Barriers to Adherence to Antihypertensive Medications among African American: An Integrated Review

ABSTRACT

This integrated review seeks to explore the barriers to adherence to antihypertensive medication among African Americans. The prevalence of hypertension is common among the African Americans due to many potential contributory factors (Huntley & Heady, 2013). This integrated review involved three studies selected, following the review of inclusion and exclusion criteria. Based on the findings of the studies, it was determined that the barriers to adherence to hypertension medications among the African Americans included patient’s knowledge of medication, long and recurrent treatment duration, education and literacy level, stained patient-health care provider relationship, lack of health care insurance plan, self-belief about medication, side effects of the medication, psychological factors, access to health care, social factors such as support systems and socio-economic and inconveniency. Furthermore, the review also highlighted that some key health care providers are not strict on the interventions that are recommended for management of hypertension, especially on the African Americans

INTRODUCTION

Hypertension poses a critical health problem in both developed and developing countries. According to the Center for Disease Control and Prevention (CDC, 2016) estimates, over 13% of hypertension related deaths occur annually. Despite the initiatives that are provided in the national and international guidelines for hypertension, recent population based studies have indicated that approximately two thirds of the patients who suffer from hypertension do not go for treatment or inadequately control hypertension. Studies also reveal that significant numbers of the victims are undiagnosed. Likewise, National Health and Nutrition Examination Survey (NHANES, 2017) gives the approximate number of Americans that have been diagnosed with high blood pressure to about a third. This translates to about 66.9 million Americans. Out of this number, approximately 35.8 million are said to have uncontrolled hypertension. According to Siu (2015), high blood pressure predisposes a person to greater risk for cardiovascular diseases, kidney problems and cerebrovascular related accidents. CDC (2016) describes hypertension as a silent killer whose signs and symptoms can remain undetected until it has resulted into a substantial damage. Hypertension affects all races; however, the prevalence among the races is disproportionate. Huntley and Heady (2013) indicate that in the United States, blacks record the greatest morbidity and mortality rates from hypertension and is ranked among the leading globally. CDC (2013) brings an aspect of financial burden related to hypertension and asserts that in 2010, the projected cost burden of hypertension in the health care sector, cost of medication and absenteeism from work is estimated to be $131 billion. Despite the public health spirited efforts to minimize the prevalence of hypertension and its related health consequences, it is imperative that significant efforts should be put in place to target the African Americans who, according to the studies, are at a higher risk of hypertension, compared to other races. To achieve this objective, knowledge of hypertension, high skills of self-efficacy and adherence to medications are some of the areas that need to be considered since they have a great potential to enhance effective management of hypertension among African Americans. 

This paper will provide a succinct background of hypertension and focus on the barriers to adherence to anti-hypertension medications among African Americans. The choice was made based on the premise that several barriers are associated with effective prevention and treatment of hypertension among African Americans. Recent studies indicate that these barriers are multifaceted; however, particular barrier and its magnitude of influence vary from person to person. The Institute of Medicine (IOM, 2016) suggests that priority should be given to a population based strategies on management of hypertension that strives to reach many people and enhance their welfare. This is necessitated by the fact that both patients and healthcare providers tend to have varied ways of interpreting sickness and treatment as well as reasons for etiology, timing, and process in pathophysiology, symptoms, causes, consequences and treatment. However, before establishing the barriers to adherence to anti-hypertension medication, it is appropriate to first explore the knowledge about hypertension, patient efficacy skills, and adherence to medication and non-adherence to medication among African Americans. Subsequently, an exploration of the relationship between patient efficacy and adherence to medication will be determined. In essence, this will provide a comprehensive background of hypertension and to facilitate an in-depth understanding of barriers to adherence to hypertension medications. Furthermore, the research questions and the theoretical framework of this study will also be stated.  

Prevalence of Hypertension 

Hypertension poses a substantial problem globally. In 2008, the general prevalence of hypertension among adults aged 25 years and above globally was around 40%. Mozaffarian et al. (2014) contend that between the years 2011 to 2012, there was 29% prevalence rate of hypertension among Americans adults ranging from 18 years and above. The authors further assert that the prevalence of hypertension was relatively higher among African Americans (45%) compared to prevalence rate among other races (29%). Since the year 2011, there is no significant change that has occurred in the hypertension prevalence.  

Hypertension Differences among Races and Gender 

Despite hypertension being a multi-racial phenomenon, many studies suggest that its magnitude on African Americans is relatively high (Cuffee, et al., 2013). Accordingly, the study by Mozaffarian et al., (2014) suggests that 40% of the African American patients were at a higher risk of having high blood pressure as opposed to Caucasians. Besides, the study suggests that African Americans were 10% less likely to control their blood pressure. Based on the American Heart Association estimates, high blood pressure is common among men compared to women. Conversely, after attaining the age of 65 years, the prevalence of hypertension shifts and women become more vulnerable and have a higher likelihood of getting hypertension than men. Martin et al., (2013) avers that African Americans are less concerned with life changes or prescribed medications. This can perhaps be credited to lack of understanding, the low level of education, severe relationship with health care practitioners, longer and recurring treatment of hypertension, socio-economic support, knowledge of medications and side effects, poor health care accessibility, psychological factors and lack of insurance plan. 

Get a brand-new guide on essay writing

Everything you need to get A+ this semester!

Get it

By continuing, you agree to the Terms And conditions and Privacy policy

The download will start within seconds. Good luck!

Download

Knowledge about Hypertension

Based on the studies carried out by the Department of Health and Human Service (HHS, 2014) and the National Heart, Lung and Blood Institute (NHLBI, 2016), over 75% of Americans acknowledges that high blood pressure can cause strokes and heart related diseases. However, despite being aware, hypertension is still a significant health problem. Besides, numerous health care providers are still faced with challenges of communication, where they still have a problem of interpreting the treatment plan for the patients in a simple manner that they can understand and follow with ease. 

Mortality and Morbidity of Hypertension

As posited by Ogedegbe, et al., (2012), high blood pressure is a high risk factor to heart diseases risk causes such as heart failure and stroke. According to Warren-Findlow, Seymour, & Huber (2012), high blood pressure has led to deaths of an estimated 45% male and close to 55% of deaths in women in the United States. Among these estimates, African Americans are the major victims of hypertension, to about 52%. Furthermore, hypertension has led to the huge financial burden in America. In the year 2010, America spent over $76.6 billion to cater for medications, related health services and compensation of lost working days in hypertension related cases (Lewis, Schoenthaler & Ogedegbe, 2012). Accordingly, Mozaffarian et al. (2014) claims that the prevalence of death among African Americans due to high blood pressure is approximately 31.8% as opposed to 23.3% among the whites. 

Prevalence of Hypertension and Self-Efficacy 

Breaux-Shropshire et al. (2012) describe self-efficacy as the person’s strong beliefs in his or her ability to undertake certain actions that are necessary to attain particular desired outcomes. To improve on one’s health management programs aimed at alleviating chronic diseases such as hypertension, self-efficacy skills are requisite elements. Therefore, for African Americans to adequately manage high blood pressure, they must instill self-confident in them as they undertake necessary self-care actions. Such self-care behaviors include self-report and focused measures of adherence to hypertension medications regimen among African Americans with hypertension. Apparently, people with adequate self-efficacy have the potential of substantially enhancing chances of adhering to medication regimen. They can easily opt to actions such as involvement in physical activities, checking on weight, avoidance of smoking and take of less salt in diets to avoid incidences of hypertension. According to Siu (2015), most African Americans patients regard compliance with diet as being strict and hard. Moreover, some studies allude that among African Americans, self-efficacy is a predictor healthy behavior such as physical exercise, weight loss and physical activities. 

Medication Adherence 

Medication adherence is described as the ability of the patient to strictly stick to the recommendations of the health care provider regarding the dosage and the stipulated rate of taking the medication (Jones, et al., 2012). Often, the interaction between the physician and the patient always determine the adherence to treatment plans by the patient. It is not anything to doubt that adherence to medication regimen by the patient is crucial in the management of any kind of disease and equally, is essential in improving the patient’s life quality. However, one of the barriers with African Americans high blood pressure patients is the adherence to medications and the achievement of optimal health care. Unfortunately, there only exist little studies regarding the methods of enhancement medication adherence for this group. Actually, African Americans in most instances complain of adverse side effects from drugs, which pose a danger of low adherence to medication among them (Cooper et al., 2012). Therefore, to increase adherence levels, it is critical for the health care provider to put into consideration of the factors that influence patient’s health beliefs, values, socioeconomic status, social structures and lifestyles. However, it is important to take into consideration of the fact that medication intervention that is appropriate for one ethnicity or race may not be appropriate for another different ethnicity or race. 

Medication Non-Adherence 

According to the American Heart Association, several factors can contribute to non-adherence to medication regimen. Lewis, Schoenthaler, & Ogedegbe, (2012) postulate that medical non-adherence, in most instances, is characterized by old age and gender, with the male gender mostly affected. Whereas, in relation to ethnicity, especially African Americans, low income, burden of the disease, reduced social support system, smoking, cognitive impairment and obesity are rampant. Intrinsically, treatment of hypertension is costly and undeniably, a major cause of financial burden to the patients, their families and health care providers. Furthermore, the study indicate that 50% and 70% of African Americans have tested positive for hypertension, yet, they have not adhered to medication regiment or changed their lifestyle. The study states that African Americans find it hard to believe in the medical therapy. Consequently, high blood pressure among them has been on a constant rise for years as compared to whites. 

Relationship between Self-Efficacy and Medication Adherence

The effective relationship between the two aspects should exist in a manner that the patient should be willing to follow in regard to the directives of the physician and acknowledge that by adhering to the medication, he or she is, in essence, enhancing disease outcome, thereby, improving on life quality. In particular, the African Americans should take note of the relationship between self-efficacy and adherence to medication since their self-efficiency is relatively low. By acknowledging the relationship between these two aspects, African Americans will be empowered and, as a result, they will be able to break the barriers to adherence to anti-hypertension medications. 

Research Questions 

• Are white Americans more knowledgeable about adherence to anti-hypertension medications than the African Americans?
• Is there any difference between the barriers to the adherence to anti-hypertension medications between white Americans and African Americans?
• Is there any connection between self-efficacy and adherence to hypertension medications?

METHOD

Purpose 

The purpose of this integrated review is to explore the knowledge of hypertension among African Americans and to determine the barriers to adherence to anti-hypertension medications among African Americans. 

Theoretical Frame Work 

This integrated review was carried out based on the methodology advanced by Holly (2004) that comprises of the stages such as problem identification, literature review and evaluation of the study, data analysis, and result summary. 

Sources of Data

The electronic sources that were used in the integrated review of literature in the current study include Cochrane Library, a site where many medical and scientific studies are found. Additionally, the site is popular for retrieving integrated reviews. Other sources of data such as Database of the National Library of Medicine (MEDLINE), EBSCO, CINAHL, which provide varied databases for outstanding nursing and related health journals, were also important for this study. The other sources included Science Direct, which has several peer- reviewed nursing articles and Proquest Central, which is a site where data are available for multidisciplinary research. Imperatively, these sources of data contain various researches that are effective to the topic. Furthermore, the choice of the sites was informed by the fact that they have the capability for advanced searches and filtering.

The keywords used while searching the databases included “barriers to adherence to anti-hypertension medication among African Americans” or “adherence to hypertension medication among African Americans” and “non-adherence to hypertension medications among African Americans”. Regarding the inclusion and exclusion criteria, specific inclusion material focused on: 

• Studies conducted among the African Americans in the United States.
• Strategies to improve adherence to hypertension medication among the study population.
• Research that was focused on the barriers to adherence to anti-hypertension medications.

All the studies that focused on the barriers to adherence to hypertension medications among the other races or ethnicities other than African Americans were excluded. Besides, articles that focused on other subject matter containing other risk factors such as heart related diseases, diabetes or obesity were equally excluded. The consideration of studies for review was placed on the research articles that were published from the year 2010 to 2017 because it was anticipated that old studies posed the risk of being obsolete. Besides, the decision was informed by the fact that new studies had the ability to indicate varied significance in the determination of the barriers to adherence to anti-hypertension medications among the African Americans and to bring aspects of available models of the latest technologies. Furthermore, the study took into a considerable reference lists of the related studies. Peer reviewed articles were also checked for relevant bibliography and reference of the citation. The searching criteria involved the location of the already identified studies in the reviews and by looking for the key words in the article. However, the challenge that was encountered with citation referencing is, in most instances, it only generated older studies and not the recently conducted research. Notably, despite using integrated and systematic reviews for forward citation, the studies were excluded. Nonetheless, duplicates were identified in the entire study and eliminated. 

After the search, 470 articles were identified. Out of the 470 articles, 452 articles did not conform to the inclusion criteria for the review and were consequently, excluded. The remaining 18 articles, which primarily focused on the barriers, adherence and non-adherence to anti-hypertension medications, were then subjected to further analysis. After the assessment of all the articles, only three were identified for inclusion in this study. The three articles were then organized by the following criteria; name of the authors, year of publication, research question, experimental design, sample population, major findings, strengths, and limitation.

Essay writing service:

• Excellent quality
• 100% Turnitin-safe
• Affordable prices

Order now

RESULTS

After the review, the overall aims and methods adopted by the three studies are summarized in the table below. Subsequently, critical comments and issues in every study are discussed. Besides, strengths, limitations and a comparison between the studies are equally highlighted. Table 1 provides a precise summary of these results.

Table 1: Summary of adherence to anti-hypertension medications Studies

Study Aims 

Two of the studies concentrated on the essence of communication in adherence to hypertension medication. A study by Jeffrey et al. (2012) was necessitated by numerous challenges facing health care sector. As such, their aim was to specifically develop and implement a practical and less expensive computer based interactive telephone counseling system called Telephone-Linked-Care to monitor, educate and provide counseling to hypertensive African Americans. Besides, the intervention would often provide a summary of the data to the primary health care provider. The researchers, therefore, tested an automated telephone counseling system by conducting a two-fold randomized and controlled trial. That is,  intervention vis-à-vis normal care control among 337 patients to determine the effectiveness of automated computer based telephone intervention system to the health-related behavior change such as adherence to the medication by the hypertensive patients, physical activities and following dietary behaviors to prevent hypertension (DASH diet). An improvement was recorded with the intervention in areas of dietary quality recording (+3.5 points, p<0.03) and energy expenditure improved by (+80kca/day, p<0.03). However, no substantial reduction in systolic BP was recorded (-2.3mmHg, p=0.25). The researchers, therefore, concluded that automated telecommunications systems are convenient, scalable, and able to relay and tailor messages, and therefore, they are suitable for promoting dietary and energy balancedself-management in urban African Americans.  

The other study by Antoinette et al. (2009) equally highlights the essence of communication between the hypertensive patients and the health care providers. The objective of this study was to examine effects of the patients’ viewpoint of the communication of medical adherence by the health care providers. The study was conducted among the hypertensive African Americans that were selected from community based primary care practices. This study was informed by increasing evidence intervention, in the sense that minority patients such as African Americans are given poor interpersonal care quality and are, therefore, dissatisfied with the relationship that they have with health care providers. Besides, only a few studies have been carried out to evaluate this strained relationship and how it occurs. Cross-sectional study was conducted using (CAATCH) among 439 patients with inadequate controlled hypertension in Community Health Centers in the New York metropolitan area. The assessment of how the patients rated their care providers’ communication was done using a perceived communication style questionnaire. On the other hand, the assessment of medication adherence was conducted using the Morisky self-report measure. 55% of the participants were found to be non-adherent with their medications while 51% believed that their health care communication was non-collaborative. The researchers, therefore, concluded that a more collaborative communication provider was pertinent for better adherence to anti-hypertensive medications in a sample population of low income African American patients. 

The third study by Abida et al. (2015), however, seemed to acknowledge that poor adherence to anti-hypertensive regimens poses a threat to the successful treatment of cardiovascular diseases such as hypertension. Despite the fact that numerous studies have evaluated distinctions in the time, be it daily, weekly or on weekends in adherence to hypertensive medications, no study has been conducted to determine whether making a routine and medication taking can be a factor in the increased medication adherence. Consequently, this study was designed to, first, spot patients’ sociodemographic factors linked to reliable routine of taking medication. Secondly, to explore the relationship between consistencies in taking medication, adherence to medication and control of blood pressure (BP). The study was conducted among the hypertensive African Americans and it involved 190 patients who were required to complete a practice based randomized controlled trial. The result indicated that consistency in medication taking is substantial and was linked with better adherence to medication. However, the relationship with consistency index did not prove any statistical essence for control of systolic BP. As such, African Americans who undergo hypertension, although take their medications, are adherent to medications in time and the result lead to a better SBP control.   

Strengths and Limitations of the Studies 

All the studies appear to lack control groups or comparisons to validate the success and results. A more thorough experimental design would have led to reliable evidence. However, the studies presented significant strengths and contributed to enrichment of knowledge on adherent and non-adherent factors to the anti-hypertension medication among the African Americans. Notably, in the Abida et al. (2015) study, the findings ought to have been interpreted cautiously due to numerous noticeable limitations. Foremost, the study findings was not culturally responsive and could not be used to represent the broader population since it majorly focused on the low income African American women. Furthermore, the study adopted MEMS electronic monitoring devises to obtain adherence data. Despite being able to observe medication adherence, the electronic devises are not effective as they do not indicate the dose that is actually taken. Controlling high blood pressure is always associated with multifaceted challenges and as such, the better SBP control program identified in favor of more prescriptions for hypertensive patients can be traced from other factors such as heightened treatment intensity, lifestyle behaviors and medications. These factors are common among the hypertensive African Americans.

In Antoinette et al. (2009), numerous limitations are evident. First, the health care providers who took part in the study may not signify the providers, based in those Managed Care organizations and private practices. Apparently, health care providers who work with poorly served patients normally prefer a biopsychosocial approach to their medical practice, and in most instances, they are motivated by issues of social justice and health care equity and, therefore, they may show a more collaborative communication with patients. Secondly, there was no indicated specific time for medical relationship between patients and the providers. It is always recommended that for the purposes of care continuity, a documentation of patients should be maintained because patients who often have a regular care provider is more satisfied with diagnostic and interpersonal motives of their care, compared to those who do not. The cross-sectional study design used in this study makes it hard for the causal interpretation to be achieved. Despite the possibility that the level of adherence to medications by the patient is likely to affect the perception of his or her care provider communication, longitudinal studies was necessary to examine the nature of this relationship. 

DISCUSSION

The results indicate various barriers to adherence to anti-hypertension drugs among the African Americans. An important aspect of consideration include race together with patient-provider communication (Cuffee et al., 2013).  Substantially, race plays a significant role in influencing the hypertensive drug adherence among the African Americans. This is in turn affected by the racial profiling that is common place among the whites and blacks. The hypertensive African American patients recorded low levels of adherence from white providers as compared to the black providers (Cuffee, et al., 2013). This is guided by the premise that white provider’s communication did not yield an effective collaborative perspective in the context of patient-provider communication. In other words, the African American hypertensive patients tend to be withdrawal under the care of white providers as opposed to their peers. This in turn influenced their perception to the therapy together with adherence to antihypertensive medications administered to them. Ideally, racial composition had a minimal influence in the adherence to the antihypertensive medications among the African American patients. However, the racial composition influenced the communication component by altering the patient-provider communication, hence, influencing adherence. Apparently, the patient-physician relationship determines the interaction between the two, thus, playing an important role in the understanding of effective hypertensive medication (Huntley & Heady, 2013). Nonetheless, race influenced the level of relationship and collaborative approach between the primary healthcare providers and the African American hypertensive patients. In the aspect of white heath care providers, African American hypertensive patients had limited rates of dialogues and, therefore, experienced non-disclosure with respect to specific medications.  Limited dialogues hindered the information sharing techniques as the African Americans failed to provide full information relating to their medical conditions. The white health care provides consequently failed to understand the conditions affecting the blacks and, hence, influenced the diagnosis of their illnesses. Moreover, the African American hypertensive patient’s preference to interpersonal communication and the provider’s characteristics interfered with the adherence to the hypertensive medication. Consequently, administration of therapy was altered as the right medications failed to be administered. Therefore, ineffective communication in relation to race contribute to lack of adherence to the antihypertensive medications among the African Americans, leading to high prevalence rates of hypertension among the racial group. 

Resource allocation among the African American communities influenced the primary base practices, hence, contributing to their health seeking behaviors. Most of the health care settings were influenced by the low-income status of the African American communities. In addition, lack of health insurance cover altered the ability of the community to seek medication attention in health care facilities that provide quality services. Based on this premise, the African Americans with hypertension faced the risk of using the symptoms of hypertension as the reason for seeking medical attention (Cuffee, et al., 2013). This meant that medical attention was sought when the hypertensive conditions were at advanced stages. In most cases, the hypertension cases was masked with the cardiac conditions as well as diabetes. At such a stage, the African American patients become prone to many prescription drugs including those taken for hypertension. Intrinsically, as the cost of medications rises and due to low income or lack of private insurance covers, the African Americans fail to adhere to the antihypertension drug regimen. This led to an estimation of between 50% and 70% of antihypertensive drug adherence among the African Americans according to the World Health Organization. 

According to the studies, age factor as well contributed to the antihypertensive drugs non-adherence by the African Americans. The younger age was at higher rates of non-adherence compared to the older population. This can be attributed to the aspect of consistency. The older populations were at risk of degenerative complications such as diabetes, organ complications and lifestyle conditions that were associated with impaired organ functioning. The population was, therefore, related to high number of chronic complications (Huntley & Heady, 2013). These generations were at a higher chance to understand the antihypertensive drugs that were prescribed to them. The younger generations many a times were preoccupied with the trending fashions, which influenced their ability to understand their health problem and some failed to understand the nature of medications administered to them. It subsequently positions the youngest population as the hardest hit by the non-adherence to the prescribed antihypertensive drugs. Besides, the younger generations were prone to inconsistent routine due to fewer medications that were administered to them.  

Apparently, routine checks for blood pressure influenced the African Americans’ adherence to antihypertensive medications. There is a direct relationship between adherence to antihypertensive medication and the BP control (Huntley & Heady, 2013). The older generations were regular in examining their BP levels as opposed to the younger generations, consequently, affecting their behavior of outcome in relative to medications that were prescribed to them. This positions the younger populations at increased risk that is associated with the non-adherence to the hypertensive medications. 

Get your paper done on time by an expert in your field.

Learn more

CONCLUSION

Improving adherence to anti-hypertensive medications among African Americans has been a significant challenge since non-adherence is a multifaceted problem. Apparently, from the three studies, it is evident that when medication adherence factors are adequately implemented, they may be critical in improving the health care among African Americans. In essence, the studies have extensively examined patient and clinical factors, since they are the two factors that often, appear to be associated with adherence and self-efficacy. Patients with high self-efficacy have higher chances of adhering to anti-hypertensive medications. However, the patients who lack self-confident are more likely to reduce medication adherence. It is, therefore, imperative that social support for the hypertensive African Americans should be enhanced to encourage self-efficacy among the African Americans. Furthermore, communication between health care provider and patients is one of the areas where, according to the studies, is crucial in adherence to medications among African Americans. In particular, African American hypertensive patients who regard health care providers’ communication as concerned and mutual have high chances of adhering to the anti-hypertensive regimen. Therefore, based on these findings, it is important to encourage mutual cross-cultural communications among health care providers to encourage the marginalized groups such as African Americans to adhere to the anti-hypertensive regimen.

With the high emergence of evidence that communication skills are capable of causing a long-lasting change in the minds of high blood pressure patients; it is, therefore, necessary for medical schools to consider systematic inclusion of communication skills training programs in their curriculum. Besides, training students on cultural humility will also be significant for medical students in enhancing the requisite skills for effective communication and interaction with a variety of patient populations. Unlike the usual multicultural medical education models, cultural humility considers cultural competency as an everlasting commitment. Health care providers should thus be trained on the need to remain humble and be careful with some biasness in their practice especially for the minority groups such as African Americans. Similarly, the students should also be trained on the importance of the patient-provider relationship, which is anchored on mutual respect, collaboration and understanding to narrow the patient and the providers’ social and cultural differences. Essentially, equipping of health care providers with adequate training on their relationship with patients from varied cultures can lead to a satisfactory patient engagement, which will most likely improve the patient involvement in treatment, leading to satisfaction and consequently, adherence to the anti-hypertensive medications.