individuals with diFFerent chronic dis- eases perceive barriers to Following therapeutic recommendations. Assess how social support may aFFect perceived barriers. Assess how a hypertensive individual's selF concept, perception oF health or locus oF control aFFect perception oF barriers. summary, interpretation oF the research Findings in the present study were discussed in Chapter VI. This chapter also included recommendations and implications For nursing practice, education, and research. APPENDIX A BELIEFS ABOUT HYPERTENSION INSTRUMENT 157 APPENDIX A BELIEFS ABOUT HYPERTENSION.INSTRUMENT Everyone has certain belier 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 Feel- ings or belier, 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 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 agree with the statement, then circle strongly disagree. 1. A person with high blood pressure should stick with his/her treatment even iF he/she doesn't think he/she is getting better. Strongly Agree Undecided Disagree Strongly Agree Disagree 2. IF my high blood pressure was getting worse I would get help. Strongly Agree Undecided Disagree Strongly Agree Disagree 3. High blood pressure can be a serious disease iF you don't control it. Strongly Agree Undecided Disagree Strongly Agree Disagree 4. My high blood pressure is well controlled. Strongly Agree Undecided Disagree Strongly Agree Disagree 10. ll. 12. 13. 158 APPENDIX A (Continued) My high blood pressure would be worse iF I did nothing about it. Strongly Agree Undecided Disagree Strongly Agree Disagree I believe that I can control my high blood pressure. Strongly Agree Undecided Disagree i Strongly Agree Disagree In general, the doctor has helped my high blood pressure. Strongly Agree Undecided Disagree Strongly Agree Disagree High blood pressure is much less serious than pneumonia. Strongly Agree Undecided' Disagree_ Strongly Agree ° Disagree My high blood pressure will go away when I don't have so many other problems. Strongly Agree Undecided Disagree Strongly Agree Disagree 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 The treatment that has been prescribed isn't exactly right For me - Strongly Agree Undecided Disagree Strongly Agree Disagree I am not really sure I have high blood pressure. Strongly Agree Undecided Disagree Strongly Agree Disagree High blood pressure is not as serious as some people say. Strongly Agree Undecided Disagree Strongly Agree Disagree 14. 15. 15. 17. 18. 19. 20. 21. 159 APPENDIX A (Continued) Right now I have more important things to worry about than my high blood pressure. Strongly Agree Undecided Disagree Strongly Agree Disagree 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 Taking care oF my blood pressure is worth the eFFort it requires. Strongly Agree Undecided Disagree Strongly Agree Disagree Treatment For high blood pressure is doing me a lot oF good. Strongly Agree Undecided Disagree Strongly Agree Disagree 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 Some patients have to take pills (medication) to help control their high blood pressure. Do you take any pills For your high blood pressure? (check one) a. Yes, take pills . b. No, do not take pills (IF you checked a., (IF you checked b., answer questions go straight to question 21 thru to 31) 31) Take Pills I could take my medications regularly iF my Family problems weren't so great. Strongly Agree Undecided Disagree Strongly Agree Disagree 22. 23. 24. 25. 25. 27. 28. 29. 30. 170 APPENDIX A (Continued) 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 medica- tions. Strongly Agree Undecided Disagree Strongly Agree Disagree IF I take my medications I may become dependent upon them. Strongly Agree Undecided Disagree Strongly Agree Disagree I am not interested in taking_my medications regularly. Strongly Agree Undecided Disagree Strongly Agree Disagree Taking my medications interFeres with my normal daily activities. Strongly Agree Undecided Disagree Strongly Agree Disagree I believe that my medications For high blood pressure will help me to Feel better. 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 171 APPENDIX A (Continued) 31. I believe that my medications will help prevent diseases (complications) related to high blood pressure. Strongly Agree Undecided Disagree Strongly Agree Disagree Everyone who has high blood pressure has to Follow some guide- lines For eating (or a diet) to help control high blood pressure. Some patients must be concerned with calories or carbohydrates, others with Fat or protein restrictions. The Following state- ments describe belier some people have about the diet they must Follow. Please indicate the extent oF your agreement with each statement by circling one choice For each statement. 32. Following my diet does not interFere with my normal daily activities. - Strongly Agree' Undecided Disagree Strongly Agree Disagree 33. I am always hungry when I stick to my diet. Strongly Agree Undecided Disagree Strongly Agree Disagree 34. I could Follow my diet iF I had a step by step plan. Strongly Agree Undecided Disagree Strongly Agree Disagree 35. I dislike the tastes oF Foods on my diet. Strongly Agree Undecided Disagree Strongly Agree Disagree 35. My personal liFe does not interFere with my diet. Strongly Agree Undecided Disagree Strongly Agree Disagree 37. I cannot understand what the doctor told me about my diet. Strongly Agree Undecided Disagree Strongly Agree Disagree 38. It has been diFFicult Following the diet prescribed For me. Strongly Agree Undecided Disagree Strongly Agree Disagree 39. 40. 41. 42. 43. 44. 173 APPENDIX A (Continued) 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. Strongly Agree Undecided Disagree Strongly Agree Disagree I believe that my diet will help prevent diseases (complications) related to high blood pressure. Strongly Agree Undecided Disagree Strongly Agree _ Disagree I must Follow my diet even iF I don't think I am getting better a Strongly Agree Undecided Disagree Strongly Agree Disagree Do you work outside your home For money either Full—time or part-time? (check one) a. Yes b. No (IF you answered yes, (IF you answered'no, answer questions 45 then go to the end oF thru to 51) the questionnaire) Work Please indicate the extent oF your agreement with each oF the Following statements that describe belier some people have about working and their illness. Circle one choice For each statement. 45. IF I changed jobs it would be easier to take my medications. Strongly Agree Undecided , Disagree Strongly Agree Disagree 45. 47. 48. 49. 50. 51. End: 173 APPENDIX A (Continued) My job does not interFere with taking my medications. Strongly Agree Undecided Disagree Strongly Agree Disagree I worry so much about my job that I can’t take my medica- tions. 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 You have now completed this part oF the questionnaire. Please begin answering the "EFFects oF High Blood Pressure" section. APPENDIX B SOCIODEMOGRAPHIC QUESTIONNAIRE 174 APPENDIX B SOCIODEMOGRAPHIC QUESTIONNAIRE The Following questions describe general things about you. Please answer all the questions to the best oF your ability. 1. Sex: 2. Age: 3. What 4. What 5. How and Male ___ Female is your racial or ethnic background? (check one) a. b. C- is your marital status? b. many living children do you have, stepchildren? a. No living children b. White Black Mexican-American Married Single, never married d. e. F. American Indian Oriental Other (speciFy) (check one) C. d. Separated Divorced Widowed including adopted Number oF living children (write in number) 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? a. b. c. d. below $5,000 $5,000-$s,999 $7,000-$a,999 $9,000-$10,999 $11,000-$12,999 (check one) F. g. h. i. j. $13,000-$14,sss $15,000-$1s,999 $17,000-$19,999 $20,000-$24,999 $25,000 or over 7. 10. 175 APPENDIX 8 (Continued) Are you working now at a regular job, unemployed, retired, a housewiFe, or what? (check one) a. Working now at a b. Unemployed or laid oFF regular Jab c. Betired (IF you answered d. Disabled a., then answer -—— questions 8 and 9) e. HousewiFe F. Other (speciFy) (IF you answered b, c, d, e, or F, then go to question 10) What is the main occupation you work at? (Write in what type oF work you do) What kind oF business or industry is that in? (Write in what they make or do. Is it your own business?) How much schooling have you had (highest grade completed)? (check one) b. C- d. e. F. g. h. None or some grammar school (less than 7 grades completed) Junior high school (9 grades completed) Some high school (10 or 11 grades) Graduated high school Technical, business, or trade school Some college (less than 4 years completed) Graduated college Postgraduate college or proFessional ll. l2. 13. 14. 15. 175 APPENDIX B (Continued) Who lives in your household besides yourselF? (check as many as apply) a- b. C. d. No one else Husband/wiFe Children (write in number living at home) Other relatives (write in relationships: example, mother-in-law; niece) Non-related persons (write in: example, 2 Friends; 1 boarder) Do you have hypertension? (check one) How Yes No (IF you answered yes, (IF you answered no, then answer question l3)' then go to question 14) long have you had hypertension? (check one) a. less than 1 year a. 9 to 11 years b. l to 2 years F. 12 to 14 years c. 3 to Five years g. 15 years or more d. 5 to 8 years Do you smoke cigarettes? _(check one) How Yes (IF you answered yes, then answer question 15) No (IF you answered no, then go to question 15) many cigarettes do you smoke in a day? (check one) a. b. c. d. less than 5 cigarettes a day 5 to 9 cigarettes a day 10 to 19 cigarettes a day 20 to 29 cigarettes a day 30 or more cigarettes a day 15. 17. 18. 19. End: 177 APPENDIX 8 (Continued) Do you drink alcoholic beverages? (check one) Yes No (IF you answered yes, (IF you answered no, then answer question 17) then go to question 18) How oFten do you drink alcoholic beverages? (check one) a. Occasionally d. l to 2 drinks a b. Weekends only day . ' a. more than 2 drinks c. Several times a week -—— . Do you have diabetes? (check one) Yes ' No (IF you answered yes, (IF you answered no, then answer question 19) then go to the end oF the questionnaire) How long have you had diabetes? (check one) a. Less than 1 year a. 9 to 11 years b. l to 2 years F. 12 to 14 years c. 3 to 5 years g. 15 years or more d. 5 to 8 years You have completed this part oF the questionnaire Please begin answering the next section. APPENDIX C PARTICIPATION LETTER 178 APPENDIX 0 PARTICIPATION LETTER October 14, 1980 Dear To improve the care we give patients with high blood pres- sure, our medical and nursing staFFs are working with researchers at Michigan State University to help patients better manage their high blood pressure. 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 15 months. In addition, you may be asked to meet with a staFF nurse during the next six months to talk with her about your high blood pressure 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. 179 APPENDIX C (Continued) 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, Dr. H. E. Crow, M.D. Director HEC/srt APPENDIX 0 CONSENT FORM 180 APPENDIX 0 CONSENT FORM The study in which you are about to participate is designed to Find out the belier that persons with diabetes (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 Follow- ing statement. ‘ l. I have Freely consented to take part in a study oF patients being conducted by the (study site name) 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 origi- nally agreeing to participate, the amount and quality oF service provided me will not change. I understand that I can withdraw From participating at any time. 4. I understand that the results oF the study will be treated in strict conFidence and that should they be published, my name will remain anonymous. I understand that within these restrictions results can, upon request, be made available to me. I, , state that I understand (print name) what is required oF me as a participant and agree to take part in this study. I, Signed (signature oF patient) Date APPENDIX E FREQUENCY DISTRIBUTION BELIEFS ABOUT DIET SUBSCALE 181 3mm. mv.m em.mm mod x0.mm vm emu amen >5 enazoauot aunt 0mm: H Cmtz zHHEmm >5 :0 #:300 two H mmn. mm.m ao.mn has an.nm mu vmu ms Lot twinnto Lagoon asp amen mg» sodium op wasp m>mc H mo.u mm.m am.vm cm xu.mm um «me me Lou nmnaLommtu pman mtp one -zouuot pancattan comp mm: pH mmm. mv.m em.un ous em.um mm mmu amen as nus; mtmtimpca 00E mmon mmHH HmcomLou >2 vmm. vn.m em.vn mus em.mu mu mma amen >5 no mUOOL m0 mmummu mLp waHmHU H mmm. mm.m xu.nm vol $5.0m mm mma amen as on inapm H cmzz hLmEJL mzmsz 5m H mmm. wa.m em.am emu em.au mu mma mmapa>apom slant HMELDC >5 Lsz mmemeCH poc mmon pmHU >5 mEHBDHHom .o.m mLoum .snnm .Hnam .snjm .snnm uz pcmsmpmpm Emmi L0 N mo .02 mo N to .02 mHaemm LmHLme mm LmHLme mm pcmsmumpm ucmemumum m>HmUme #02 UHD Dm>HmUme mHmowDJm umHD pjon< wumwumm COHvDDHmeHD huchUmLm h U.— SE... m XHDzmml< APPENDIX F FREQUENCY DISTRIBUTION BELIEFS ABOUT MEDICATION SUBSCALE 182 4mm. m.u Nm.vm mvH $0.3 m vmu mH PH ULmL 30£ Lmupms 0: on umJE ComLma m mCHLumeom ma monumUHUms mEmek «on. m.u eo.mm emu ao.m m mm“ mLammmLQ nonan Lea; >5 doipcou HHHB mCoHuwuHumE >E m>mHHmD H vow. O.N Nh.mm NmH xv.m mH vma mepmn mCHuumm E.H xCHnu Q.EOU H we Cm>m mcoHpmuHDmE MLJm InmLu UDDHD LmHL >E mxmv vmfle H mmm. m.q ed.mm cu em.c n mmu mmapa>euom >uamn emstoc >2 Lass mmmeLmucH mCOHmeHDmE >E mCHJMF 0mm. m.v aq.mm has em.m v «mu >3Lmsnmmt mcoaumoanme >2 mCmep CH DumMLmPCH 90E Em H mmm. m.m am.vn VH3 Nm.n NH mmH Emnp Co ucmncmumn mEoumn >mE H mCOHumUHDmE >E mxmu H uH omm. q.v eo.mm omu an. a mmu mcoaumuanms >5 mxmp op mpanmt >CmE 00v mECmLO Op m>m£ UHDOZ H mew. m.v Nu.vm mvH Nm.n m VmH m5 Em>wm mm: LouUOU min mcoHme IwnmE mLP HHm >D Dmmjmcoo Em H .o.m mLoum .Hnnm .Hnnm .snnm .Hnaw nz pcmemumum Emmi to N to .02 mo N Lo .02 mHQEmm LUHLme mm fllu LmaLme mm pcmsmpmpm ucmsmumum m>HmUme #02 Dan UU>HmOme g mumumfljm CDHumUHUmE #303< mmmwuvc EoflajflHmeHO >UEmJUMLm m UHLmr u XHDZMlQ< APPENDIX 0 FREQUENCY DISTRIBUTION BELIEFS ABOUT IMPACT OF JOB ON EFFICACY 0F TREATMENT SUBSCALE 183 own. «.3 em.mm nod an.m m was mcoapmoaume >5 mcaxmu Iva; mmeLmuCH no: mmon Dan >2 0mm. m.m xu.mm mm em.m so was nmnatummta mpanmc xLo; on» onuou ou pHauHmmHD 5000 mm: pH vmm. o.v em.mm oou xm.m m mud pmmLm om p.cmLu: 00> >E k0 mMLJmnmLu nip ma ufimam; >E HOLDCOU UHjou H vow. 0.? Nm.mm mm Nm.m m HHS umHU >E zouHom 0p Lmemm mn UHjoz 9H mnofi DmmCmLU H uH 0mm. m.v an.hm mos Nm.H N NHH mcoHp ImuHUmE >E mxmp p.cm0 H PmLH 00m >E #3000 £035 om >LL0: H see. b.v Rm.mm hbH Nm.u N NHH mCOHp ImUHDME >E mxmp op LmHmmm 00 also; pa mnos nmmcmcu H tH .o.m mLoum .snnm .Hnam .Hnam .anam uz pcmempmpm 5mm: to N L0 .02 to N L0 .02 mHQEmm LmHLme mm pcmsmumpm m>amotmm poz nae LmHLme mm quEmumum Dm>HmUme mumumflfiw accsummth L0 >UmUHme w m mHDmP xHflzwml< :0 301 L0 UONQEH Pjofl< mLmHHUm COHPJDHLumHD >UC0300Lk APPENDIX H CORRELATION MATRIX: MODIFYING VARIABLES AND MAJOR STUDY VARIABLES USING PRODUCT MOMENT CORRELATION Correlation Matrix: Study Variables Using Product 184 Table 10 ModiFying Variables and Major Moment Correlation Belier Belier About About Belier Impact Commitment About oF Job on to Commitment EFFicacy oF Medications to Diet Treatment Age .0591 .2330** .0459 Sex .0590 .0572 .1549 Race .0094 .0459 .1340 Marital Status .0973 -.0557 -.0802 Living Arrangement -.O204 .1341 .0824 Educational Status .2253** .0031 .1285 Work Status -.1083 .0032 -.O4l2 Income .1209 .0595 .0390 Duration oF Diagnosed Hypertension -.0905 -.1232 -.O458 Systolic Blood Pressure .1710* -.0221 .2024* Diastolic Blood Pressure -.D20l .1225 .0225 *signiFicant at the .05 level **signiFicant at the .01 level LIST OF REFERENCES LIST OF REFERENCES Alderman, M. 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