MSU RETURNING MATERIALS: Place in book drop to LIBRARjES remove this checkout from “ your record. FINE_S_ will be charged if book is returned after the date stamped beIow. Mxmwfl‘. J.-- 700 $1 @2292; THE RELATIONSHIP OF KNOWLEDGE AND PERCEIVED BENEFITS TO COMPLIANCE WITH DIET AND BLOOD PRESSURE By Carolyn E. Roe, R.N., C. A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of MASTER OF SCIENCE College of Nursing 1986 deterni to com; diet cc collecI EXperiz therap. Weight m8dica ABSTRACT THE RELATIONSHIP OF KNOWLEDGE AND PERCEIVED BENEFITS TO COMPLIANCE WITH DIET AND BLOOD PRESSURE By Carolyn E. Roe, R.N., C. The purpose of this retrospective and descriptive study was to determine the relationship of knowledge and perceived benefits of diet to compliance with diet and to each other, and the relationship of diet compliance to improvement in blood pressure. Data utilized were collected among 67 hypertensive clients who participated in an experimental nursing intervention to foster compliance with therapeutic regimens and who were prescribed a low sodium and/or weight loss diet. Interviews, self-administered questionnaires, and medical record audits were the methods used to obtain data. Data were analyzed using descriptive statistics, product moment correlations, and t-tests. A significant finding was a positive relationship between perceived benefits of diet and compliance with diet. There was no relationship between knowledge and compliance nor knowledge and perceived benefits. Although compliance with diet significantly declined from intake to termination of the study, blood pressure significantly improved. Improved blood pressure was significantly related to medication compliance, examined as an extraneous variable. Nursing interventions intended to foster compliance with diet among hypertensives can consider these findings in a plan of care. Copyright by CAROLYN E. ROE 1987 guidance Quality her asz JOnes f( I c enCOurai maderst. Mo 10:18 am have be. of know La: me thto; Harold ; SUppOrt: ACKNOWLEDGEMENTS Sincere thanks and appreciation are extended to Barbara Given, R.N., Ph.D. and Charles W. Given, Ph.D. for the use of their data that made this study possible, and for their continuous assistance. Without their help this study would not have been possible. I would also like to thank the other two members of my committee, Carol Garlinghouse, R.N., MSN, and Brigid Warren, R.N., MSN, for their guidance throughout the study. Their feedback improved upon the quality of the study. Thanks are also extended to Andrea Bostrum for her assistance early in the study. I am also most grateful to Carole Jones for her outstanding typing and editing abilities. I owe a great debt to Judi Daniels, without whose support and encouragement completion would have been more difficult. Her understanding was invaluable. Most special appreciation is extended to Brian Coyle, who worked long and hard to assist me. There is no doubt this study would not have been completed without him. His willingness to share his wealth of knowledge was invaluable. Lastly, I owe the greatest thanks to my family for standing by me throughout the process of completing this study. To my husband Harold and my son Jason, thank you for being understanding, supportive and, most of all, patient. iv "-~ A 5.1:; \.' us: or F1 CEAPTER r4 r4 II. TABLE OF CONTENTS LIST OF TABLES . . . . . . . . . . . LIST OF CHAPTER I. II. III. FIGURES O O O O O O O O O 0 THE PROBLEM . . . . . . . Introduction and Background Purpose of the Study . . . Problem Statement . . . . Definition of the Variables Knowledge . . . . . . Perception . . . . . Perceived Benefits of Compliance . . . . . Blood Pressure . . . Assumptions . . . . . . . Limitations . . . . . . . Overview of Chapters . . . CONCEPTUAL FRAMEWORK . . . Overview . . . . . . . . . Treatment of Hyertension . The Health Belief Model . Knowledge . . . . . . . . Perceived Benefits . . . . Compliance . . . . . . . . Compliance and Improved Blood Pressure Nursing Theory . . . . . . Nursing Intervention . . . Summary . . . . . . . . . REVIEW OF THE LITERATURE . overv1ew C O O O O O O O I The Health Belief Model . Knowledge and Compliance . ImplicatiOns of the Review Perceived Benefits and Compliance Implications of the Review Dietary Compliance . . . . . . . . Implications of the Review viii ix 17 17 17 23 27 33 34 35 37 42 45 47 47 47 49 59 60 63 64 72 CiAPTER I! r1. CHAPTER Iv. VI. The Relationship of the Low Sodium and Weight Loss Diets to Blood Pressure . . . . . . . . . . . . Sodium Restriction and Blood Pressure . . . . Weight and Blood Pressure . . . . . . . . . . Implications of the Review . . . . . . . . . Measuring Dietary Compliance . . . . . . . . . . . Implications of the Review . . . . . . . . . Nursing Intervention . . . . . . . . . . . . . . . Summary . . . . . . . . . . . . . . . . . . . . . METHODOLOGY AND PROCEDURES . . . . . . . . . . . . Overview . . . . . . . . . . . . . . . . . . . . . Research Questions . . . . . . . . . . . . . . . . Population . . . . . . . . . . . . . . . . . . . . Sample . . . . . . . . . . . . . . . . . . . . . . Experimental and Control Groups . . . . . . . . . Operationalization of the Study Variables . . . . Knowledge . . . . . . . . . . . . . . . . . . Benefits . . . . . . . . . . . . . . . . . . Compliance . . . . . . . . . . . . . . . . . Blood Pressure Improvement . . . . . . . . . Extraneous Variables . . . . . . . . . . . . Development of Instruments . . . . . . . . . . . . Scoring . . . . . . . . . . . . . . . . . . . Validity . . . . . . . . . . . . . . . . . . Reliability . . . . . . . . . . . . . . . . . Data Collection Procedures . . . . . . . . . . . . Human Subjects Protection . . . . . . . . . . . . Statistical Analysis of Data . . . . . . . . . . . Summary . . . . . . . . . . . . . . . . . . . . . DATA PRESENTATION AND ANALYSIS . . . . . . . . . . Overview . . . . . . . . . . . . . . . . . . . . . Sample Characteristics . . . . . . . . . . . . . . Sociodemographic Variables . . . . . . . . . . . . Extraneous Variables . . . . . . . . . . . . . . . Research Questions . . . . . . . . . . . . . . . . Reliability of Instruments . . . . . . . Understanding High Blood Pressure (Diet) . . Perceived Benefits . . . . . . . . . . . . . Data Presentation . . . . . . . . . . . . . . . . Other Findings . . . . . . . . . . . . . . . . . . Summary . . . . . . . . . . . . . . . . . . . . . SUMMARY AND CONCLUSIONS . . . . . . . . . . . . . oveniew O I O O O O O O O O O O O O O I O O O O O Sociodemographic Characteristics of the Sample . . Extraneous Variables . . . . . . . . . . . . . . . vi 73 74 77 79 80 82 83 86 87 87 87 88 89 90 94 94 94 95 96 96 96 98 99 100 101 104 105 106 108 108 108 109 112 113 114 114 117 118 127 132 134 134 134 142 v.9,” QDE‘N .L: APPENDICES A O LETTER 0 O O O O O 0 O O O O O O O 0 O O O O O O O O 0 17 S B 0 CONSENT FORM 0 O O O O O O O O O O O I O O C O O O O O l 76 C s SOCIO’DEMOGRAPHIC s e s e e s e e o s e s e e e e s o 17 7 UNDERSTANDING HIGH BLOOD PRESSURE (DIET) . . . . . . . 179 BELIEFS ABOUT HIGH BLOOD PRESSURE . . . . . . . . . . 181 Efficacy of Treatment . . . . . . . . . . . . . . 181 Benefits of Diet . . . . . . . . . . . . . . . . 182 Barriers to Following Diet . . . . . . . . . . . 183 COMMITMENT TO DIET . . . . . . . . . . . . . . . . . . 184 HYPERTENSION CLIENT INTERVIEW . . . . . . . . . . . . 185 D O NURS ING CARE PLAN 0 I O O O O O O O O O I O O I O O O 1 8 7 REFERWCES O O O O O O O O O O O O O O O O O O O O O O O O O O O 1 9 0 vii {a (a D C 5.7 HIE-r TABLE 1.1 2.1 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 5.9 LIST OF TABLES Classification of Blood Pressure . . . . . . . . . . . Stepped-Care Approach to Drug Therapy . . . . . . . . Distribution of Subjects by Sociodemographic Variables of Sex, Age, and Race . . . . . . . . . . . . . . . . Distribution of Subjects by Marital Status, Income, Education, and Duration of Hypertension . . . . . . . Mean Scores and Reliability Coefficients for the Scales Understanding High Blood Pressure (Diet). Commitment to Diet, and the Subscales Beliefs About High Blood Pressure . . . . . . . . . . . . . . . . . T-Test for the Significance of Mean Differences in Scores for the Instruments Understanding High Blood Pressure (Diet), Commitment to Diet, and the Subscale Efficacy Treatment . . . . . . . . . . . . . T-Test for the Significance of Mean Differences in Diet Compliance and Blood Pressure . . . . . . . . . . The Correlation Between Knowledge Scores, Perceived Benefits of Diet Scores (Commitment to Diet), Efficacy of Treatment Scores, and Compliance with Diet Scores at Intake . . . . . . . . . . . . . . . . . . . . . The Correlation Between Knowledge Scores, Perceived Benefits of Diet Scores (Commitment to Diet), Efficacy of Treatment Scores, and Compliance with Diet Scores at Termination . . . . . . . . . . . . . . . . . . . . Correlations Between Changes in Systolic and Diastolic Blood Pressure and Weight and Compliance with Diet and Medications and Change in Diet Compliance . . . . . . . . . . . . . . . . . . . . . . The Relationship of the Sociodemographic Variables to Knowledge about, Perceived Benefits of, and Compliance with Diet . . . . . . . . . . . . . . . . viii 13 19 110 111 116 119 121 124 126 129 130 q 138 C11 LIST OF FIGURES FIGURE 1. The Health Belief Model . . . . 2. The Health Belief Model Modified by B. Given 3. Adaptation of the Modified Given Model to Study Variables . . . . . . . . . . . . 4. A Process of Human Interaction 5. Combined Model for Care of the Hypertensive Client 6. Client Identification, Participation, and Assignment (Experimental Phase) . . . . . . . . . . 7. Nurse/Client Intervention . . . 8. Combined Model for Care of Hypertensive Clients to Foster Participation in the Dietary Regimen . . . . ix 28 29 30 41 43 92 93 158 CHAPTER I The Problem Introduction and Background Cardiovascular disease is the number one cause of death in the United States (American Heart Association, 1985) and the leading cause of cardiac disease is hypertension (American Heart Association, 1985; Marcinek, 1980). It is estimated that more than 65 million Americans have high blood pressure (The Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure, JNC, 1984). According to Kaplan (1983), hypertension is responsible for cardiovascular disease that kills one million Americans each year and is probably the greatest public health problem of the times (Kochar, 1981). Hypertension is the number one cause of morbidity and mortality from stroke and contributes significantly to kidney failure (American Heart Association, 1985; Andreoli, 1981; Barker, Feldt, and Fiebel, 1983; Borhani, 1981; Fink, 1981; Haines and Ward, 1981; Marcinek, 1980; Smeltzer, 1980). There are 58 million Americans estimated to be at risk for morbidity and mortality associated with high blood pressure (Subcommittee on Definition and Prevalence of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure, 1984). It costs billions of health care dollars annually (Fink, 1981) and billions of dollars to the American economy in lost productivity (Hoyt, 1978). Hypertension is the most common reason for physician office visits in the United States (Kaplan, 1984), and it is the lead research. control a Pressure 2 the leading preventable cause of death in the world today (Kaplan, 1978). The goal of treatment for high blood pressure is to prevent morbidity and mortality from hypertension and can be accomplished through compliance with the recommendations of the Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure (JNC, 1980, 1984). Among these recommendations are dietary alterations to control weight and restrict salt intake. Several researchers and experts have presented convincing evidence that weight control and sodium restriction contributes significantly to blood pressure control (Anderson, Fagerberg, and Hedner, 1984; Berchtold, Jorgens, Finke, and Berger, M., 1981; Cunningham and Hill, 1982; Dustan, 1983; Dyer et a1., 1982; Egam and Julius, 1983; Eliahou, 1981; Fries, 1976; Frolich, 1982; Gillum et a1., 1983; Shils and Goodhart, 1980; Guthrie, 1983; Havlik, Hubert, Fabsitz, and Manning, 1983; Holbrook, Cottrell, and Smith, 1984; Hovell, 1982; Hunt, 1983; Kaplan, 1983, 1985; JNC, 1982, 1984; Langford, 1982; Margie and Hunt, 1981; McCarron, Stanton, and Henry, 1983; Moser, 1982; Reisen, Abel, and Modan, 1978; Schweiker, 1983; Sims and Berchtold, 1982; Stamler, Stamler, Reidlinger, Algera, and Roberts, 1978; Stamler, et a1., 1980; Tobian, 1978; Tuck, Sowers, Dornfeld, Kledzik, and Maxwell, 1981; Working Group on Critical Behaviors in Dietary Management of High Blood Pressure, 1983; Young and Landsburg, 1982). According to several experts, dietery treatment for hypertension should be vigorously pursued for clients who are at low risk for other atherosclerotic factors and when diastolic pressure is less than 100 mm Hg since drug treatment may expose clients to unnecessary : .'V:J -mdl‘ ALL. patient Rosenstoci associate 3 cardiovascular risks (Kaplan, 1983; Perez-Stable, 1983; and Ziegler, 1984). If diet is to be effective in the treatment of hypertension, individuals must comply with the dietary prescription, and gaining patient compliance to dietary restrictions is often difficult (Glanz, 1980; Haynes, Sackett, and Tayler, 1980; Kirscht and Rosenstock, 1977; Silverberg, 1980). Dietary noncompliance is generally even higher than noncompliance with medication regimens (Glanz, 1980; Kirscht and Rosenstock, 1977). One explanation for this may be that both are associated with high degrees of noncompliance (Becker, 1979; Glanz, 1980). Although there is generally a lack of sufficient data about dietary compliance and the data available is of poor quality, there is data from studies that indicates dietary compliance for cardiovascular disease ranges from 13-76 percent (Glanz, 1980). Past researchers have explored several reasons for failure to comply with health regimens (Andreoli, 1981; Daniels and Kochar, 1979; Given, Given, and Simoni, 1978; Given and Given, 1983; Glanz, Kirscht, and Rosenstock, 1981; Haynes et a1., 1980; Hershey, Morton, Braithwaite, and Reichgott, 1980; Hulka, 1979; Kirscht and Rosenstock, 1977; Loustau, 1979; Morisky et al., 1980; Nelson, Stason, Neutra, and Solomon, 1978; Powers and Wooldridge, 1982; Rosenstock, 1975; Swain and Steckel, 1981). The health belief model has been used as a framework for many of these studies. According to the health belief model, an individual's likelihood to take action or comply with a therapeutic regimen, including diet, depends on whether or not there is: 1) perceived susceptibility to 2) per: the per There a 4 the disease and the disease is perceived as posing a threat; 2) perceived benefits to following the treatment plan that outweigh the perceived barriers (financial, emotional, and social costs). There are a number of factors included in the model which can modify these perceptions. One such factor is knowledge. Although the health belief model has been used to explore reasons for noncompliance with treatment regimens, there is little research specifically related to dietary noncompliance (Glanz, 1981). Research in the area of dietary compliance is therefore critical. Diet is becoming increasingly important in the treatment of hypertension (Kaplan, 1983, 1985; Gillum et a1., 1983; Werking Group on Critical Patient Behaviors in the Dietary Management of High Blood Pressure, 1982). Dietary adherence can contribute to blood pressure control and therefore help decrease the high levels of hypertension associated with morbidity and mortality. Compliance with diet can decrease the need for medication to control blood pressure and therefore decrease the associated iatrogenic effects (Kaplan, 1983; Gillum, 1983; Perez-Stable, 1983; Zeigler, 1984). Through blood pressure control, there can be a decrease in health care costs associated with the complications of hypertension (Connelly, 1984). Nursing has a major role in contributing to hypertension control. A role for nursing in hypertensive care was established in 1975 by the National High Blood Pressure Education Program in cooperation with the American Nurses' Association and the National League for Nursing. Six goals were developed and include: 1) promoting client/family understanding of the disease and the prescribed treatment; 2) facilitating successful adjustment to the diagnosis and treatment; side effe hypertens ACC: 'nowledgq knowledg. CO: illnesS (America noncOmpl involves apprOpri conditio PrOmOte and the PESearch 5 3) facilitating assumption of responsibility by the client for self-care within psychological and physical capabilities; 4) achieving blood pressure control consistent with the medical goal; 5) limiting side effects from medications; and 6) limiting end organ damage due to hypertension or its treatment (Giblin 1978; Grim and Grim, 1981). Accomplishing these goals requires that nurses are not only knowledgeable about hypertension and its treatment, but also knowledgeable about strategies that facilitate client involvement and compliance with the treatment regimen, including the dietary prescription. Nursing should assist the client to develop the necessary skills to adopt the role of complier (Dracup and Meleis, 1981). Compliance and, conversely, noncompliance are human responses to illness and it is nursings' role to diagnose and treat such responses (American Nurses' Association, 1980). Gordon (1984) identifies noncompliance as a nursing diagnosis. Treatment of this diagnosis involves understanding reasons for noncompliance and developing appropriate strategies to ameliorate, improve, or correct the condition in order to prevent illness (such as end organ damage) and promote health (American Nurses' Association, 1980). Nursing theory and the health belief model can provide a conceptual framework for research involving dietary compliance and contribute to the development of the necessary treatment strategies. Facilitating dietary compliance will contribute to achievement of the blood pressure goal and so contribute to limiting end organ damage associated with high blood pressure. Nursing intervention that facilitates compliance with a dietary regimen will not only, thererc. oorbidit the need IEIIGVQ t aPPFOprig Approprié faCtOrs ‘ a 150 “Eec 6 therefore, contribute to a decrease in hypertension mortality and morbidity, but also contribute to cost containment since the complicating conditions of prolonged hypertension require medical intervention. Since weight loss and sodium restriction can decrease blood pressure, strategies that promote compliance with these prescriptions can also lessen the need for medications and so the iatrogenic effects of treatment (Andreoli, 1981; Connelly, 1984; Kaplan, 1983, 1985). Even if medications are used, it does not relieve the client of the need to follow the prescribed diet (Kaplan, 1985), nor does it relieve the health care provider of the responsibility for developing appropriate knowledge and perceptions to promote adherence. Appropriate strategies can be developed from research that explores factors that influence compliance with dietary regimens. Research is also needed to determine if there is a relationship between dietary adherence and blood pressure control since such data contributes to the scientific rationale for nursing intervention. Data from this study will be used to examine the changes that occur in two aspects of the health belief model among hypertensive clients who participated in a nursing intervention: knowledge about diet and perceived benefit of diet. Data from the study will also be used to examine the relationship of compliance with diet to blood pressure improvement. Purpose of the Study The purpose of this study is to determine the relationship between and among selected characteristics and dietary compliance in individuals with hypertension who participated in an experimental nursing intervention. In particular, knowledge about diet and perceiv a major knowled engage CODCer: t0 plan Support health- 7 perceived benefits of therapy, specifically diet, will be examined as they relate to compliance with diet prescriptions. Whether or not compliance with diet contributes to blood pressure improvement will also be explored. An individual's perception of treatment benefits is a major component of the health belief model that is modified by knowledge. Both influence the likelihood that an individual will engage in health related behaviors. The data obtained can be used to contribute to nursing knowledge concerning factors that influence compliance and, therefore, can help to plan client care. The research can also contribute to empirical support of the health belief model as a framework for promoting health-related behaviors. Problem Statement The specific problems are: 1. How does knowledge about diet and perceived benefits of diet relate to compliance with diet before and after a nursing intervention? Specifically: a) is there a relationship between client knowledge about diet and compliance with diet before and after a nursing intervention? b) is there a relationship between client perceived benefits of diet and compliance with diet before and after a nursing intervention? c) is there a relationship between client knowledge about diet and perceived benefits of diet before and after a ‘nursing intervention? 2. How does compliance with diet relate to blood pressure levels IDefOre and after a nursing intervention? Research is needed to answer these questions. The data obtained Vr111.be utilized to provide information concerning the characteristics (I) 't.) '1 J H t? t( '41". 8 of hypertensive individuals that are related to compliance with diet prescriptions. Data will be used to answer questions concerning the relationship of knowledge to compliance, perceived benefits to compliance, and the relationship of knowledge to perceptions of benefits, specifically concerning diet. The data will also be used to explore the relationship of dietary compliance to blood pressure levels. The information can be used to facilitate appropriate provider-client interaction to promote compliance behaviors in future clients and contribute to the National High Blood Pressure Education Program's (NHBPEP, 1972) and the United States Public Health Service's (1983) goal to control hypertension and therefore decrease associated mortality and morbidity. The knowledge can be used to contribute to information concerning the defining characteristics of compliance which is a human response to illness amenable through appropriate nursing intervention (American Nurse's Association, 1980). The data can also be used to contribute to the development of strategies to treat noncompliance, an acceptable nursing diagnosis (Gordon, 1984). The research can also be used to provide information to improve understanding of health related behaviors and factors that contribute to client participation in therapeutic regimens. Since the health belief model is a framework that shows how knowledge and perceptions are related to health actions of individuals, the data from the study vrill provide empirical support for activities directed toward knowledge, perceptions and beliefs thought to influence the likelihood of compliance . Ln 9 Since resource conservation is becoming critical in health care, data concerning factors that contribute to client compliance can be utilized to determine priorities for provider activities. For example, if improving knowledge about diet contributes to compliance, then it is worthwhile to invest health care dollars and provider time in dietary educational efforts. Knowledge concerning factors that promote compliance with diet as a treatment regimen can decrease health care costs in general by decreasing the use of the health care system from iatrogenic effects of medications used to treat hypertension (Kaplan, 1983, 1985). Control of hypertension, whether diet is used as a sole treatment or as an adjunct to medications, decreases the costly care that would be required due to damage to the kidneys, brain, heart and eyes from sustained blood pressure elevations (Andreoli, 1984; Connelly, 1984). The data utilized in the study to answer the research questions were collected as part of a federally funded research project, Patient Contributions to Care: Link Process to Outcome (SROINU00662, 1982), B. Given and C. W. Given, co-principal investigators. Definition of Variables The variables in this study are knowledge about diet, perceived benefits of diet, compliance with the dietary prescription, and blood pressure. Knowledge Defined Knowledge is defined as the cognitive resources the client has to ciescribe hypertension and the therapeutic regimen. Knowledge for this ggtudy includes factual information that clients recall and report when gyestioned about the dietary treatment plan (Given and Given, 1982, C) I >11 10 p. 26). This study is limited to information clients have and how they use it and will not address how such information is obtained. The Joint National Committee (1984) states there is evidence from recent research that health education along with frequent reinforcement of the educational messages increases long term adherence, blood pressure control and therefore reduces mortality. Given et al. (1978) found that knowledge was positively associated with perceived benefits from medications and that both influenced compliance. Knowledge showed more correlation to compliance at the beginning of treatment whereas perceived benefit showed more correlation later in treatment (Given et a1., 1978). Given and Given (1983) state that knowledge can become the basis for developing appropriate beliefs concerning benefits to treatment. Perception Defined Perception is the individual's views of reality that include the awareness of persons, objects and events (King, 1981, p. 20). Individuals differ in their views of reality based on past experience, values, self concept and their sensory and intellectual capabilities. Perceptions are influenced by context and processes. They are subjective, universally influenced by current interests, needs and goals, and can only be observed in terms of transactions with the environment (King, 1981). Based on a review of the literature, nursing theorist King (1981, p. 4) defines perception as a process of human transaction with the environment that gives meaning to one's experience, image of reality .and impacts behavior. The process of perception involves organizing, 11 interpreting and transforming information from sensory input and memory (King, 1981). Perceived Benefits of Diet Perceptions of benefits to diet for this study are defined as the specific beliefs and attitudes the client has concerning following the diet, specifically a weight loss and/or sodium restricted diet. Benefits include how following the diet would contribute to hypertension control and prevent complications that would impair future role performance (Given and Given, 1982, p. 27). Nelson et a1. (1978) found that perceived benefit of the treatment regimen for hypertension contributed positively to blood pressure control. Cummings, Becker, Kirscht, and Levin (1982) found that beliefs concerning efficacy of behavior and barriers to behavior were consistent predictors of adherence to medical regimens in hemodialysis patients which require dietary management. Black (1984) states that demonstrating to the client the benefits of following the treatment by showing clients their blood pressure reading increases compliance. Compliance Compliance is the extent to which to client follows the therapeutic recommendations of health care providers (Daniels and Kochar, 1980; Dracup and Meleis, 1982; Given and Given, 1982, p. 28). For this study, compliance is based on the clients report of following a dietary prescription for weight loss and/or sodium restriction. A five point scale ranging from all of the time to none of the time is the measure to elicit stated compliance with the dietary prescription, specifically sodium and/or calorie restriction. 12 Blood Pressure Blood pressure is defined as the actual measurement obtained using two or more readings at intake and termination of the nursing intervention. The World Health Organization (1981) defines hypertension as synonomous with essential hypertension and as such, it is designated by physiological and anatomical changes which ultimately lead to an elevation of diastolic and systolic pressure, changes in the vascular bed and impairment of involved tissue. The report of the JNC (1984) states that "hypertension in adults is confirmed when the average of two or more diastolic blood pressures on at least two visits is 90mm Hg or higher, or when the average of multiple systolic blood pressures on two or more subsequent visits is consistently greater than 140 mm Hg" (p. 1045). Table 1.1 represents the classification of blood pressure according to the JNC. Hypertension is operationalized in this study as a systolic pressure greater than 140 mm Hg. systolic and/or a diastolic pressure greater than 90 mm Hg. on two occasions at least two months apart, which is consistent with the standard of practice (Chobanian, 1982; Given and Given, 1982, p. 61). Improved blood pressure is defined in this study as a statistically significant decrease in systolic and/or diastolic blood pressure from intake to termination of the nursing intervention. Ifl 13 Table 1.1 Classification of Blood Pressure Range, mm Hg Category Diastolic Less than 85 Normal B/P 85-89 High normal B/P 90-104 Mild hypertension 105-114 Moderate hypertension 115 Severe hypertension Systolic, when diastolic is 90 or less Less than 140 Normal B/P 140-159 Borderline isolated systolic hypertension 160 Isolated systolic hypertension Source: Joint National Committee on Detection, Evaluation, and fPreatment of High Blood Pressure (1984). 14 Assumptions The following assumptions are made in this research: 1. Compliance with a therapeutic regimen, including diet, is a health behavior that will improve present and future health status. 2. Health-related perceptions influence compliance with diet and other health-related behaviors. 3. The concepts of knowledge about diet, perceived benefits of diet, and compliance as defined in this study are real and measurable phenomena. 4. Measurement of stated compliance is a reliable method of measuring compliance to therapeutic regimens, including diet, in hypertensive clients. 5. Client behaviors can impact and control chronic disease. 6. The testing instruments are sensitive to the concepts of 'knowledge about diet, perceived benefits of diet, and stated compliance with diet. 7. The sample is representative of hypertensive clients :receiving care in primary care sites. 8. Compliance with diet has an additive effect on blood pressure control. Limitations This research has the following limitations: 1. Subjects who agreed to participate in this study may be Chifferent from those who refused. Therefore, it is possible that the ffilndings are not representative of all hypertensive clients in primary care settings . 15 2. The points in time at which data were collected may not be representative of the usual perceptions and behavior of the sample. Other points in time may be more typical. 3. Individual differences in perceptions of answer choice may have affected responses. 4. The need to express a socially desirable response may have affected the responses of individuals. 5. All possible factors affecting compliance with diet are not addressed in this study. Findings may be due, in actuality, to an interrelatedness of factors other than the ones identified. Examples of such factors which are not included in this study are: other aspects of the health belief model, provider-client relationship, developmental stages and social support. 6. This study is limited to those clients who participated in a inursing intervention and were prescribed a low sodium and/or weight Iloss diet so results cannot be generalized to other client groups. Overview of Chapters Presentation of this study is organized into six chapters. Imnformation in Chapter I is the introduction, the purpose of the research, the problem statement and research questions, the background fo'the problem, definitions of variables, and the assumptions and limitations. In Chapter II, the concepts and relevant theory are 1t1tegrated into a conceptual framework that is the basis for the Study. A literature review is presented in Chapter III which links tilis research with the work and ideas of others concerned with l'lylaertension and compliance with treatment. A presentation of the ulethods of research used to conduct the study is found in Chapter IV. 16 Included are the research design, instrumentation, procedures and human rights protection. Data and analyses are presented in Chapter V. A summary and discussion of findings, implications for nursing and education, and recommendations for future research are presented in Chapter VI. (V U) CHAPTER II Conceptual Framework Overview This chapter includes a discussion of the treatment of hypertension, the health belief model, and nursing theory as delineated by King (1981). The concepts of knowledge, perceived benefits, compliance and their relationship to blood pressure are presented within the context of the health belief model and nursing theory. The concepts are integrated for application of nursing intervention relative to hypertensive clients. The purpose of this study is to examine the relationship of these variables within a conceptual framework to determine if the variables of knowledge about the dietary regimen and perceived benefits of diet significantly influence the hypertensive client's compliance with the dietary prescription (specifically, sodium and/or calorie restriction) and if compliance with the diet prescription influences blood pressure levels. Treatment of Hypertension Treatment of hypertension results in a reduction in morbidity and mortality. Borhani (1981, 1982) and Kochar (1981) collected data from a Veteran's Administration study and the results demonstrated that blood pressure control reduces the incidence of CHF, MI, and CVA. The Framingham Study that involved over 5000 male and female participants had results that provide evidence that hypertension is the most powerful contributor to CVA and that the atherosclerotic process leading to both coronary artery disease and cerebral 17 18 thromboses is related to blood pressure levels. There was also evidence from the findings that controlling blood pressure decreases morbidity and mortality to approximately that of normotensive individuals (Dawber, 1980; Kannel, 1982). The Hypertension Detection and Follow-up Program (1982) has conducted yearly studies of mortality on over 10,000 participants with diastolic pressures greater than 90mm Hg. Among the findings from this group is that treatment decreases the overall mortality associated with hypertension even in those clients with mild levels of high blood pressure. It is, therefore, the recommendation of the Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure (1980, 1984) that blood pressure be reduced to normotensive levels or as near normotensive as possible. The JNC supports the use of pharmacological therapy using the stepped care approach (Table 2.1) in those clients whose diastolic blood pressure is consistently above 95 mm Hg. and for those clients who are at high risk for lcardiovascular and cerebrovascular morbidity and mortality such as clients with target organ damage or diabetes mellitus. The JNC (1984) further recommends that nonpharmacological treatment be utilized as both definitive therapy and as an adjunct to pharmacological therapy to control blood pressure. Nonpharmacological therapy is becoming especially important as definitive treatment for clients with mild hypertension (diastolic Pressures of 90-104 mm Hg.) and for clients with isolated systolic hYpertension whose pressures are less than 160 mm Hg. Clients who Table 2.1 19 Stepped Care Approach to Drug Therapy Step Drug Regimen Begin with less than a full dose of either a thiazide-type diuretic or a B-blocker, proceed to full dose if necessary and desirable. If BP control is not achieved, either add a small dose of an adrenergic-inhibiting agent or a small dose of thiazide-type diuretic; proceed to full dose if and desirable; additional substitutions may be made at this point. If BP control is not achieved add a vasodilator, hydralazine hydrochloride, or minoxidil for resistant cases. If BP control is not achieved, add guanethidine monosulfate. Source: Joint National Committee on Detection, Evaluation & Treatment of High Blood Pressure (1984). 20 participated in the Multiple Risk Factor Intervention Trial and whose diastolic pressures were between 90-94 mm Hg who were treated with the stepped care approach actually had more deaths than clients whose blood pressures decreased without treatment (Grim, Cohen, Smith Faber—Gerad, & Neation, 1985; Kaplan, 1983; Moser, 1984). Perez-Stable (1983) states that only clients with diastolic pressures between 90-100 mm Hg whose risk for atherosclerosis can be decreased by lowering blood pressure should be considered candidates for drug therapy. McAlister (1983) reviewed the findings from the Hypertension Detection and Follow-up Program and several other studies and states these trials fail to show significant reproducible benefits from treating uncomplicated mild hypertension. The Medical Research Council Working Party (1985) found that active treatment of mild hypertension had no overall effect on mortality and that although there was some benefit in men, treatment had an adverse effect on women, but treatment was associated with a reduction in the incidence (If CVA. Kaplan (1984) believes that the chemical changes caused by the pharmacological agents used to treat hypertension may actually precipitate coronary heart disease since hypokalemia, hypercholesterolemia, and glucose intolerance occur with drug use. Flamenbaum (1983), in a review of several studies, reported several consequences associated with antihypertensive agents including altered lipid metabolism, hypokalemia, hyperglycemia, increased renin activity, metabolic alkalosis or acidosis, and an elevation in uric acid levels. 21 As a result of the controversial evidence regarding treatment of mild hypertension, The JNC (1984) and the World Health Organization's International Society of Hypertension (WHO/ISH, 1983) recommend aggressive nonpharmacological treatment for those clients with a diastolic pressure of 90-94 mm Hg who are otherwise at low risk while blood pressure is carefully monitored. Kaplan (1985) supports The JNC and WHO/ISH recommendations and states there is a need for better controlled, long-term studies on efficacy of drug treatment for mild hypertension. Kaplan (1985) further recommends that nonpharmacological treatment be included in the management of all hypertensives. The nonpharmacological treatment recommended by The JNC (1984) includes: weight reduction, sodium restriction, alcohol restriction, dietary fat restriction, cessation of smoking, exercise, and stress reduction. Reduction of weight in overweight hypertensives and reducing dietary sodium are the two consistent recommendations in the literature to contribute to hypertension control (Gillum et a1., 1983; Guthrie, 1983; Hodges and Rebello, 1985; Kaplan, 1984, 1985; National High Blood Pressure Education Program, 1979; The JNC, 1984). Moore (1982) adds nonpharmacological treatment to the stepped care approach by stating that step 1A should be the foundation of all hypertension ‘management and should include client education, a low sodium diet, weight reduction, tobacco cessation, exercise, and stress management. Nonpharmacological treatment, whether as the sole treatment for a client with hypertension, or as an adjunct to pharmacological treatment, requires alteration in behavior and requires client adherence to be successful. The critical behaviors for the 22 hypertensive client are making the decision to control blood pressure and to adhere to diet and professional attitudes that reflect a positive approach and sensitivity to racial, cultural and individual differences that can positively influence adherence (The JNC, 1984). Nurses can facilitate adherence, specifically to diet, by assessing clients for adherence problems including readiness to control blood pressure and to learn related behaviors, suggesting solutions to adherence problems, educating clients, and monitoring progress (The JNC, 1984). Nursing is especially effective in meeting health care needs of hypertensive clients through use of the nursing process to assist clients to modify life styles and the environment to cope with hypertension and prevent complications (Grim and Grim, 1981). Dietary prescriptions for weight loss and sodium restriction require lifestyle and environmental changes that can be enhanced by appropriate nursing strategies. The Report of the Working Group on Critical Patient Behaviors in the Dietary Management of High Blood Pressure (Working Group, 1982) includes ten steps to facilitate permanent changes in eating habits to control blood pressure. The client must: 1) acknowledge the disease; 2) consider diet as a sole or adjunctive method to help control blood pressure; 3) participate in assessing current dietary patterns; 4) acknowledge that diet changes must be long term; 5) participate in developing strategies and dietary goals; 6) assist in planning dietary changes; 7) make the necessary changes; 8) participate in the assessment of success of each change; 9) participate in the assessment (If blood pressure goal attainment; and 10) participate in developing a plan for maintaining dietary changes as goals are reached. The role 23 of the professional is to facilitate successful outcomes at each step in the dietary management program (Working Group, 1982). In summary, blood pressure control can occur using pharmacological and/or nonpharmacological measures either separately or together in a therapeutic regimen. Control, however, requires that the client follows the therapeutic regimen whether it involves a new behavior, such as pill taking, or an alteration in behaviors such as dietary modification. Facilitating successful outcomes requires that the nurse understand factors that increase the likelihood that the client will engage in the behaviors necessary for implementation of the regimen, including diet. The health belief model can be used as an explanation of factors that increase the likelihood that individuals will follow a recommended treatment plan and can be used to develop and provide a rationale for strategies to assist the hypertensive client in developing critical behaviors for blood pressure control, including those behaviors for dietary management outlined by the Working Group (1982). The Health Belief Model The health belief model as introduced in Chapter I is a psychological formulation originally developed to explain health-related behaviors. The model was first used as an attempt to explain why some individuals engage in preventive health behaviors at an individual decisionemaking level and others do not. The variables of the health belief model were drawn and adapted from social psychological theory developed by Lewin in 1948. Lewin's theory postulates that an individual exists in life spaces that are 24 composed of regions. These regions may have a positive valance, a negative valance, or be relatively neutral. If illness were represented in the life space, it would be in a region of negative valance which would then be expected to exert a force to move the individual away from that region, unless doing so would require that the individual enter a region of even greater negative valance. Another assumption of Lewin's theory is that the subjective world of the individual is what determines behavior rather than the objective environment. The theory is more concerned then, with the current subjective state of the individual rather than with history or experience (Maiman and Becker, 1974; Rosenstock, 1974). Since Lewin's early attempt to predict behavior when choices are made, other theories have evolved. Maiman and Becker (1974) call them models of motivation. Included are Tolman's model called performance behavior, Rotter's reinforcement or social learning model, Edward's risky-choice model, Atkinson's risk-taking model, and Feather's decision-making-under-certainty model. All five deal with an individual's perceived benefit compared to belief that an action will lead to desired outcomes. Rosenstock's model incorporates all five theories. The model "analyzes an individual's motivation to act as a function of the expectance of goal attainment in the area of health behavior" (Maiman and Becker, 1974; p. 21). According to the original health belief model (Rosenstock, 1960), in order for an individual to take action to avoid illness, the individual would need to believe: That they were personally susceptable to the disease; that the occurrence of the disease would have at least moderate severity on some aspect of their life; and that suscep 1 its se‘ such a< Accord: 25 taking a particular action would be beneficial by reducing their susceptibility to the disease or, if illness has occurred, by reducing its severity. The individual must also believe that the benefits of such action would be greater than perceived physical, social, or psychological barriers, such as cost, inconvenience, and discomfort. According to the health belief model then, even though an individual may be ready to take action, the likelihood of taking such action to reduce the threat of disease depends on beliefs about the probable . effectiveness of the action in reducing the threat and about the barriers that would be encountered if such action is taken (Rosenstock,1974). The health belief model also proposes that a cue to action (stimulus) must occur to trigger appropriate behavior. The cue might be internal, such as perception of bodily state, or external, such as illness of a family member or friend or exposure to mass media. There are also modifying factors in the model that influence behavior. The modifying factors include: demographic variables (age, sex, race, etc.); structural variables (knowledge, prior contact); and sociopsychological variables (personality, social class, peer and reference group pressure). The modifying factors and the cues both influence perceptions concerning susceptibility, severity, and threat of disease. The modifying factors also influence perceptions of benefits and barriers to taking action (Rosenstock, 1974). The health belief model has been utilized to examining preventive health behaviors: screening tests for tuberculosis, cervical cancer, rheumatic fever, and dental disease (Rosenstock, 1974). Pender (1982) modified the model in an attempt to synthesize available literature Pen (1 (I) '3 lsb mOd1 been aCti heal dire. (197‘ 26 concerning individual decision-making about engaging in health promoting behavior such as exercise. Although the original model and Pender's model are concerned with preventive and health promoting behavior, there have been a number of studies which have used one or more variables to predict client compliance with therapeutic regimens to treat chronic disease (Andreoli, 1981; Becker, Maiman, Kirscht, Hafeman, & Drachman, 1977; Cerkoney and Hart, 1980; Cummings, Becker, & Maile, 1982; Devon and Powers, 1984; Given and Given, 1982; Glanz, Kirscht, & Rosenstock, 1981; Green, Weinberger, Jerin, & Mamlin, 1982; Hershey et a1., 1980; Kirscht and Rosenstock, 1977; Morisky, Bowler, & Finlay, 1982; Taylor, 1979). The model presented in Figure 1 is modified frdm the original health belief model formulated in the 1950's by Hochbaum, Levanthal, Kegeles, and Rosenstock (Rosenstock, 1974). The same variables of perceived susceptibility, perceived severity, and benefits minus barriers are applied to chronic illness. The threat components of the model are perceived severity and susceptibility. The model assumption is that individuals will not take action unless the course of action is believed to be beneficial in reducing the threat and the perceived barriers do not outweigh the perceived benefits (Kasl, 1974). Motivation to take necessary action is an added concept in the modified model for application to chronic illness. Motivation has been operationalized as the state of readiness to take specific action. Psychological readiness can occur due to: concern about health matters in general; willingness to seek and accept medical direction; intention to comply; and positive health activities. Kasl (1974) adds that illness behavior takes place in the presence of 'YJ 27 symptoms which may themselves provide motivation for compliance. In the original model and in Pender's model (1982), health behavior takes place in the absence of disease or symptoms and so the intervention issues are educating individuals and finding the appropriate cues for action, rather than motivation. Given (1982) modified the health belief model in order to develop an intervention model for the management of chronic disease (Figure 2). The most significant alterations by Given are the inclusion of the client's decision not only to comply, but to assume responsibility for managing chronic disease, to take action necessary for disease management, and to improve health state. The model suggests that client involvement in all aspects of care is a major contributor to health outcomes. The model further suggests that client knowledge is a critical component that influences perceptions. The Given model (1982), taken from the health belief model, is a framework to examine the variables of this study which are the hypertensive client's knowledge about the prescribed dietary regimen and perceived benefits of following the diet as they relate to compliance with diet through modifying eating behaviors and so contribute to improved blood pressure. Figure 3 illustrates the interrelationship of the variables to be studied. Knowledge According to the model in Figure 3, knowledge about diet therapy for sodium restriction and/or weight loss influences perception of 'benefits of the diet. Perceived benefits and knowledge influence the cilient's decision to assume responsibility to modify eating behaviors, .sam_ .Hmmu new .saaa .nuaumm acne eouaaum Hosea Losses assume «as 28 a ouawum ransom OH onququ .mMHHH>HHu< mHAHHHmom «20HH<>HHOZ ”Auxdm 2H mmmzagn .MUH>Q< zuxuuua . ; .4Hnux mmaz uaaawmdummh .m:OHmz»m mmuzqqn mnH mo auazmzxouuu ”onHU< OH muau rHqu>Mm nw>Huummm shun muz<~aazoo .mmmzsaH map on “onaue mo noozuauaHa s yin, IF. . .u. pumaHnHammumam mmuzaaH oozommo no o am>~muaua — HuHmuzum I "Banana mmuzqqu mo quzhdumk OH NW. 14 monHmuumum A<=9H>HQZH mmmHmmHmummm HuHuumum t. . .fi] . .SUOmoxurmm mzoahmmumum A<=GH>anH . um¢OHu-------T HZNSUDDH e z 3.3 mmgz 28849— /| ZOHHU< HZMHHU a Hagan». 4‘ _ a zoEmuummmT Mudmommmn UCCC (one \ru‘ rest 39GB the c high. Press healtf CUrreI estab] deScrj calori as Ser preSSu: asked I regall dietary 42 NursingfIntervention The nursing diagnosis for the hypertensive client of noncompliance or potential noncompliance with diet is complex. Compliance means following the prescribed sodium and/or calorie restriction and engaging in the lifestyle adjustments that are necessary for following the regimen. The nurse can intervene in this process by using components of the health belief model with King's goal attainment theory and the nursing process. Using King's conceptual model, the hypertensive client and the nurse are mutual participants. Each brings to the nurse-client relationship perceptions, judgments, knowledge, skills and abilities. Each becomes part of the environmental experience of the other. At the onset of King's process of human interaction (Figure 5), the client may act by saying, "I've been told my blood pressure is too high." A reaction by the nurse occurs, "Tell me more about your blood pressure." The process continues with assessment of the client's health status. During assessment, baseline data is gathered. The client's current knowledge about dietagy treatment for‘hypertension can be established. Assessment criteria may include asking the client to describe current dietary practices, including current salt use and calorie consumption. Assessment may also involve objective data such as serum and urine sodium levels, height and weight as well as blood ‘pressure. If a diet has already been prescribed, the client can be aasked to name the prescribed diet, to provide a twenty-four hour recall of dietary intake, and to indicate appropriate foods for the dietary prescription from a list. 43 .udOfiHo o>wwcouuomhc ecu how Hones vocaoaou n seamen xuammmmm --zq~aaua min 223.8 onEHummm . _ . n ,F mauoxm . _ azmzm>omm=H qu>Hmome ..z Huu< .mmunz meammmmm cocoa oza moz<~umzoo oneaazmzmumzH quzzHmzmemuaw= euHmommm A ona<=u<>u " ¥L_12 The second screening of the potential participants in the study conducted by trained auditors and the principal investigators resulted in a sample of 156 hypertensives who met all the study criteria. Letters were sent to each of the eligible participants that described the purpose of the study, its potential benefits, the length of time and requirements for participation, and a disclaimer that refusal to participate would not jeopardize care they were currently receiving (See Appendix A). Subjects willing to participate were asked to return a postcard. A name and telephone number was also provided for those who might want additional information. Follow-up on all letters and postcards was done via telephone by an interviewer. During this time, the study was again described and questions answered. One hundred fifty-eight clients, aged 24 to 65, agreed to participate and completed an intake interview and were enrolled in the study. The final sample was 90 voluntary and not randomly selected so results of the study can only be generalized to hypertensive clients who possess characteristics similar to those of this sample. Experimental and Control Group At the conclusion of the intake interview, the clients were assigned to either an experimental or control group. It had been anticipated that no more than 50 clients would be selected per site for the study, so an array of 54 numbers were randomly ordered. Assignment was achieved by consulting a table of random numbers from 1 to 100 and randomly selecting 54 numbers. Once the random array was selected, the numbers were assigned to the experimental and control group clients using a two-thirds/one-third split favoring assignment to the experimental condition. A description of how clients were selected and assigned to the experimental and control groups appears in Figure 6. Subjects in the experimental group (n=109) were asked to meet a nurse intervenor eight times over a 6-month period. The goal of the intervention was that the nurse and client collaborate to identify a plan and specific strategies to involve the client in carrying out the health behaviors needed to follow the therapeutic regimen. All materials for the intervention phase were standardized and systematized to facilitate use by nurse intervenors at each site. Extensive documentation by the nurse enabled staff to analyze the context and focus of each visit and insured consistency among the intervenors. The format and activities of the nurse/client interventions that took place over the eight visits is described in Figure 7. As a Speci teceivc the ex with i Yeglm: inter group not 3‘ attr: the stud Pres 91 Assignment to the control group did not involve participation in a specific nursing intervention. The subjects in the control group received usual health care from their providers. Providers for both the experimental and control clients were asked to complete a form with information regarding health status and current therapeutic regimen at each visit to the provider for the duration of the intervention period. The eighteen who were lost from the experimental group (those missing more than one-half of the outcome measures) were not included in the outcome analysis. Chi square analysis indicated attrition was not related to the experimental condition nor to any of the sociodemograhic variables. The final sample for analysis in this study were the subjects assigned to the experimental group who were prescribed a diet to restrict sodium and/or reduce calories. 92 Identification of clients -- each site Population of hypertensive client in each research site i Identified clients from medical record screened to determine: 1. If client! meet criteria of being hypertensive. 2. If clients' cars meets minimum criteria. 3. The severity of the disease AL Conduct Client Interviews 1 Independent Dependant Variable Variable Random assignment Routine Clinical and 23:33:12.: Control care *9 behavioral < stoop health stats EXPCFi' gouggn. Clinical and manta cur. .fi —) DQHCVIOI'II BFOHP . intervention health stats Figure 6 Client identification, participation, and assignment (experimental phase), Given and Given, 1982. 93 Visit One/Visit Two 1. O‘U‘lwa 0. Client identifies (recognizes) problems in taking medications/following diet. Nurse and client set goals for overcoming problems. Nurse and client identify solutions for problems. Nurse graphs weight, blood pressure (blood sugar). Client receives focus on beliefs about diet and medication-taking. Nurse and clients focus on beliefs about diet and medication-taking. Visit Three/Visit Four UNH s ss \omNo\U'|4‘-\ 0 Nurse and client identify barriers to problemesolving. Client and nurse identify strategies for solving problems. Nurse and client state what client support person(s) and nurse will do to solve problems. Client and/or nurse identify new or unsolved problems. Client evaluates compliance and ability to achieve goals. Client sets new goals. Client selects new alternative solutions. Nurse graphs weight, blood pressure (blood sugar). Client receives information on specific aspects of therapy, drugs, and diet. Visit Five/Visit Six 1. 2. 3 4 5. 6 Nurse reinforces successful strategies. Nurse and client introduce new strategies. Nurse emphasizes benefits of medications and diet and success in overcoming problems (barriers). Nurse introduces exercise and its benefits. Client and nurse identify new goals. Client and nurse set strategies to solve problems related to exercise. Visit Seven d-‘UNH .. Client evaluates ability to achieve goals and progress made. Client and nurse identify new problems. Client and nurse identify strategies for solving problems. Client receives information on complications, extent of control. Visit Eight 1. Nurse assures client how he/she can continue on his/her own. 2. Nurse will be available but client and nurse will not meet on regular basis. 3. Client and nurse evaluate effectiveness of program and progress made. Figure 7 Nurse/Client intervention visits. Given and Given, 1982. 94 Operationalization of the Study Variables Knowledge Knowledge about diet is defined as the cognitive resources available to the client to describe the dietary regimen. Knowledge is the factual information the client can recall and report to specific questions concerning diet including purpose, acceptable and unacceptable foods, and/or levels of caloric intake (Given and Given, 1982, p. 26). Knowledge concerning dietary treatment of hypertension was measured using the scores from the instrument, Understanding High Blood Pressure (Appendix C). A high score on the instrument was indicative of a high level of factual knowledge concerning diet. Benefits Perceived benefits of treatment is defined as the expressed beliefs and attitudes of the client concerning the benefits to undertaking aspects of the therapeutic regimen (Given and Given, 1982, p. 27). Efficacy of dietary treatment was measured using a total of seven items developed by Given and Given on the Commitment to Diet scale (Appendix C). The Commitment to Diet scale was developed because the original reliability studies on the scale to measure beliefs concerning perceived benefits of diet and barriers to following diet (Appendix C. Beliefs) failed to confirm that clients had distinct cognitive beliefs concerning barriers and benefits. The original scale had adequate levels of internal consiStency but were highly interrelated suggesting they were similar constructs (Given and Given, 1982) and the items did not discriminate between the two. This finding was supported by 95 Cummings et al. (1978) who found that perceptions of benefits and barriers demonstrated a strong negative correlation (r--.655) suggesting that the two constructs may represent opposite ends of a single continuum and so should not be treated as separate health beliefs. The format used for measuring the beliefs concerning commitment to diet was a questionnaire using Likert-type responses ranging from "strongly agree" to "strongly disagree." Respondents recorded their level of agreement with each item describing the concepts. A high degree of perceived benefits was ascertained by assigning a numerical score to each possible response so that a high degree of benefit and a low degree of barrier to diet was indicative of high commitment to diet. Both positively and negatively worded statements were sued to prevent response bias. Also included in the measurements were beliefs concerning the benefits of treatment for hypertension in general. Those beliefs were measured using the subscale, Efficacy of Treatment (Appendix C). A high score on this subscale was indicative of belief that treatment for hypertension is beneficial. Compliance Compliance with the dietary treatment is defined as the extent to which the client carries out the therapeutic recommendations of the health care provider concerning diet (Given and Given, 1982, p. 28). Compliance with diet and medications was measured using the Hypertension Client Interview (Appendix C). The client's stated frequency of compliance with medications was measured using items 1-3. Item 4 b was used to measure dietary compliance. Medication 96 compliance was measured as a possible confounding variable to the relationship of dietary compliance and blood pressure improvement. A numerical score was assigned to each of the responses so that a high score was indicative of a high degree of compliance. For this study, only those clients who were prescribed sodium restricted and/or weight loss diets were included in the analyses items 4 and 4a). Blood Pressure Improvement Blood pressure control is defined as a systolic pressure equal to or less than 140 mm Hg and a diastolic pressure less than or equal to 90 mm Hg. For this study, blood pressure improvement was considered a statistically significant decrease in systolic and/or diastolic blood pressure at the .05 level of significance. Extraneous Variables Extraneous variables are defined as independent variables that may influence the results of the study (Polit and Hungler, 1983). The sociodemographic data of age, sex, race, marital status, income, educational background. and duration of hypertension were examined using the items on the Sociodemographic instrument (Appendix C). These sociodemographics were utilized as extraneous variables and examined for possible correlations to the major study variables. As mentioned, medication compliance was examined as a possible confounding variable effecting change in blood pressure. Weight was also examined for possible use as an additional measure of compliance with weight loss diets. Development of Instruments The instruments in this study were drawn from those designed for Patient Contribution to Care: Link to Process and Outcome (Given and 97 Given, 1982). The original questions used to measure Beliefs about High Blood Pressure evolved from two sources. A literature review of hypertension was conducted to determine clients' perceptions concerning disease and treatment, including perceptions of benefits to therapy. Beliefs concerning high blood pressure were also developed by conducting in-depth interviews over a six month period involving a convenience sample of 30 hypertensives. During the interview, clients were asked to relate how they perceived treatment helped to control hypertension. From these two sources, and the statements concerning benefits of treatment, benefits and barriers to diet were developed. A five-point Likert scale ranging from "strongly agree" to "strongly disagree" was used to record responses (Appendix C-Beliefs). The commitment scale (Appendix C), discussed previously, was the final scale developed to measure perceived benefits of diet. Data relevant to the subscales were also analyzed in this study using the sample prescribed a sodium restricted and/or weight loss diet. The original scale to measure knowledge, Understanding High Blood Pressure, was developed by collecting questions and statements that could be used to measure dimensions of client knowledge. The multiple choice questions evolved from an extensive review of hypertensive literature and client education about treatment, including diet. Responses were classified as either correct or incorrect. The question from the original 27 item instrument that specifically addressed diet were the items used to measure knowledge about diet for this study (Appendix C-Understanding High Blood Pressure-Diet). ‘ The original instruments to measure knowledge and beliefs concerning hypertension from which the instruments in this study were 98 derived, were administered to two samples of hypertensive clients (n-154 and n-97 respectively) and responses were factor analyzed to provide evidence of content and construct validity. The reliability of the instruments was also established based on data analysis from the two samples. The criteria used for inclusion into the instrument analysis samples were the same as the original research sample from which the sample in this study was obtained. The samples for instrument analysis were drawn from populations of hypertensive clients receiving treatment at ambulatory care centers serving as training sites for residents in family practice. Scoring The knowledge instrument (Understanding High Blood Pressure-Diet, Appendix C) was scored by classifying responses as correct or incorrect based on a review of the literature (Given and Given, 1982). A knowledge score for diet was obtained for each hypertensive client prescribed a sodium restricted and/or weight loss diet and who completed the study from the experimental group at intake and termination. The Commitment to Diet instrument (Appendix C) was scored by assigning a point value ranging from one to five for each of the five possible responses from strongly agree to strongly disagree. Scoring was reversed for items worded negatively. For example, a score of five was assigned to the response, "strongly agree" to the statement, "Following my diet does not interfere with my normal daily activities." A response of "strongly disagree" to the statement, "It has been difficult following the diet prescribed for me," was also assigned a score of five. A high score on the Commitment instrument 99 was indicative of perceiving benefits of diet. The scores were calculated for the experimental subjects who completed the instruments at intake and terminated and who were prescribed a sodium restricted and/or weight loss diet. Stated compliance was scored from five (all of the time) to zero (none of the time) to obtain a compliance score for each participant at intake and termination using the questions on the Hypertensive Client Interview (Appendix C). Medication and diet compliance were scored for the participants of the experimental group prescribed a sodium restricted and/or weight loss diet. Validity Validity refers to the degree to which an instrument measures what it is intended and presumed to measure. Content validity is concerned with adequate sampling of content. There are no objective methods to confirm the adequacy of content coverage of an instrument. One way to establish validity is by relying on experts to determine if items are representative of the trait to be measured (Fink and Kosecoff, 1984); Polit and Hungler, 1983; Rossi and Freeman, 1982). Content validity is concerned with establishing the degree to which the items comprising a scale represent the characteristics to be measured (Fink and Kosecoff, 1984). The content validity of an instrument is based on judgment. The scales that were used in this study were derived from scales developed from literature review, interview of hypertensive clients, factor analysis using two samples of hypertensive clients, and the expert knowledge and judgment of the principal investigators and research colleagues. Face validity, determined by inspecting items to 100 see if the instrument contains important items to measure the variables (Dempsey and Dempsey, 1986) was based on the expert opinion of the principal investigators and colleagues. Factor analysis data obtained by the original investigators was used to suggest ways to revise the instruments and so to improve the measurement of the construct. Factor analysis was also used to determine the internal structure for the sets of variables and so contributed to instrument validity. Reliability Measures of reliability, or internal consistency were conducted for the original instruments used to derive those in this study. Internal consistency refers to the extent to which all of the instrument items, or subscales, measure the same attribute (Polit and Hungler, 1983). A measure is reliable to the extent that application of the instrument produces the same results repeatedly (Rossi and Freeman, 1982). The less the scores on a given instrument are influenced by error, the more reliable the instrument. One of the most useful indices of reliability is Cronbach's alpha. The normal range of value of values of the alpha coefficient is from 0.00 to 1.00. The higher the coefficient, the higher the degree of internal consistency (Polit and Hungler, 1983). The Cronbach's alpha for the Commitment to Diet instrument (Appendix C) was .69 based on data analysis from the sample used to develop the original instruments. The items represented those with the strongest correlation coefficients from the subscales of Benefits of Diet and Barriers to Following Diet (Appendix C). A KR 20 (used for dichotomous data) on the entire 27 item instrument used to measure 101 knowledge was .63. The reliability scores computed by Cronbach's alpha and KR 20 measure the homogeniety of items thought to measure the same construct. The closer the correlation, the greater the internal consistency. The reliability coefficients for the scales used in this study were computed and are reported in Chapter V. Cronbach's alpha for self-reports of compliance is reported in the literature as .92 (Morisky et al., 1980, 1986). The Hypertensive Client Interview (Appendix C) is an instrument that measures self-reported compliance. The principal investigators used factor analysis to investigate the internal consistency of the compliance measure by using the responses to items 1-3 on the Hypertensive Client Interview and reported that the resulting scale had an acceptable level of internal consistency (Given and Given, 1982, p. 39). Reliability coefficients were not calculated on the compliance measures in this study. The reliability of the blood pressure measurements in the original study was determined using test-retest. The results were .79 for systolic and .78 for diastolic indicating a high level of stability of the measure (Given and Given, 1982). Data Collection Procedures Data were collected from three sources: 1) interviews with clients; 2) the structured self-administered questionnaires, and 3) the client's medical records. Included in this section is a description of the training and supervision of the interviewers and the procedures for data collection. The research interviewers included three graduate students from Michigan State University College of Nursing, and trained lay 102 interviewers. The lay interviewers were recruited by personnel at the centers and were subsequently interviewed by the research staff before being hired. The research interviewers received two days of instruction which included an overview of the research, ethics of interviewing, and the responsibilities and techniques of interviewing. Role-playing was also utilized to promote skill acquisition. After interviewing skills were mastered, each interviewer was given a list of clients to contact from the 256 hypertensives identified as eligible participants for the study from each of the four sites. During the telephone contact, the study was again explained. If the client agreed to participate, an appointment was made at the site where the client usually received care with the interviewer. The interviewer met with the subject at the site and explained the nature and the purpose of the study. The interviewers were responsible for obtaining the written consent for participation or for recording the reason a client chose not to participate. Progress was monitored by research associates and spot-checks were performed to assure accuracy and quality of performance. Research staff members were available by phone on an ongoing basis, and were present at the sites for the initial client interview. After obtaining the client's written consent (Appendix B), five self-administered questionnaires were given to the participant. Portions of three of these instruments were used for this thesis: Beliefs about High Blood Pressure; Understanding High Blood Pressure (Diet); and Sociodemographic data (Appendix C). The interviewers periodically checked the participants progress and allowed 40 to 70 minutes for completion of the questionnaires. Upon completion of the 103 instruments, the interviewer reviewed each for omissions and then administered the Hypertensive Client Interview (a portion of which was used in this study-Appendix C) and another questionnaire to explore client symptomatology. The instruments were returned to the project personnel for coding. The instruments were pre-coded with the date of completion, site, and a participant code number. Following the intervention phase of the project, all subjects were asked to complete the same five self-administered instruments and were again interviewed. The interviews of the experimental group took place upon completion of the nursing intervention which was generally slightly longer than six months from intake into the study. Medical record audits were conducted on four occasions: 1) at screening to determine eligibility for inclusion into the study; 2) at entry into the study; 3) at the end of the intervention; and 4) at three months following the end of the intervention. Auditors were graduate students in the Family Clinical Nurse Specialist program at Michigan State University. The chart auditors met weekly with research associates who monitored progress, performed spot checks of completed audits, and clarified any concerns or misunderstandings. To assure that the audits were conducted accurately, a detailed manual of instruction was prepared and used by the staff prior to the start of each set of audits. The principal investigators and research associates randomly checked audit forms during each set. Data from the audits used in this study were the blood pressures and weights recorded at intake and termination. 104 Human Subjects Protection The rights of the respondents were protected through adherence to standard criteria set forth by the Michigan State University Committee on Research Involving Human Subjects. All participants were sent a letter from the agency where they normally received care before being contacted by an interviewer (Appendix A). The letter described the study and its benefits, assured participants of anonymity and confidentiality, and requested participation in the study. The letter was signed by either the medical director of the health-care center where the client received care or by the client's private physician. An interviewer initiated telephone contact with potential subjects who returned a postcard indicating a willingness to participate in the study. Clients who requested more information were also contacted as well as those who did not return the postcard. During the telephone conversation, the study was again described and questions answered. If the client indicated a willingness to participate, an appointment time was arranged to meet with the interviewer at the site. At the initial contact with the potential subject, the interviewer again described the study and told each potential participant that they had the right to refuse to participate without fear of jeopardizing the health care they were receiving. The client was also told that they could withdraw at any time during the study. The client was then asked to sign a consent form. The consent form provided an explanation Of the research, including the purpose of the study, the use of the results, and assurances of anonymity and confidentiality (Appendix B). Confidentiality and anonymity were 105 assured through the use of code numbers on the instruments used for data collection and analysis. Consent forms and questionnaires were separated immediately upon return to Michigan State University. Statistical Analyeis of the Data Data from those clients assigned to the experimental group who were prescribed a low sodium and/or weight loss diet were examined for this study. Descriptive statistics were used to describe the sociodemographic characteristics of the sample. Tables summarizing distribution and percentages of subjects by demographic variables are presented in Chapter V. Descriptive statistical analysis allows for presentation of quantitative facts concerning the sample (Dempsey and Dempsey, 1986; Polit and Hungler, 1983). Reliability coefficients were calculated for the instruments used to measure knowledge about diet, perceived benefits of diet (commitment to diet scale), and the subscales on the instrument Beliefs About High Blood Pressure (Appendix C). The reliability data are reported in Chapter V. Data from those clients assigned to the experimental group and prescribed a low sodium and/or weight loss diet were also analyzed to examine the effects of the nursing intervention. A dependent t test was used to determine if there were statistically significant differences in mean scores for knowledge about diet, commitment to diet, and perceived efficacy of treatment from intake to termination. A dependent t was also computed for blood pressure, weight, and compliance both with diet and medications. Findings considered statistically significant were those at the .05 level. The dependent or correlated t-test is the basic parametric procedure for testing 106 differences in group means between pre and post intervention measures. Results can be used to provide information as to whether the differences in score sizes or outcome measures occurred by chance alone (Polit and Hungler, 1983). Each of the research questions were answered by computing correlation coefficients using Pearson Product Moment. This procedure was also used to describe the relationships between the study variables and the sociodemographic and extraneous variables. The Pearson r is calculated to express the magnitude and direction of a relationship between variables. The value ranges are from -1.00 to 1.00. All correlations between -1.00 and 0.00 are indicative of negative relationships implying that as the score on one measure increases, the score on the other measure decreases. Coefficients of 0.00 to 1.00 indicate positive relationship between variables (Polit and Hungler, 1983). For this study, coefficients of 0.00-0.2 were considered as indicative of no relationship between variables. Coefficients of 0.2-0.35 were considered representative of low relationships. A coefficient of 0.35-0.85 was considered descriptive of a moderate relationship and a correlation of greater than 0.85 as indicative of a high correlation between variables (Borg and Gall, 1979). The level of significance to draw conclusions about any relationships found in this study was .05. Summary In this chapter the research methodology was described and discussed. The specific topics addressed were the research question, the population and sample, and operational definition of the 107 variables, instrument development, data collection procedures, human subjects protestion, and procedures for data analysis. An analysis of the data and findings relevant to the research questions are presented in Chapter V. A summary of the findings, implications, and recommendations are presented in Chapter VI. CHAPTER V Data Presentation and Analysis Overview A description and analysis of the sample is discussed in this chapter. Reliability measures of the instruments and mean scores before and following the intervention are presented. Data relevant to each of the research questions are presented to examine the relationship between the major study variables of knowledge about diet and perceived benefits of diet to compliance with diet and to each other. Data concerning the relationship of dietary compliance to blood pressure are also included. Additional relevant findings from data analysis are also discussed. Sample Characteristics The sample for which data were available and analyzed for this study consisted of 67 persons who were diagnosed and medically treated for hypertension and who were assigned to an experimental nursing intervention. The subjects in the sample analyzed were prescribed a low sodium and/or calorie restricted diet as part of the medical treatment plan for hypertension. Subjects in the study were literate and showed no evidence of stroke, cancer, end-stage renal disease, blindness, psychiatric problems, or pregnancy and lactation. Subjects who participated in the intervention had at least two elevated blood pressures of 140/95 mm Hg or higher within six months prior to intake into the study. 108 109 Among the 99 subjects who were assigned to the experimental group and who completed the intake interviews, 67 had prescribed low sodium and/or calorie restricted diet. Among these, 32 were told to follow a low sodium diet, 11 a reducing diet, and 24 a combination of a low sodium and low calorie diet. In sum, the sample analyzed in this study consisted of 67 literate subjects diagnosed as uncomplicated hypertension. Part of the therapeutic regimen for these subjects was a low sodium and/or calorie restricted diet. Sociodemoggaphic Variables The sociodemographic variables addressed in this study include: sex, age, race, marital status, income, education, and duration of hypertension. Distributions concerning the sociodemographic variables of sex, age, and race are presented in Table 5.1. The sample analyzed was distributed as follows: Seg: Among the 67 participants, 43% were male (n=29) and 572 were female (n-38). ége: The age of the participants ranged from 24-65. The mean age was 47 with a standard deviation of 10.4 years. Rees: The majority of the 67 participants were white (882, n-59). Seven were black (112) and one described race as other. The sociodemographic variables concerning marital status, income, education, and duration of hypertension are presented in Table 5.2. Distribution and percentages concerning the variables are included. Table 5.1 Distribution of Subjects by Sociodemographic Variables of Sex, Age, and Race. 110 Variable Subject Percentages Sex Male 29 43 Female 38 57 n=67 1002 Age 24-35 9 13 36-45 17 26 46-55 26 39 56-65 15 22 n=67 1002 Race White 59 88 Black 7 11 Other 1 1 N=67 1002 111 Table 5.2 Distribution of Subjects by Sociodemographic Variables of Marital Status, Income, Education, and Duration of Hypertension. Variable Subject Percentages Marital Status Married 48 72 Single 6 9 Separated 1 1 Divorced 7 11 Widowed 5 7 n=67 1002 Income Less than $5,000 2 3 $5,000-10,000 9 14 , $11,000-17,999 11 16 $25,000 or over 29 44 n-67 1002 Education Less than 7 grades 2 3 9-11 grades 10 15 Graduated High School 25 38 Technical Education 1 1 Some College 16 24 Graduated College 7 10 Post College 6 9 n-67 1002 Duration of Hypertension Less than 1 Year 8 12 1-5 Years 32 48 6-10 Years 19 28 11-15 Years 1 1 More than 15 Years 6 11 No Data 1 1 n-67 1002 112 Marital Status: Among the 67 subjects, the majority were married (722, n-48). Six reported being single (92). one was separated, seven were divorced (112), and five reported widowhood (72). Ipepme: Income data were available for 66 of the 67 subjects in the study. Two (32 had income less than $5,000 and 19 (442) had incomes greater than $25,000. The majority of subjects had incomes greater than $18,000 (n-44). Education: Among the 67 subjects, 182 (n-12) had less than a high school education. High school was completed by 382 (n-32) and 442 (n=34) had education beyond high school. Duration of Hypertension: The average duration of hypertension among the 66 participants who responded was between one and five years. The mean duration was 3.4 years with a standard deviation of 1.6 years. In sum, the typical participant was white, either male or female, 47 years old, and married. The typical subject had an income of at least $18,000, a high school education and beyond, and a diagnosis of hypertension for at least three years. Extraneous Variables The extraneous variables analyzed include medication compliance and weight. Medication compliance was examined as a confounding variable with regard to blood pressure control. Weight was examined as a possible measure of compliance with diet. Medication Compliance All 67 subjects were taking at least one medication for hypertension. The majority (622, n-42) were taking at least two medications. The mean compliance score at intake to the intervention 113 was 4.74 (range of 1-5) with a standard deviation of .60. The mean compliance score following the intervention was available for 60 subjects and was 4.44 with a standard deviation of 1.6. A two-tailed correlated t-test indicated there was no significant change in medication compliance from intake to termination. The scores indicate compliance with medications was high both at intake and termination. Weight Weights were available on only 54 of the subjects at intake and 44 at termination. Since the two-tailed correlated t indicated there was no significant change in weight from intake to termination, weight data was not used as a measure of compliance among these subjects. Further analysis of data concerning weight change among the participants was beyond the scope of this study. Research Question The research questions to be answered are: Question 1. Is there a relationship between client knowledge about diet and perception of benefits of diet to stated compliance with diet before following an experimental nursing intervention? Specifically: Question Is. Is there a relationship between client knowledge scores about diet and diet compliance scores before and following an experimental nursing intervention? Question 1b. Is there a relationship between client perceived benefits of diet scores and diet compliance scores before and following an experimental nursing intervention? 114 Question 1c. Is there a relationship between client knowledge scores about diet and perceived benefits of diet scores before and following an experimental nursing intervention? Question 2. Is there a relationship between client compliance scores concerning diet and blood pressure before and following an experimental nursing intervention? Reliability coefficients for each of the instruments used to answer these questions were obtained. The next section describes the procedures and results of the establishment of reliability. Reliability of Instruments The reliability coefficients for each of the instruments used in data analysis are presented in Table 5.3. The information in this section is a description of the procedures used to determine reliability of the instruments as well as how each instrument was scored. Understanding High Blood Pressure (Diet) Understanding High Blood Pressure (Diet) was the instrument used to measure the variable knowledge about diet. The statistical procedure to determine reliability of the instrument was the Kuder-Richardson 20 (KR 20). The level of cognitive knowledge about diet was obtained by assigning a numerical value of one to each of the correct responses so that the higher the obtained value, the greater the degree of knowledge about diet. The reliability coefficient for Understanding High Blood Pressure (Diet) was .45 The decrease in reliability from the original instrument can be explained, in part, by the fact that only seven items were used to measure knowledge about diet. The original 115 instrument measured knowledge about hypertension in general and consisted of 27 items. The reliability coefficient of .63 for the original instrument was obtained using different and larger sample sizes (n-154, n-97). The number of items influences reliability. Reliability is not a property of the instrument itself but of an instrument administered to a specific sample under specific conditions (Polit & Hungler, 1983). The .45 reliability coefficient suggests that the subparts of the instrument used to measure knowledge were not homogeneous or equivalent in measuring the attribute: knowledge about diet. The low reliability indicates the tool is not stable, consistent, or dependable in measuring knowledge about diet. The degree of error in measuring knowledge, due to the low reliability, calls into question the accuracy of findings in measuring knowledge about diet. If an instrument is not a reliable measure of a concept it cannot accurately measure that concept. Changes suggested in the instrument to improve reliability are discussed in Chapter VI. 116 Table 5.3 Mean Scores and Reliability Coefficients for the Scales Understandipg High Blood Pressure (Diet) and Commitment to Diet and Subscales of Beliefs About High Blood Pressure. Scale Participants Mean S.D Reliability Understanding High Blood Pressure (Diet) n-57 4.6 1.09 .45 Commitment to Diet n-53 2.4 .56 .62 Beliefs About High Blood Pressure Efficacy of Treatment n-63 4.1 .46 .75 Benefits of Diet n-67 2.3 .57 .64 Barriers to Following Diet n-58 2.8 .31 -.56 Note: S.D. - Standard Deviation 117 Perceived Benefits The Cronbach's alpha was the statistical procedure used to determine the reliability of instrument used to measure perceived benefits of diet: Commitment to Diet. Reliability coefficients were also calculated for each of the subscales on the Beliefs About High Blood Pressure instruments. The subscales include: Efficacy of Treatment, Benefits of Diet, and Barriers to Following Diet. The alpha coefficient for Commitment to Diet was .62 indicating a low to satisfactory reliability for making group level comparisons concerning perceived benefits of diet. The reliability coefficient for the subscale of Efficacy of Treatment was .75 and was developed to measure belief in the benefits of treatment for hypertension in general. The subscale Benefits of Diet had an alpha coefficient of .64. These two scales have acceptable reliability coefficients for making group level comparisons. The subscale Barriers to Following Diet had a negative reliability coefficient so will not be utilized for analysis. It will be recalled that the instrument, Commitment to Diet, consists of the items with the highest alpha coefficients for the subscales to measure benefits and barriers of diet. Mean scores for each of these instruments were obtained by assigning a value of 1—5 for each response so that a high score reflects higher commitment to diet, higher perceived efficacy of treatment, higher perceived benefits of diet, and low perceived barriers to following the diet respectively. The mean scores are reported in Table 5.3 along with the reliability coefficients. Reliability studies for the compliance measure and blood pressure data used this study were beyond the scope of this study. The 118 original investigators did reliability studies on both these measures as discussed in Chapter IV. In sum, the instruments used to measure the variables of knowledge about diet and perceived benefits of diet have varying degrees of reliability. The instrument to measure knowledge has an alpha coefficient that brings into question the accuracy of the findings relevant to measuring the knowledge variable. The instrument used to measure benefits of diet has an acceptable coefficient for making group level comparisons as do the subscales that measure belief in the benefits of treatment in general and beliefs in benefits of diet. The subscale, barriers to following diet, had an unacceptable reliability coefficient for use in analysis of data for this study. Data Presentation The major research questions and subquestions are addressed in this section after a presentation of data concerning scores before and following the experimental nursing intervention. A probability of .05 is the level considered as statistically significant for all procedures used in data analysis. The Pearson Product Moment coefficient of correlation (r) was the statistical procedure used to answer each of the research questions. The degree and direction of significant relationships among the variables are also discussed. 119 Table 5.4 T-Test for the Significance of Mean Differences in Scores for the Instruments Understanding High Blood Pressure (Diet), Commitment to Diet and the Subscale Efficacy of Treatment. Mean Mean Instrument Subjects Scores Difference T Probability Understanding High Blood Pressure (Diet) n=67 4.4 .28 1.22 .23 4.1 Commitment to Diet n=50 2.4 .12 1.64 .11 2.3 Beliefs About High Blood Pressure Efficacy of Treatment n-56 -.28 -5.02 (.001 J-‘b O. #N 120 Mean scores and standard deviations for each of the instruments at intake into the study are presented in Table 5.3. The mean scores at termination were also calculated and a two-tailed correlated t was performed to examine the significance of any changes that resulted. The results of this analysis are presented in Table 5.4. The only significant finding was an increase in perceived efficacy of treatment which increased from a mean pretreatment score of 4.2 to a termination score of 4.4 significant at p- .001. A correlated t-test was also computed to examine the significance of change in compliance with diet. Data from this analysis are in table 5.5. The mean compliance with diet score at intake was 2.7. At termination, the mean score was 2.5. Compliance with diet significantly decreased from intake to termination (t-2.44, p-.02). Also presented in Table 5.5 are the results of the t-test for significance of change in systolic and diastolic blood pressure. The mean systolic pressure before treatment was 147 mm Hg. At termination the mean systolic blood pressure was 136 mm Hg. There was a significant change in systolic blood pressure from intake to termination (t-5.62, p- .001). At intake, the mean diastolic pressure was 93 mm Hg and at termination, the mean diastolic pressure was 87 mm Hg. There was also a significant decrease in diastolic pressure from intake to termination (t-5.25, p .001). 121 Table 5.5 T-Test for the Significance of Mean Differences in Diet Compliance and Blood Pressure. Mean Mean Variable Subjects Scores Difference T Probability Compliance With Diet n=53 2.7 .43 2.44 .02 2.5 Systolic Blood Pressure n=45 147 10.91 5.62 .001 136 Diastolic Blood Pressure n=45 93 5.4 5.25 .001 87 122 In sum, among the instruments used to measure the variables of knowledge about diet and perceived benefits of diet and efficacy of treatment in general, the only significant difference in mean scores was in beliefs concerning the efficacy of treatment which increased from intake to termination, but both systolic and diastolic pressure significantly improved. These findings are discussed further in Chapter VI. The research questions and other findings are addressed in the remainder of this section. Question 1. Is there a relationship between client knowledge about diet and perception of benefits of diet to stated compliance with diet before and following a nursing intervention? Question Is. Is there a relationship between client knowledge scores about diet and diet compliance before and following a nursing intervention? There was no relationship between the variables measuring knowledge about diet (Understanding High Blood Pressure-Diet) and stated compliance with diet at intake (r-.06, p-.32). There was also no relationship between the two variables at termination (r-.16, p-.12). It must be kept in mind that the accuracy of this finding is questionable considering the reliability of the knowledge instrument. Question 1b. Is there a relationship between client perceived benefits of diet scores and compliance with diet before and following a nursing intervention? The correlation between benefits of diet as measured by the commitment scale and compliance with diet was moderate, positive, and highly significant at intake (r.51, p-.001). Following the 123 intervention, the relationship between benefits of diet and diet compliance remained moderate, positive, and significant (r-.38, p-.005). There was no relationship between perceived efficacy of treatment in general and compliance with diet (r--.l6, p-.11) at intake. Following the nursing intervention, the relationship between these two variables did not change (r--.11, p-.20). Question 1c. Is there a relationship between knowledge scores about diet and perceived benefits scores before and following a nursing intervention? There was no correlation between the scores measuring knowledge about diet and benefits of diet at intake (r--.05), p-.35). The lack of relationship between these two variables persisted at termination (r--.10, p-.23). There was, however, a low, but significant and positive relationship between knowledge about diet and perceived efficacy of treatment in general at intake (r-.35, p-.002). This relationship did not persist at termination (r-.l3, p-.16). Again, it must be pointed out that the accuracy of these findings are questionable. A summary of the findings at intake are presented in Table 5.6. The termination correlations are presented in Table 5.7. The correlations at intake (Table 5.6) also indicate that there was a low, negative and significant relationship between perceived efficacy of treatment and benefots of diet at intake (r--.27, p-.02). At termination, the relationship between these two variables remained the same (r--.30, p-.01). Table 5.6 124 The Correlation Between Knowledge Scores, Perceived Benefits of Diet Scores (Commitment to Diet), Efficacy of Treatment Scores, and Compliance with Diet Scores at Intake. Knowledge Benefits Efficacy Diet Variable about Diet of Diet of Treatment Compliance (Commitment to Diet) Knowledge about Diet 1.00 Benefits r--.05 of Diet p-.35 1'00 (Commitment to Diet) Efficacy of r-.35 r=-.27 1 00 Treatment p-.002 p-.02 ' Diet r-.06 r-.51 r--.16 1 00 Compliance p-.32 p-.001 p-.ll ' 125 Based on the analyses of data to answer research question 1 using la-lc, there is no relationship between knowledge about diet and compliance with diet at either intake or termination of the experimental nursing intervention. There is a moderate, positive, and highly significant relationship between perceived benefits of diet and compliance with diet at both intake and termination of the nursing intervention. However, there was no relationship between beliefs in the benefits of treatment for hypertension in general and compliance with diet. There was no relationship between knowledge about diet and perceived benefits of diet at either intake or termination, but there was a low, positive, and significant relationship between knowledge about diet and efficacy of treatment in general at intake into the nursing intervention. The relationship, however, did not persist at termination. Any relationship involving knowledge should be cautiously interpreted due to the low reliability of the knowledge instrument. Correlations were also computed for change in diet compliance from intake to termination and knowledge about diet before and following the nursing intervention, perceived benefits of diet pre and post treatment, as well as beliefs in the benefits of treatment for hypertension. The only significant relationship was a highly significant, moderate, and negative relationship between perceived benefits of diet before treatment and change in diet compliance (r--.37, p-.006). It will be recalled, however, that there was a significant decrease in dietary compliance from intake to termination of the intervention (t-2.44, p-.02). 11...; E I: . 12...... r. w. . .2 .9 :2. 5.x :2..-.....,:..:.... .32.... 22-5.5. .v......1.:.: .- .r. Table 5.7 126 The Correlation Between Knowledge Scores, Perceived Benefits of Diet Scores (Commitment to Diet), Efficacy of Treatment Scores, and Compliance with Diet Scores at Termination. Knowledge Benefits Efficacy Diet Variable about Diet of Diet of Treatment Compliance (Commitment to Diet) Knowledge about Diet 1.00 Benefits r--.10 1.00 of Diet p=.23 (Commitment to Diet) Efficacy of r-.13 r--.30 1.00 Treatment p-.16 p=.01 Diet r-.16 r=.38 r--.11 1.00 Compliance p-.12 p-.005 p-.20 127 Question 2. Is there a relationship between compliance with diet and blood pressure before and following a nursing intervention? There was no relationship between compliance with diet and either systolic or diastolic blood pressure either before or following the experimental nursing intervention. There was also no relationship between change in compliance with diet from intake to termination and change in diastolic or systolic blood pressure (r--.l7, p-.12 for systolic pressure change and r-.03, p-.43 for diastolic pressure change). The possible explanations for these findings are discussed in Chapter VI. Other Findings Since both diastolic and systolic blood pressure significantly decreased during the intervention (t-5.25, p<§001 for diastolic and t-5.62, p<§001) for systolic blood pressure), correlations were computed to determine if any of the major study variables other than diet compliance contributed to the significant decrease in blood pressure. There were no significant findings. There was, however, significant and negative correlation between medication compliance and systolic blood pressure at intake (r--.26, p-.05) and at termination (r--.38, p-.006). The relationship between diastolic blood pressure and medication compliance at termination approached significance and ‘was also negative (r--.22, p-.07). There was also a significant and ‘negative correlation between compliance with medication at intake and termination with change in both systolic and diastolic blood pressure CTable 5.8). Based on this finding, medication compliance contributed tOtthe blood pressure improvement among the participants in this .Study. This finding is further discussed in Chapter VI. 128 Compliance with diet and weight were also correlated to examine the relationship between these two variables. There were no significant findings at either intake or termination. There was a positive and significant correlation between change in compliance with diet and change in weight (r-.31, p-.03). The only significant correlation between the independent variables in this study and weight was a positive relationship between benefits of diet at termination and weight at intake (r-.25, p-.05). The correlation between perceived benefits of diet and weight at intake approached significance (r-.22, p-.07) as did the correlation between perceived benefits of diet and weight at termination (r-.24, p-.08). Compliance with diet was correlated with compliance with medications at both intake and termination. The significant finding was a negative and highly significant relationship between compliance with medication and compliance with diet at intake (r--.37, p-.001). The Pearson r was also calculated to examine the relationship between the sociodemographic variables of sex, age, race, marital status, income, education, and duration of hypertension to each of the major study variables including: knowledge about diet, perceived benefits of diet, perceived efficacy of treatment in general, and compliance with diet. The correlations between the sociodemographic variables and changes in the dependent variables of diet compliance, systolic and diastolic blood pressure, and weight were also examined. The significant findings are in Table 5.9. Sex was found to have a low but significant relationship to knowledge about diet intake (r-.21, p-.05) indicating that female Table 5.8 129 Correlations Between Changes in Systolic and Diastolic Blood Pressure and Weight and Compliance with Diet and Medications and Change in Diet Compliance. Change in Systolic Change in Diastolic Change in Variable Blood Pressure Blood Pressure Weight Compliance with Diet N.S N.S. N.S (Intake) Compliance with Diet N.S. N.S. N.S. (Termination) Compliance with Medication r--.39 r--.42 N.S. (Intake) p-.004 p-.002 Compliance with Medication r--.27 r--.50 N.S. (Termination) p-.04 p-.001 N.S. Change in r-.31 Diet Compliance N.S. N.S. p-.03 130 Table 5.9 The Relationship of the Sociodemographic Variables to Knowledgg about, Perceived Benefits of, and Compliance with Diet. Duration of Variable Sex Age Hypertension Knowledge about Diet r-.21 N.S. N.S. (Intake) p=.05 Perceived Benefits of N.S. r--.27 N.S. Diet (Intake) p-.03 Perceived Benefits of N.S. r--.28 r-.26 Diet p-.03 p-.03 (Termination) Compliance with Diet r=.22 r--.23 N.S. (Intake) p-.04 p-.05 Compliance with Diet r'.25 r--.35 N.S. (Termination) p-.04 p=.005 131 participants had more knowledge about diet at intake into the study. Female participants were also slightly more compliant with diet at intake (r-.22, p-.04) and termination (r-.25, p-.04) than male participants. Age was found to be significantly and negatively correlated to perceived benefits of diet at intake (r--.27, p-.03) and termination (r--.28, p-.03). There was also a negative and significant relationship between age and compliance with diet both at intake (r--.23, p-.05) and termination (r--.35, p-.005). The correlation between beliefs in the benefits of treatment for hypertension and age were positively and significantly correlated (r-.24, p-.03). Younger participants were, therefore, more likely to perceive benefit of diet and to comply with diet, but older participants were more likely to perceive benefits to treatment in general. Duration of hypertension and perceived benefits of diet were also found to be slightly, but significantly related (r-.26, p-.03). The relationship suggests that the longer the duration of diagnosed .hypertension, the more benefits of diet perceived. The only significant findings when the sociodemographic variables were correlated with changes in diet compliance, blood pressure, and weight were a positive but low relationship between education and change in compliance (r-.22, p-.05) and a negative correlation between education and change in systolic blood pressure (r-—.25, p-.04). These relationships suggest that more education was associated with change in diet compliance and less education with change in systolic blood pressure. 132 Summar In sum, there is evidence from the data that there is no relationship between client knowledge about diet and compliance with diet either at intake or termination of the nursing intervention. There is evidence that there is a positive and significant relationship between perceived benefits of diet and compliance with diet both at intake and termination of the study. There is no relationship between the two variables of knowledge about diet and belief in the benefits of diet at either intake or termination. Although belief in the benefits of treatment in general had a low and significant relationship to knowledge about diet at intake, the relationship did not persist. There was no relationship between compliance with diet and either systolic or diastolic blood pressure at intake or termination. There was also no relationship between change in blood pressure and compliance with diet either at intake or termination or to change in compliance. There was, however, a significant relationship between medication compliance and blood pressure at intake and termination and the change in blood pressure. The only significant changes from intake to termination among the major study variables that were positive were in systolic and diastolic blood pressure and belief in the benefits of treatment in general. There was a negative and significant change in compliance with diet. The only sociodemographic variables significantly related to the major study variables were sex, age, and duration of hypertension. The only significant correlation between the major study variables and 133 the changes in the dependent variables were between education and change in diet compliance and education and change in systolic blood pressure. A discussion of the findings are presented in Chapter VI. also in Chapter VI are recommendations for nursing practice, education, and future research based on the results of this study. CHAPTER VI Summary and Conclusions Overview A summary and interpretation of the research findings will be presented in this chapter. The sociodemographic characteristics of tile study sample will be discussed and compared to sample (fliaracteristics of other research. The findings related to the research questions will be presented and will be compared to findings frxnn other studies. Lastly, the implications of the findings for turrsingpractice, education, and future research will be addressed. Sociodemographic Characteristics of the Sample The sociodemographic variables among participants in this study ‘will.be discussed and compared to those of subjects in related research. The sociodemographic characteristics examined in this study ixufilude: sex, age, race, marital status, income, education, and duration of hypertension. §E§° Among the sample in this study there were 29 males (43%) and 38 females (57%). According to the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC, 1985). the prevalence of hypertension is high among males. The frequency of hypertension among noninstitutionalized adults is 2.3 million females compared to 3.0 males. This differs from earlier data reported by Cummings et al. (1982) who reported that women were more likely to have hypertension than men. 134 135 Considering the prevalence data, the sample would have been more representative of the hypertensive population if the proportions of males and females were similar to the national statistics. The sex distribution in this study, however, is similar to some of the major studies involving hypertension such as the Hypertension Detection and Follow-up Program (1979, 1980, & 1982), and the Farmingham Study (Dawber, 1980; Kannel. 1978). Several of the major clinical trials for hypertension treatment were restricted to males only such as the Veterans Administration Cooperative Group (Borhani, 1981, 1982; Kochar, 1981), the Multiple Risk Factor Intervention Trial (MRFIT, 1977; Grim et al., 1985). Studies concerning dietary intervention for hypertension to lower blood pressure were either generally restricted to males (Anderson et al., 1984; Gillum et al., 1983; Jeffery et al., 1983; Stamler et al., 1980) or did not report any outcomes significantly related to sex of the participant (Heyden et al., 1984; Reisen et al., 1978; Tuck et al., 1981; Velasquez and Hoffman, 1985). Only two researchers reported significant differences between the sexes related to diet. Holbrook and colleagues (1984) found among a sample of normotensives that females consumed significantly less sodium whereas weight in males was more significantly correlated with blood pressure. The large scale Farmingham Study (Dawber, 1980) had results that weight change in males contributed more to lowering blood pressure than weight change in females. Among the findings in this study were that females were slightly Inore knowledgeable about diet and complied better with diet both at intake and termination. Two other researchers found sex correlated 136 with compliance (Nelson et al., 1980; Widmer, Cadoret, and Troughton, 1983), but both these studies examined medication compliance only. Major reviewers of the compliance literature state that sex is not a significant predictor of compliance with therapeutic regimens (Becker, 1979; Glanz, 1980; Hershey et al., 1980; Kirscht & Rosenstock, 1977; Janz & Becker, 1984). There does not appear to be any support in the literature that sex is related to more knowledge about diet. This is partly because studies concerning compliance with hypertensive diets are limited and usually involve a specific age or sex (Glanz, 1980, 1986). Cummings et al. (1982) specifically examined sex in relationship to knowledge about diet and found no significant correlations. Considering the role of females in American society, it seems logical that females would be slightly more knowledgeable about diet than males. Ag_. The age of the participants in this study ranged from 24 to 65 with a limit for acceptance into the study of 65. The mean age of the sample was 47. Many of the major studies involving hypertensives ,used samples with similar ranges (The Australian Trial, 1984; Hypertension Detection and Followbup Program, 1979, 1980, 1982). The sample involved in the Farmingham Study with over 10,000 participants, ranged in age from 30 to 62. According to the JNC (1985) the largest prevalence rate for hypertension is among those aged 65 to 74 (64.320), but 41.32 of hypertensives in the United Stated are aged 45 to 54, making this sample appropriate to study although younger than most hypertensives. Cummings et al. (1982) in a telephone survey found there was a higher prevalence of hypertension among those older than 56. 137 Among the subjects in this study, younger participants perceived significantly more benefit of diet and complied better with diet both at intake and termination. There is limited support for these relationships in the literature. For compliance in general, Cummings et al. (1980) found that younger hypertensives were less likely to comply with treatment. Haines and Ward (1981) in another survey of hypertensives, found that younger clients were more likely to discontinue medication on their own. Nelson et al. (1980) found no correlation between age and medication compliance. Based on a review of the studies concerning dietary adherences, Glanz (1980, 1986) states there is no persistent relationship between age and dietary adherence. Kirscht et al. (1977), however, did find less tendency for diet compliance among subjects older than 60, but Cummings et al. (1980) found that older clients tended to comply better with diet. Eggs. The sample in this study was predominantly white (88%). There were seven blacks among the participants and one who described race as other. Among the population of the United States, there is a higher proportion of hypertensives who are black. According to the JNC (1985), 38.22 of hypertensives are black, while 28,82 are white. The remaining 29.82 include all other races. The survey done by Cummings et al. (1980) involved primarily black hypertensives. Glanz et al. (1981), in a review of intervention studies to improve compliance among hypertensives, report that most participants are black. The findings from this study, due to the predominance of white participants, should not be generalized to the hypertensive population. 138 Among participants in this study, there was no relationship between race and the major study variables. None of the studies reviewed concerning perceptions of benefits of diet or knowledge about diet had findings that indicated a significant relationship between race and these two variables. There were also no studies identifying race as a predictor of diet compliance among those reviewed. Marital Status. The participants in this study were, for the most part, married (72%). The remaining subjects were almost equally distributed among those single, divorced, or widowed. There were no relationships between marital status and either knowledge or perceived benefits concerning diet in this study. There also was no relationship between marital status and dietary compliance. In studies by Cummings et al. (1982) and Haynes et al. (1982) no relationship was found between marital status and compliance. Research conducted by others, however, has produced results that indicates there is a relationship between support and compliance. Nelson et al. (1980) reports that living alone correlated with noncompliance to treatment among hypertensives. Both Cummings et al. (1980) and Greene et al. (1982) state that social support is related to compliance. Glanz (1980, 1986), in reviews of dietary compliance literature, reports that social support contributes significantly to success in weight reduction programs, but that type of support is usually provided by peers and programs managers. Other authors have found that unhealthy or inadequate support systems contribute to low rates of success in weight loss programs (Jeffery et al., 1984; Popkess-Vawter, 1982; Russ, Ciavarella, & Atkinson, 1984). No similar 139 findings were found in relationship to compliance with low sodium diets. 122293. Only two participants in this study had incomes less than $5,000. A large percentage of the samples (442) had incomes greater than $25,000. Most participants in this study earned over $18,000 per year. There was no relationship between income and the major study variables. Another researcher had similar findings. Nelson et al. (1980) reported that socioeconomic status was not related to compliance with hypertensive regimens. Many of the intervention studies to increase compliance with hypertensive regimens are limited to subjects in low income brackets (Glanz & Scholl, 1981). For example, the studies done by Morisky and colleagues, beginning in 1980, and those done by Webb (1980), and Hershey et al. (1980) involved participants with incomes under $5,000. Generalizations from findings from this and other studies are limited to those with similar income characteristics. Education. The sample analyzed in this study was well educated. Only 12 of the participants (18%) had less than a high school education. Twenty-five (382) completed high school and the remainder (442) had educational preparation beyond high school. The subjects in this study were more highly educated than those found in most of the intervention studies concerning compliance with hypertensive regimens (Glanz & Scholl, 1981). Education was not discussed as a confounding variable in most of the studies concerning compliance with regimens in general or diet in particular among hypertensives. Even among those studies that specifically used educational interventions there was no indication 140 that educational level was a predictor of either increased knowledge, perceived benefits, or compliance with regimens. There were no correlations between the major study variables and education in this study. There was, however, a low but significant relationship between the change in diet compliance from intake to termination (which significantly decreased) and education such that increased education was associated with the change. Perhaps those with higher education were less inclined to follow the recommendations concerning diet by providers, although this finding is not consistent with the literature. Another finding was a significant relationship between change in systolic blood pressure and education so that less education was associated with the significant decrease in systolic blood pressure that occurred from intake to termination of the study. There is also no support for this finding in the literature. Further, education was not associated with compliance with medications among this sample which was the only variable examined in this study that was significantly related to the drop in blood pressure. Duration of Hypertension. The average duration of hypertension among the participants in this study was 3.4 years. Duration of hypertension was slightly, but significantly, correlated to beliefs in benefits of diet at termination and the relationship was close to significance at intake. A longer duration of illness would suggest more experience with treatment and more established beliefs, but there does not appear to be support in the literature indicating that duration is associated with an increase in perceived benefits of treatment. One could conclude that perhaps more experience would 141 increase knowledge about diet and so perception of benefits, but duration was not associated with knowledge about diet or compliance with diet. Subjects with a longer duration of hypertension may be told so frequently by providers that the prescribed diet was good for them that they did perceive it as beneficial. As will be discussed later, perceived benefits of the diet prescribed was found to be associated with compliance. Duration of treatment is a factor reported by some authors as a major contributor to noncompliance (Becker, 1979; Becker & Maiman, 1980; Glanz, 1979, 1980, 1986). In relationship to dietary compliance, the indefinite nature of the treatment is consistently mentioned as a contributor to the high levels of nonadherence (Given et al., 1984; Glanz, 1980, 1986; Tillotson, 1984). In sum, the sample in this study consisted of generally younger hypertensives, more females, and more whites than the national averages reflect for the diagnosis of hypertension. The income level and educational level was generally higher than most studies. .Significant relationships were found between less age and perceived benefits to diet and diet compliance, between being female and having more knowledge about diet at intake and complying better with diet, and between longer duration and more belief in the benefits of diet. There was also a significant relationship between change in diet compliance and higher education and change in systolic blood pressure and less education. There were no other significant relationships between sociodemographic variables and the major study variables. Major reviewers of the compliance studies, including those using the health belief model, report that there are no significant, 142 consistent predicators of compliance based on sociodemographic characteristics (Becker, 1979; Glanz, 1980; Janz & Becker, 1984). Many reviewers of the health belief model for application of the model for nursing practice to foster compliance do not even discuss the significance of sociodemographic characteristics (Champion, 1984; Given et al., 1984; Lousteau, 1979; Mikail, 1981). The sociodemographic variables are not modifiable by nursing intervention. It appears that the usefulness of sociodemographic information is limited to perhaps recognizing some client groups who may be at higher risk for noncompliance. Extraneous Variables The extraneous variables addressed in this study were weight and medication compliance. Medication compliance was included because a number of studies have results that demonstrate a strong and significant correlation between medication compliance and blood pressure control (The Australian Therapeutic Trial, 1980, 1984; Borhani, 1981, 1982; Greene et al., 1979; Haynes et al., 1982; Hershey et al., 1980; Inui et al., 1976; Morisky et al., 1980; Sackett et al., 1978; Watts, 1981; Widmer et al., 1983). It would, therefore, seem logical to statistically control for medication compliance if a relationship existed between diet compliance and blood pressure improvement. Indeed, among the 67 participants in this study, the only significant relationship to blood pressure at intake and termination and to the significant decrease in blood pressure was medication compliance. Although medication compliance did not significantly change, it was high at intake and remained high at 143 termination. In fact, the high compliance with medication may be a reason that there was no measurable impact from diet compliance. Weight was included as an extraneous variable for possible use as an objective measure of dietary compliance. However, weight did not change from intake to termination and was not correlated with blood pressure at intake or termination. However, change in weight among the sample (which was nonsignificantly increased) was correlated to change in diet compliance (which significantly decreased). A possible explanation for this finding is that weight increased because compliance with diet worsened or that weight loss was not sustained. In sum, the extraneous variable of medication compliance was the only variable in this study that significantly related to the improvement in blood pressure among the 67 participants in this study. Weight was not related to compliance with diet nor blood pressure at any point in the study nor to the change in blood pressure. Statement of the Research Questions The research questions will be presented along with a brief review of the findings relevant to each question. A discussion of the findings and comparison to the literature will also be included. Qgestion 1. Is there a relationship between client knowledge about diet and perception of benefits of diet to stated compliance with diet before and following an experimental nursing intervention? Specifically: Question Is. Is there a relationship between knowledge scores about diet and compliance with diet scores before and following an experimental nursing intervention? 144 No relationship was found between the scores on the instrument to measure knowledge about diet and stated compliance with diet at intake or termination of the nursing intervention. Before a discussion of these findings is presented, it must be mentioned that the instrument used to measure knowledge about diet had a low reliability coefficient which brings into question the accuracy of the results. The findings concerning the lack of relationship between knowledge and compliance is supported by several researchers. Glanz and Scholl (1981), in a review of 18 studies concerning educational strategies to increase compliance, found that while information increases knowledge, there is rarely an impact on compliance. Becker (1979) and Becker and Maiman (1980) in a review of compliance literature also state that there is rarely a correlation between knowledge and adherence with therapeutic regimens. Further, these authors state that interventions to increase knowledge are only beneficial where a knowledge deficit interferes with the client's ability to comply. Several researchers who conducted studies involving education interventions report similar findings (Bille, 1977; Glanz et al., 1981; Morisky et al., 1980; Powers and Pohaten, 1982; Sackett et al., 1975; Steckel and Swain, 1977, 1981, 1982; Tanner and Noury, 1981). Other authors, however, do report a positive relationship between knowledge and compliance (Given et al., 1979; Hafeman & Madison, 1980; Inui et al., 1976; Sackett, 1980; Wyka et al., 1980; Zismer et al., 1982). There are few studies that include data concerning the relationship of knowledge about diet to diet compliance specifically. 145 Three studies were reviewed; one was among hemodialysis clients (Cummings et al., 1983), one among diabetics (Korhanen et al., 1983). and one among hypertensives (Nugent et al., 1984). No significant relationship was found between knowledge about diet and compliance with diet in any of the studies. Perhaps findings concerning the relationship of knowledge to compliance are inconsistent because 1) interventions to provide knowledge vary significantly among researchers and 2) measures of compliance are inconsistent. For instance, Steckel and Swain (1977, 1981, 1982) used only the distribution of an informational handout as the educational strategy whereas Wyka et al. (1980) provided five weeks of classes that not only focused on information, but also behaviors important for control of hypertension. The measures of compliance are as varied as the educational interventions ranging from self-report only, objective criteria such as medication counts or laboratory data, or outcome criteria such as weight and blood pressure. These discrepancies make comparison of the research difficult. Among the entire experimental group from which the sample for this study was obtained, the principal investigators found that knowledge about hypertension was generally high at intake. Included in the instrument to measure that knowledge were the questions specific to diet. Knowledge about diet was not high at either intake or termination of the study and it did not improve. Because knowledge in general was high, the focus of the interventions was not on providing information, although when deficits were identified in a nurse-client interaction they were addressed. Perhaps if data 146 concerning the level of diet knowledge (especially for the subset prescribed diet) had been available, the outcome of the study concerning the relationship of knowledge about diet to diet compliance may have been different. A more rational conclusion, however, is that knowledge about diet, in terms of factual information, may not be related to compliance with diet. Considering the findings from this study and those in the literature, providers of care to hypertensive clients should not assume knowledge will lead to compliance with diet. On the other hand, knowledge cannot be ignored because without adequate information to carry out the regimen, compliance is not possible (Becker, 1979). Whether or not knowledge is related to compliance, clients have a right to information about treatment regimens (Glanz and Scholl, 19891). Knowledge levels should, therefore, be assessed at each interaction and deficits addressed so that compliance with diet is possible. Question 1b. Is there a relationship between client perceived benefits of diet scores and compliance with diet before and following an experimental nursing intervention? There was a positive and significant relationship between perceived benefits of diet and diet compliance both at intake and termination of the study. The relationship between belief in the benefits of treatment and compliance with the treatment regimen is supported in the literature by major reviewers of compliance studies (Becker, 1979; Janz & Becker, 1984; Lousteau, 1979; Mikhail, 1981). Several individual researchers who obtained data from intervention studies concerning diet compliance also support the relationship 147 between perceived benefits of treatment and compliance (Cummings et al., 1982; Maiman et al., 1977; O'Connell et al., 1985; Wyatt et al., 1980). The measurements of perceived benefits, like those of knowledge and compliance, are inconsistent among studies. Becker (1979) and Janz and Becker (1984) cite the measurement inconsistencies as a major problem in attempts to compare findings among compliance studies. The principal investigators of the original study from which this sample was obtained reported that hypertensive clients did not appear to have distinct cognitive differences in beliefs concerning barriers and benefits of diet and so the final tool utilized to measure benefits of diet was a commitment to diet scale derived from the variables with the highest correlations on the subscales measuring benefits and barriers of diet. The relationship of benefits and barriers is supported by Cummings et al. (1978) who found a strong negative relationship between the two measures. The recommendation, based on this finding, is to not treat the two concepts as separate entities (Cummings, et al., 1978). It must be kept in mind that the positive findings concerning the relationship between perceived benefits of diet and compliance with diet in this study are a reflection of not only believing the diet is beneficial, but also perceiving fewer barriers to following the prescribed diet. Based on the findings, both benefits and barriers should be assessed in relationship to diet. If inappropriate beliefs or specific barriers are identified, they should be addressed using whatever resources are available and necessary. Nurse providers, in particular, have the nutritional expertise to provide the information 148 to improve perceptions concerning the benefits of diet and to provide the skills to overcome barriers. Nurses also have the necessary counseling and coordinating skills to assist with mobilizing the necessary resources for assisting clients to overcome barriers to dietary compliance. Question 1c. Is there a relationship between knowledge scores about diet and perceived benefits of diet scores before and following an experimental nursing intervention? There was no relationship between the scores measuring knowledge about diet and perceived benefits of diet at either intake or termination of the study. The accuracy of findings from this study concerning knowledge about diet are questionable due to the low reliability of the instrument. The only researchers who specifically addressed the relationship of knowledge to perception of benefits are Given et al. (1978). Inui et al. (1976), in an experiment involving provisions for physician tutorials about the health belief model, found that clients of those physicians who were tutored were not only more knowledgeable about the treatment regimen for hypertension, including diet, but also had more appropriate beliefs concerning efficacy of treatment. The two variables, however, were not correlated. In a review of the health belief model, Lousteau (1979) suggests that misunderstandings the client may have about illness and treatment can contribute to inaccurate beliefs. Anderson (1982) points out that clients with chronic disease must have adequate information to believe that they are at risk for complications and that following the treatment regimen will decrease that risk. Although knowledge alone does not ensure 149 appropriate beliefs, it can become the basis for developing such beliefs (Given & Given, 1983). The lack of relationship between knowledge and perceived benefits concerning diet in this study may have been influenced by the measurement difficulties. Another explanation is that many providers do not emphasize the role of diet as a critical component of the treatment plan since compliance with diet is difficult to establish and maintain (Glanz, 1980). Therefore, perhaps the role of diet was not stressed as an important part of the overall regimen early in treatment. Participants in this study had a mean duration of 3.4 years and so were exposed to intervention by physician providers far longer than they were exposed to the nursing intervention. Physician providers often do not take the necessary time to assure that clients have the appropriate perceptions concerning diet nor the necessary information. Given that perceived benefits and fewer barriers are related to compliance, than at the very least, hypertensive clients need adequate information concerning the relationship of diet to blood pressure and the necessary skills to overcome barriers. Providers of care to hypertensive clients should increase their own knowledge about the role of diet and assess their perceptions concerning beliefs in the benefits of diet. Certainly if the provider does not believe that diet is worth the effort it takes to foster compliance, that will have an impact on the client's perceptions. Dietary regimens should receive at least as much attention from providers as pharmacological treatment and perhaps more since the behavioral changes necessary for compliance are more complex (Glanz, 1986). The clinical nurse specialist in 150 primary care is the ideal provider of the care hypertensive clients require for compliance with diet. Question 2. Is there a relationship between compliance with diet and blood pressure before and following an experimental nursing intervention? There was no relationship between compliance with diet and either systolic or diastolic blood pressure at intake or termination. There was also no relationship between the change in diet compliance (which significantly decreased) and change in blood pressure (which significantly improved). An explanation for this finding is that, among the participants, diet compliance was not high at either intake or termination (2.7 and 2.5 respectively with a range of 1-5) and compliance with diet became significantly worse. Compliance with medications was very high among the participants of this study and remained high and significantly correlated with blood pressure levels, a finding well supported in the literature (Green et al., 1979; Haynes et al., 1982; Hershey et al., 1980; Inui et al., 1976; Morisky et a1., 1980; Sackett et al., 1978; Widmer et al., 1983). Early intervention sessions by the nurses focused on medication compliance which is another explanation for why diet compliance not only did not improve, but supports the highly significant relationship between medication compliance and blood pressure. Post study interviews of the clients by the principal investigators were conducted and a finding was that as the nurse-client relationship progressed, clients responded more honestly to the issue of compliance both with medications and diet. This certainly helps to explain why compliance with diet appears to have 151 significantly declined and why compliance with medication did not significantly improve. There are contradictory findings in the literature concerning the relationship of compliance with a low sodium diet and blood pressure. Nugent et al. (1984) found that even though participants complied with a low sodium diet as measured by less urine sodium excretion, there was no significant improvement in blood pressure. Other researchers found that clients who complied with low sodium diets as measured by urine chloride titrator sticks did have have significant improvement in blood pressure (Kaplan et al., 1982; Luft et al., 1984; Sloan, 1985). Researchers who controlled sodium intake in their studies but did not address the issue of compliance, also had contradictory results. Most notable are the two double blind, controlled experiments conducted by MacGregor et al. (1982) and Watt et al. (1983) that had exactly opposite results concerning the relationship of sodium intake to blood pressure. The researchers who examine the effect of weight loss on blood pressure demonstrate that there is a positive relationship (Gillum et al., 1983; Heyden et al., 1984; Hunt & Margie, 1980; Jeffery et al., 1983; Langford et al., 1985; Ramsey et al., 1978; Reissen et al., 1978; Stamler et al., 1980). These studies, however, do not address the issue of compliance. Weight and blood pressure were the outcome criteria. In spite of the lack of support in this study for the relationship of diet compliance to blood pressure, low sodium intake and weight loss are clearly related to a decrease in blood pressure. Even if not viewed as definitive treatment for hypertension, providers 152 should consider that perhaps low sodium and low calorie eating can decrease the need for medication. Diet should, at least, receive as much attention in the treatment regimen as medication. Providers, however, must have an adequate understanding of the data available that supports the relationship between sodium and weight and blood pressure and share this information with hypertensive clients. Other Findings The other findings that will be discussed include the significant changes that occurred among the variables from intake into the study to termination and the relationships concerning beliefs in the benefits of treatment in general and the major study variables. A correlated t test was computed to test the effect of the intervention on the major variables. The significant results, some of which have been already mentioned, were a significant decrease in compliance with diet and both systolic and diastolic blood pressure, and an increase in belief in the benefits of treatment for hypertension. With regard to belief in treatment efficacy, there was a significant and positive relationship between that and knowledge about diet at intake only. There was also a significant negative relationship between perceived efficacy of treatment in general and perceived benefits of diet. Some of the explanations for these findings have been discussed elsewhere. In review, the fact that medication compliance was high and remained high explains the significant relationship of medication compliance to improvement in blood pressure. The fact that diet compliance declined may be related to the order of the intervention, which focused on medications first, or that clients responded more honestly to questions concerning diet compliance at termination. 153 Since perceived efficacy of treatment in general significantly improved and was negatively related to perceived benefits of diet, another explanation is that these clients believed more firmly that the medication regimen was more beneficial for control of their blood pressure and so felt it was more important to comply with the medication prescriptions. Considering the order of the intervention, that belief was probably reinforced by the nurse providers. It will be recalled that the mean duration of hypertension the participants was 3.4 years. Therefore, subjects had been exposed to other providers for far longer than the six months of the nursing intervention. Clients may have developed strong beliefs in medication as the primary treatment for hypertension before the intervention. Since beliefs in the benefits of treatment and perceived benefits of diet were negatively correlated, perhaps these participants believed that the medications and not the diet were the actual treatment for hypertension. The fact that most of the research concerning treatment for hypertension involves pharmacological measures only, indicates that providers also believe this to be true. The small correlation between beliefs in the benefits of treatment in general and knowledge about diet at intake should be viewed with the same caution as the other findings with regard to knowledge due to measurement problems. It must also be remembered that knowledge about diet was low at intake and remained so at termination. Perhaps the relationship can be explained again by the possibility that these clients did not perceive diet as an important part of the treatmeht regimen. 154 Based on these findings, more attention should be given to diet during treatment interactions. Clinical nurse specialists are ideal providers of the care hypertensive clients need for the clients to have appropriate perceptions of the benefits of diet and the skills to overcome barriers to following the diet. Clients should have the necessary information about the relationship of sodium and weight to blood pressure and believe that diet is an important part of the treatment regimen. There is no doubt, based on findings in this study and other research, that medication compliance improves blood pressure so efforts to foster medication compliance should also be part of any treatment plan. It must be remembered, however, that the skills required to take medications are far less complex than those required to comply with diet and require far less commitment (Glanz, 1986). In sum, the lack of relationship between knowledge about diet and compliance with diet found in this study is supported in the literature. The accuracy of the findings are questionable due to measurement problems. The fact that perceived benefits of diet was related to compliance with diet is supported in the literature, but must be interpreted as to include fewer perceived barriers to following the diet. The fact that knowledge about diet and perceived benefits of diet were unrelated may be due to measurement problems. This finding is not supported by the literature. Only the extraneous variable of medication compliance was consistently and significantly correlated to improvement in blood pressure. The fact that compliance with diet declined may be related to the order of the intervention, the belief that medication compliance was more beneficial for treatment, or the more honest response of participants at termination 155 of the study. The fact that belief in the benefits of treatment was negatively associated with perceived benefits of diet supports the conclusion that among these participants, there may not have been a great deal of value placed on following the prescribed diet. There is a discussion of the implications of these findings for nursing practice, education and research in the remainder of this chapter. Included will be a readjustment of the model used as a basis for this study which incorporates data from the findings. Implications for NursigggPractice This section will describe the implications for nursing practice based on the research focusing on the role of the clinical nurse specialist. Based on the literature, there is no doubt that nurses have a critical role in assisting hypertensive clients to comply with therapeutic regimens, including diet. The Task Force on the Role of Nursing in High Blood Pressure Control (1981) develOped guidelines for nurses caring for hypertensive clients stating that nurses are an invaluable resource in providing primary care to clients with uncomplicated hypertension. Although the nursing intervention in this study had no significant impact on diet compliance, the explanations for this must be kept in mind. The order of intervention, the mind-set of the participants from previous experience, and the increase in honesty to compliance questions are all possible explanations for the finding. The six month intervention time may not have been long enough to alter dietary behavior. While medication compliance involves adding new behaviors, diet compliance requires changing old, perhaps long standing behaviors which are more complex, require multiple decisions 156 throughout each day, and has a social impact (Given et al., 1984; Glanz, 1980, 1986). At any rate, nursing should not abandon efforts to increasing dietary compliance or be considered as ineffective in these efforts based on the results of this study. If other providers, such as physicians, do not choose to focus on diet, than, at least, they should not undermine its importance. The clinical nurse specialist should have control over the care needed to foster diet compliance and certainly, he/she is educationally qualified to render such care. Although diet compliance was not related to blood pressure improvement in this study, there is sufficient support in the literature (cited earlier) that both restricted sodium intake and weight loss contribute to improved levels of hypertension. Nursing should, therefore, continue to foster behaviors to promote compliance with these regimens. Participants in this study had low levels of dietary compliance which is a finding supported by the literature (Glanz, 1980, 1986). In order to provide appropriate care for hypertensives on a dietary regimen, nurses must pay constant attention to nonadherence and explore solutions to dietary compliance problems (Grim & Grim, 1982; Heine, 1981; McCord, 1986). Exploration of compliance problems can occur within the nursing process framework applying King's theory, the research concerning the health belief model, and the roles of the clinical nurse specialist. In Figure 8, a combined model for care of hypertensive clients to foster diet compliance is presented. 157 Modifying Factors The major modifying factor explored in this study was knowledge about diet. While the data analysis from the sample in this study did not result in information that knowledge either effected perceived benefits of diet or compliance with diet, the limitations previously mentioned concerning these findings must be considered. It must also be kept in mind that the sample in this study did not have characteristics similar to typical hypertensives in the United States. Therefore, it would be inappropriate to conclude that knowledge about diet is not related to either perceived benefits, or for that matter fewer barriers, or to diet compliance. While knowledge does not guarantee compliance, without adequate information, clients cannot comply (Becker, 1979; Becker & Maiman, 1980). Knowledge about diet should remain in the model as a modifying factor and as an influence on actions taken by hypertensive clients both before and following nursing intervention. Based on results of this study, age, sex, and duration of hypertension should be included in the model as modifying factors. Since younger clients perceived more benefit of diet and/or fewer barriers, nurses should more carefully assess the older client to determine their perceptions concerning these beliefs. Younger clients also complied better with diet which suggests that nurses should focus more attention on diet compliance problems of the older hypertensive. 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(READ CATEGORIES) APPENDIX D APPENDIX D NURSING CARE PLAN Nursing Diagnosis: Nonparticipation in diet regimen related to lack of knowledge, skill, inadequate perception of benefits, or barriers concerning diet resulting in noncompliance with the low sodium and/or weight loss dietary prescription. Outcome Criteria: The Client will: 1. Report consumption of foods consistent with the dietary prescription. 2. Have a systolic B/P of _____ and a diastolic B/P of 3. Will have a chloride titler of 4. Will lose _____ pounds (Time perameters as well as specific indicators should be mutually established.) Nursing Activities: '1. Assess the client's current knowledge concerning the dietary prescription (have client state the diet, provide 24-hour recall, choose appropriate foods from a list, etc.). Reassess at each visit. 2. Assess the client's current perceptions concerning the relationship of dietary behavior and blood pressure (ask how salt and/or weight effects blood pressure, how diet would help decrease symptoms or prevent complications, if diet is worth the effort). Reassess at future visits. 187 188 3. Provide written and verbal information as needed about the relationship of diet to high blood pressure and the principles of dietary management (relationship of sodium or weight to hypertension, how decreasing sodium and or weight contributes to control, how diet can decrease the need for drugs and therefore cost and side effects). Reinforce at each visit. 4. Provide written and verbal information about diet and reassess knowledge and reinforce at each visit (sample menus, shopping lists, prohibited foods, foods that can be eaten freely, other ways to season foods, how to read labels). Consider financial, ethnic and other variables for dietary planning. Reassess and reinforce at each visit. 5. Seek feedback and clarify understanding at each stage. 6. Mutually develop dietary and blood pressure goals. 7. Mutually develop a strategy for incorporating needed dietary changes into lifestyle. 8. Assist the client to develop a specific plan to implement each strategy. 9. Assist the client to anticipate obstacles to dietary compliance and to use problem solving to overcome (ask how will plan for eating in restaurants, at work, or visiting friends). 10. Mutually develop methods of measuring success at each step of dietary change. 11. Involve the client in self-monitoring for both compliance and progress toward outcomes as much as possible) monitoring urine sodium, recording weights, keeping a food diary). 189 12. At future visits, assist the client to assess degree of success and identify obstacles if goals are not achieved. Reestablish goals and strategies as needed. 13. Involve the client's significant other in the process as much as possible and agreed upon. 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