Knowledge, compliance with treatment regimen, and level of disease control among hypertensive patients

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1 Knowledge, compliance with treatment regimen, and level of disease control among hypertensive patients Item Type text; Thesis-Reproduction (electronic) Authors Watanabe, Elaine Harumi, Publisher The University of Arizona. Rights Copyright is held by the author. Digital access to this material is made possible by the University Libraries, University of Arizona. Further transmission, reproduction or presentation (such as public display or performance) of protected items is prohibited except with permission of the author. Download date 03/09/ :13:45 Link to Item

2 KNOWLEDGEj COMPLIANCE WITH -TREATMENT REGlMEN AND LEVEL OP DISEASE CONTROL AMONG HYPERTENSIVE PATIENTS by E laine Harumi Watanabe A T hesis Subm itted to the F a c u lty of the COLLEGE OF NURSING In P a r t i a l F u lfillm e n t of the Requirem ents For the Degree of MASTER OF SCIENCE In the G raduate College THE UNIVERSITY OF ARIZONA

3 STATEMENT BY AUTHOR This t h e s is has been subm itted in p a r t i a l f u l f illm e n t of requirem ents fo r an advanced degree a t The U n iv e rsity o f A rizona and is d e p o sited in the U n iv e rsity L ib ra ry to be made a v a ila b le to borrow ers under ru le s of the L ib rary. B rie f q u o ta tio n s from th is th e s is are allow able w ith o u t s p e c ia l perm issio n, p ro v id ed th a t accu rate acknowledgment of source is made. Requests f o r p erm issio n fo r extended q u o ta tio n from o r re p ro d u c tio n of t h i s m anuscript in whole or in p a r t may be g ra n te d by the head of the m ajor departm ent or th e Dean of th e G raduate C o l leg e when in h is judgment the proposed use of the m a te ria l is in the i n t e r e s t s of s c h o la rs h ip. In a l l o th e r i n sta n c e s, however, p erm issio n must be o b tain ed from the a u th o r. SIGHED: t U A t U zaaum.; iv a J x A C jj ll - APPROVAL BY THESIS DIRECTOR T his th e s is has been approved on the date shown below: Lois P ro sser A ssociate P ro fesso r of N ursing Date

4 ACKNOWLEDGMENTS The re s e a rc h e r w ishes to express g r a titu d e to h er th e s is committee members: Miss Lois P ro sse r, chairman; Dr. J e s s ie P e rg rin, and Dr. E leanor Bauwens f o r th e ir guidance and a s sis ta n c e during th is study. A p p reciatio n is extended to Dr. C h arles Nugent and Dr. R ichard C undiff f o r encouraging the re se a rc h e r to c o n tac t t h e i r p a tie n ts. The re se a rc h e r would also lik e to extend sin c e re thanks to those p a tie n ts who so w illin g ly gave of t h e i r time to p a r t ic ip a te and thus made th is stu d y p o s s ib le. The re se a rc h e r would lik e to thank h er husband fo r h is continued support and encouragement throughout th is study.

5 TABLE OF CONTENTS Page LIST OF TABLES...v i ABSTRACT...v i i i CHAPTER I. INTRODUCTION... 1 Purpose of the S tu d y... 3 Statem ent of the Problem... I4. A s su m p tio n s D e f i n i t i o n s... I4. L i m i t a t i o n s... 5> T h e o re tic a l Framework... 5 I I. REVIEW OF THE LITERATURE...II4. K n o w led g e...ii4. Com pliance...19 Sum m ary I I I. METHODOLOGY... 2lj. Design of the S t u d y... 21}. Study Sample D ata C o lle c tio n In stru m e n t...2? Demographic D a ta...27 K n o w led g e...29 Com pliance...30 C o n t r o l...32 IV. PRESENTATION AND ANALYSIS OF DATA...36 C h a r a c te r is tic s of the S a m p le...36 K n o w led g e Knowledge and Demographic Data IjJ M edication Compliance S a lt C o m p lia n c e...ij.? Weight C o m p lia n c e... lj.8 Appointment Com pliance Knowledge and Com pliance...50 i v

6 V TABLE OF CONTENTS Continued Page C o n tro l Knowledge and C o n tro l... 5>6 Compliance and C ontrol V. DISCUSSION OF FINDINGS F in d in g s in R e la tio n to L ite r a tu r e Review. 59 D i s c u s s i o n... 6 l C o n clu sio n s Recommendations VI. SUMMARY APPENDIX A: CONSENT FORM FOR PHYSICIAN APPENDIX B: CONSENT FORM FOR PARTICIPATION IN A STUDY MEASURING KNOWLEDGE, COMPLIANCE TO TREATMENT REGIMEN AND LEVEL OF DISEASE CONTROL APPENDIX C: QUESTIONNAIRE LIST OF REFERENCES 82

7 LIST OF TABLES Table Page 1. D is tr ib u tio n of S u b jects by A g e D is tr ib u tio n of S u b jects by R ace D is tr ib u tio n of S u b jects by S e x _. D is tr ib u tio n of S u b jects by M arita l S ta tu s D is tr ib u tio n of S u b jects by Years of Schooling D is tr ib u tio n of S ubjects by Source of Income D is tr ib u tio n of S u b jects by Average Annual Inc ome... k-0 8. D is tr ib u tio n of S ubjects by Years w ith H y p erte n sio n... I4.O 9. D is tr ib u tio n of S ubjects by Family H is to ry of H y p e rten sio n D is tr ib u tio n of S u b jects by H ollin g sh ead S o c ia l G l a s s D is tr ib u tio n of S u b je cts by Humber of C lin ic V is its in P ast Twelve M onths D is tr ib u tio n of S u b jects by C orrect Responses to Knowledge Q u estio n s M ultiple R egression A nalysis of Knowledge and S e le c te d Demographic...D a t a... lj-2 I{.2 lj-3 I4I]. II4.. D is tr ib u tio n of S ubjects by Humber of M edications Taken... I D is tr ib u tio n of S ubjects by M edication Com pliance... I} D is tr ib u tio n of S ubjects by S a lt Compliance.. I D is tr ib u tio n of S u b jects by Humber of Pounds L o s t... 1 _9 v i

8 v i i LIST OF TABLES Continued Table Page 18. D is tr ib u tio n o f S u b jects by Weight Compliance. I Knowledge by M edication C o m p lia n c e... 5 l 20. Knowledge by S a lt C o m p lia n c e... 5 l 21. Number and P ercen t of H ypertensive P a tie n ts by Compliance Level and Area of Treatm ent Regimen (N = 2 1 ) D is tr ib u tio n of S ubjects by Weight C ontrol Scores D is tr ib u tio n of S u b jects by Blood P ressu re C ontrol Scores D is tr ib u tio n of S u b jects by Levels of D isease C o n tro l Blood P ressu re C ontrol R ates by M edication C o m p lia n c e... 57

9 ABSTRACT The study was designed to answer th e fo llo w in g two q u estio n s: (1) Is th e re a r e la tio n s h ip between h y p e rte n siv e p a t i e n t s f knowledge of t h e i r d isease and t h e i r com pliance to th e p re s c rib e d tre atm e n t regimen; and (2 ) is th e re a r e la tio n s h ip between p a t i e n t s ' compliance w ith t h e i r treatm en t regimen and t h e i r l e v e l of d ise a se c o n tro l as measured by blood p re ssu re and w eight? Learning th eo ry combined w ith the ed u c a tio n a l o b je c tiv e s of the c o g n itiv e and a f f e c tiv e domain comprise the th e o r e tic a l framework fo r the stu d y. The q u e s tio n n a ire was divided in to fo u r p a rts w ith q u e stio n s seeking in fo rm atio n about s u b je c ts ' demographic d a ta, knowledge of the d ise a se, com pliance to the p re sc rib e d tre a tm e n t regimen, and le v e l of d ise a se c o n tro l. The sample of 21 s u b je c ts was chosen from a l i s t of p a tie n ts who were b eing fo llo w ed in e ith e r a G eneral Medicine or Endocrine C lin ic of a U n iv e rsity M edical Center, S ix m ales and 1 5 fem ales re p re s e n te d the sam ple. H igher knowledge was found to be r e l a t e d to a c c e p t able m edicatio n compliance at the s ig n ific a n c e le v e l. S u b jects who took t h e i r p re s c rib e d a n tih y p e rte n siv e m edicatio n as ordered had h ig h er knowledge. A cceptable m ed icatio n com pliance was found to be r e l a t e d to a ccep tab le blood p r e s sure c o n tro l at th e.013 s ig n ific a n c e le v e l. S ubjects who v i i i

10 i x took t h e i r p re s c rib e d a n tih y p e rte n siv e m ed icatio n as ordered were in b e t t e r blood p re ssu re c o n tro l.

11 CHAPTER I INTRODUCTION One of our forem ost h e a lth hazards today is h y p e rte n sio n. Based on fin d in g s of the N atio n al H ealth Survey of 1962 and p ro je c te d to to d a y s p o p u latio n, th e re are more th an 23 m illio n Americans who have h y p erte n sio n. And of th e se, many thousands die every year as a d ire c t r e s u l t of t h e i r d ise a se. A n tih y p erten siv e th erap y can e x e rt a s ig n if ic a n t b e n e f ic ia l e f f e c t in co m plications of h y p erten siv e re tin o p a th y, co n g estiv e h e a rt f a i l u r e, in c re a sin g azotem ia, c e re b ro v a sc u la r th ro m b o sis, c e re b ra l hem orrhage, and m yocardial i n f a r c tio n as shown by the two stu d ie s done by the V eterans A d m in istratio n C ooperative Study Group on A n tih y p erten siv e Agents (1967: 1028, and 1970: lli}-3). An in d iv id u a l diagn osed as having h y p e r te n sio n i s u s u a lly a b le to work and fu n c tio n in d ep en d en tly in h is d a ily l i f e and does n ot req u ire h o s p it a liz a t io n. Regular fo llo w -u p in an o u tp a tie n t s e t t i n g i s the su g g e ste d course o f m edical c a r e. I t i s the p a t ie n t h im s e lf, not the h e a lth care p r o f e s s io n a l, who has th e r e s p o n s i b i l i t y fo r the day to day management o f the d is e a s e. I t i s su g g e sted th a t the in d iv id u a l must have knowledge about h i s d isease and

12 an a t tit u d e o f accep tan ce o f h is d is e a s e in order to make r e s p o n sib le d e c is io n s about d a ily management. F r e is (1973: 1 7 ) has n o ted th a t com pliance i s the g r e a te s t roadblock to the s u c c e s s fu l lo n g -te rm treatm en t of h y p e r te n sio n. Compliance fo r a h y p e r te n siv e p a tie n t in v o lv e s n ot o n ly r eg u la r m ed ica tio n in ta k e and appointm ent k eep in g, but o fte n changes in d ie ta r y h a b its w ith a d ecrea sed s a l t in ta k e and adequate c a lo r ic in ta k e to m a in ta in an optimum w e ig h t. I t i s " g e n e r a lly agreed th a t r e s t r i c t i o n s on b eh avior or changes in p erso n a l h a b its are most d i f f i c u l t to f o llo w w h ile m ed ica tio n s appear to be th e e a s ie s t type o f regim en to f o llo w (D avis 1966: IOI4I 1.). S tu d ies have shown th a t the more complex the regim ens the g r e a te r th e p ercen t o f noncom pliance. Compliance to the p r e sc r ib e d treatm en t program in f e r s the p a tie n t has a b a s is o f knowledge about h is d is e a s e and an u nderstanding o f each trea tm en t. Longterm fo llo w -u p o f any ch ron ic d is e a s e r e q u ir e s p a r tic u la r a t te n t io n to p a t i e n t s 1 e d u c a tio n a l n e e d s. Y et s tu d ie s have shown th a t p a t ie n t s are not know ledgeable about t h e ir d i s ease and t h e ir m e d ic a tio n s. Many h y p e r te n siv e p a t ie n t s fo llo w a treatm en t program fo r a few weeks or months, o b ta in symptomatic r e l i e f and/or are inform ed th a t b lood p ressu re has been red u ced, and d isc o n tin u e a l l trea tm en t. The meaning o f h y p er te n sio n and th e accompanying impact on

13 h is l i f e s ty le o fte n make i t d i f f i c u l t fo r the in d iv id u a l to accept the treatm en t program, e s p e c ia lly i f he fe e ls w e ll. Once a treatm e n t regim en is p re sc rib e d f o r a pat i e n t and he becomes p a rt of the m edical care system, i t is ap p are n tly assumed by p h y sic ia n s and n u rses th a t the p a tie n t knows about h is d ise a se and is complying to the p re sc rib e d tre a tm e n t. Nurses can in c o rp o ra te teach in g o b je c tiv e s in the n u rsin g care of p a tie n ts w ith chronic i l l n e s s e s. But b efo re teach in g is done, n u rses need to a s c e rta in e x a c tly what p a tie n ts know about t h e i r disease and what they are doing w ith the treatm en t regim en in the home. These kinds of d ata c o lle c tio n can become an importa n t asp ect of n u rsin g r e s p o n s ib ility. As p a tie n ts gain knowledge about th e ir d isease and as i t s meaning is i n t e g rated in to th e ir l i f e s ty le, i t is hoped th a t they w ill become more com pliant to the treatm en t regim en. Purpose of the Study The purpose of the stu d y was to measure hyp erte n siv e p a t i e n t s knowledge of t h e i r d isea se and i t s r e la tio n s h ip to t h e i r compliance with a p re sc rib e d t r e a t ment regimen. The s e le c te d components of compliance in v e s tig a te d were: (1 ) tak in g m ed ication, (2 ) u sin g s a l t, (3) c o n tr o llin g w eight, and (Ij.) keeping appointm ents. I t was h y p o th esized th a t i f p a tie n ts were complying to th ese

14 components of t h e i r care, t h e i r blood p re ssu re and w eight would be in b e t t e r c o n tro l th an i f th ey were n o t complying Statem ent of the Problem The follow ing two q u estio n s were asked: 1. Is th e re a r e la tio n s h ip between h y p erten siv e p a t i e n t s 1 knowledge of t h e i r d isease and t h e i r compliance r e la te d to ta k in g m ed icatio n, u sin g s a l t, c o n tr o llin g w eight, and keeping appointm ents? 2. I s th e re a r e la tio n s h ip between p a t i e n t s compliance w ith the treatm en t regim en and t h e i r le v e l of d isease c o n tro l as measured by blood p ressu re and w eight? Assum ptions The assum ptions u n d e rly in g the stu d y a r e : 1. E s s e n tia l h y p e rten sio n is o fte n an asymptomati d is e a s e. 2. H ypertension can, in most in s ta n c e s, be e f f e c tiv e ly c o n tro lle d w ith m edication, decreased s a l t in ta k e, and w eight c o n tr o l. 3. Compliance is a complex phenomena involving the in d iv id u a l s behaviors and a ttitu d e s tow ard both h is d ise a se and the recommended tre atm e n t regimen. defined: D e f in it io n s For purposes of the stu d y the fo llo w in g term s are

15 H y p e rten sio n, E s s e n tia l h y p e rten sio n or hyperte n sio n of unknown cause. Knowledge. Cognizance or u n d erstan d in g of hyp erte n sio n as measured by the q u e stio n n a ire used in the study. Com pliance. Adherence to the p re s c rib e d m edical regim en r e l a t e d to ta k in g a n tih y p e rte n siv e m ed icatio n s, u sin g s a l t, c o n tr o llin g w eight, and keeping appointm ents. C o n tro l. R eg u latio n of w eight and blood p re ss u re. L im ita tio n s The lim ita tio n s of th e study in clu d ed the fo llo w ing: 1. The sample, s e le c te d from e i t h e r a G eneral Medicine or Endocrine C lin ic of a u n iv e r s ity M edical C en ter, was sm all. 2. There was no c o n tro l of o th e r m edical conditio n s of the s u b je c ts. 3. There was no c o n tro l of the amount or kind of in s tr u c tio n the su b je c ts had rec eiv ed about h y p erte n sio n. T h e o r e tic a l Framework Learning th eo ry combined w ith e d u c a tio n a l objectiv e s o f the c o g n itiv e and a f fe c tiv e domain com prise the th e o r e tic a l framework. many d if f e r e n t k in d s : Learning is complex and th e re are m asterin g motor s k i l l s, memorizing in fo rm atio n, le a rn in g f e e lin g s, concepts, and i n t e l l e c t u a l

16 s k i l l s such as g e n e ra liz in g and problem so lv in g. A ll th e o rie s of le a rn in g r e s t on a concept of man and behavior (Taba 1962: 7 8 ). F ie ld th eo ry, as form ulated by Lewin (1954: 8 l ), s ta te s th a t behavior is th e fu n c tio n of the p re se n t l i f e space. Learning is a change in the co g n itiv e s tr u c tu r e or in the way o f p e rc eiv in g events and g iving meaning to them. F ie ld th e o ry views le a rn in g as e s s e n t i a l l y a s o c ia l p ro cess. To le a rn, one must i n te r a c t w ith o th e rs. Learning occurs la r g e ly in response to b asic m o tiv atin g needs and goals and is enhanced by i n t e r e s t and m o tiv atio n as w ell as by p r a c t i c e. A ll resp o n ses or le a rn in g are tra n s f e r a b le. Taba ( : 82) wrote th a t... a l l s itu a tio n s are new and the responses to them are reo rg an ize d a p p lic a tio n s of the p revious o n es." The main road to tr a n s f e r of le a rn in g is v ia grasping the e s s e n tia l p r in c ip le s of a problem or s itu a tio n, or by evolving an approach to and a method of viewing s itu a tio n s which can be ap p lied to the next s i t u a tio n (Judd e t a l. 1936: 198). Readiness c r u c ia lly in flu e n c e s le a rn in g. Bruner ( : 1 5 ) noted th a t "... th e most ap p ro p ria te p a tte r n of re a d in e ss at any given moment would be th a t on which would lead, on the average, to the most v e r i d ic a l guess about the n a tu re of th e w orld around one at the moment."

17 M aturation and p r io r experience are two f a c to rs th a t determ ine an in d iv id u a l's re a d in e ss (Redman 1968: 37). The c o g n itiv e, a f f e c tiv e, and psychomotor domains are the th re e major p a r ts of Bloom's (1956: 7) taxonomy of e d u c a tio n a l o b je c tiv e s. The co g n itiv e domain in clu d es those o b je c tiv e s which deal w ith the r e c a l l or re c o g n itio n of knowledge and the development of i n t e l l e c t u a l s k i l l s, w hile the a ffe c tiv e domain in clu d es o b je c tiv e s which d escrib e change in i n t e r e s t, a t t i t u d e s, and v a lu e s. The c l a s s i f i c a t i o n s of the taxonomy range from the simple to the more complex behaviors and from the co n crete to the a b s tr a c t. The c o g n itiv e taxonomy co n tain s s ix major c la s se s : (1 ) knowledge, (2 ) comprehension, ( 3 ) a p p lic a tio n, (j+) a n a ly s is, (5 ) s y n th e s is, and (6 ) e v a lu a tio n. Knowledge involves the r e c a l l of s p e c ific s and u n iv e rs a ls, or the p sy ch o lo g ica l p ro cesses of remembering. The process of r e l a t in g is a lso involved in th a t a t e s t s itu a tio n re q u ire s the o rg a n iz a tio n and re o rg a n iz a tio n of a problem so th a t i t w ill fu rn is h the a p p ro p ria te s ig n a ls and cues fo r the knowledge the in d iv id u a l p o ssesses (Bloom 1956: 62). Comprehension re p re s e n ts the low est le v e l of u nd erstan d in g, such th a t the in d iv id u a l knows what is being communicated w ithout n e c e s s a r ily r e l a t in g i t to o th er m a te r ia l. The emphasis is on the m ental p ro cesses

18 o f o rg an izin g and re o rg a n iz a tin g m a te ria l to achieve a p a r t ic u la r purpose (Bloom 1956: 89). The a p p lic a tio n categ o ry in v o lv es the use of abs tr a c tio n s in p a r t ic u la r and co n crete s itu a tio n s, which may be in the form of g en eral id e a s, r u le s of procedures, te c h n ic a l p r in c ip le s, or th e o rie s (Bloom 1956: 120). The a n a ly sis category i s d iv id ed in to th re e p a rts a n a ly sis of elem ents, a n a ly sis of r e la tio n s h ip s, and a n a ly sis of o rg a n iz a tio n a l p r in c ip le s. A nalysis emphasiz e s th e breakdown o f the m a te ria l in to i t s c o n s titu e n t p a rts and d e te c tio n of the r e la tio n s h ip s of the p a rts and of the way they are organized (Bloom 1956: 162). S y n th esis re q u ire s p u ttin g to g e th e r elem ents and p a rts so as to form a w hole. I t in v o lv es arran g in g and combining p ie c e s, p a rts, or elem ents to c o n s titu te a p a t te rn o r s tr u c tu r e not c l e a r l y th e re before (Bloom : 189). E v a lu a tio n is d efin ed as the making o f judgments about the v alu e, fo r some purpose, of id e a s, s o lu tio n s, or m ethods. I t involves the use of c r i t e r i a to make e ith e r q u a n tita tiv e o r q u a lita tiv e judgm ents. E v alu a tio n involves some com bination of a l l the o th er beh av io rs of knowledge, comprehension, a p p lic a tio n, a n a ly s is, and s y n th e s is. I t re p re s e n ts not only an end p ro cess in d e a lin g w ith c o g n itio n, but also a major l i n k w ith the a ffe c tiv e b e h av io rs. Although e v a lu a tio n is l a s t in the

19 co g n itiv e domain, i t is not n e c e s s a r ily the l a s t ste p in th in k in g or problem solving (Bloom 1956: 2 1 l\.). M a rtin Ts (1970: 16) concept of "ex p lain in g " and "understanding" were used to complement Bloom*s taxonomy of ed u c a tio n a l o b je c tiv e s. U nderstanding and ex p lain in g something to someone d i f f e r from one another in th a t the l a t t e r is an a c t i v i t y and the form er is n o t. One who ex p lain s something to someone is try in g to g e t th a t person to le a rn o r u n d erstan d som ething. He is im p artin g knowledge, n o t seeking i t, and h is problem is one of communicatio n, of g e ttin g something across to someone. U nderstanding, the c o g n itiv e verb, in v o lv es seein g connections or r e la tio n s h ip s. E xplaining something to someone "does not n e c e s s a r ily r e s u l t in u n d erstan d in g, any more th an teach in g n e c e s s a r ily r e s u lts in le arn in g " (M artin 1970: 146). There can be ex p lan atio n w ithout u n d erstan d in g as w ell as u n d erstan d in g although no exp la in in g has taken p la c e. To u nderstand something one must p lace i t in some la r g e r co n tex t or framework as w ell as analyze i t (K ingsley 1957: 4 0 ). F e e lin g s and fla sh e s of in s ig h t are n e ith e r a guarantee th a t someone has understood something nor essen t i a l fo r someone s u n d erstan d in g something. As Ryle (1949: ) said : Even i f you claim ed th a t you had experien ced a f la s h or c lic k of com prehension and had a c tu a lly done so, you would s t i l l withdraw your o th er

20 claim to have u n d erstood th e argument, i f you found th a t you could n o t paraphrase i t, i l l u s t r a t e, expand or r e c a s t i t ; and you would a llo w someone e l s e to have u n d erstood i t who co u ld meet a l l exa m in a tio n q u e stio n s about i t, but no rep o rted c l i c k o f compreh e n sio n. There i s no doubt th a t th e t e s t o f u n d erstan d in g l i e s in perform ances (M artin 1970: II4.8 ). M artin Ts concept o f "exp lan ation " f i t s Bloom s knowledge c a te g o r y, w h ile h er con cep t o f "understanding" cou ld be compared to Bloom s a n a ly s is and s y n t h e s is c l a s s e s. Taba (1962: ) a lso d is c u s s e s the nature o f 10 know ledge. Her d iv is io n s of knowledge are s im ila r to Bloom s. The f i r s t l e v e l i s th a t o f s p e c if i c f a c t s, d e s c r ip t iv e id e a s at a low l e v e l o f a b s tr a c tio n, and s p e c if i c p r o c e s se s and s k i l l s. as s t a t i c, "dead end." T h is kind o f knowledge i s d escrib e d I t s m astery does not produce new id e a s, does not lu re the mind onward (Taba 1962: 175). B asic id e a s and p r in c ip le s r e p r e se n t the n e x t l e v e l o f know ledge. The th ir d l e v e l o f c o n te n t i s composed of conc e p ts, or complex system s o f h ig h ly a b str a c t id e a s. Thought sy stem s, th e fo u rth l e v e l, are composed o f propos i t i o n s and co n cep ts which d ir e c t the flo w o f in q u iry and th o u g h t. The a p p lic a tio n of knowledge in v o lv e s g en era tin g c e r t a in d is c ip lin e d methods o f form ing q u e s tio n s, d ev elo p in g l o g i c a l ways o f r e la t in g id e a s, and f o llo w in g a r a t io n a l method o f in q u ir y. T h is a b s tr a c t, fo u r th l e v e l o f

21 11 knowledge as d escrib e d by Taba encompasses Bloom 's c l a s s i f ic a tio n s of a p p lic a tio n, a n a ly s is, s y n th e s is, and e v a lu a tio n. While sequence and c o n tin u ity are im portant in le a rn in g, the sequence c o n s is ts not so much in th e successio n of d e t a i l s in th e v ario u s areas of knowledge as in the c o n tin u ity of le a rn in g ste p s lead in g toward the formatio n of id eas and the use of c o g n itiv e p r o c e s s e s. Taba ( : 189) w rote: This suggests a tw o -fo ld sequence fo r le a rn in g ex p erien ces: th e sequence of ideas to be d e a lt w ith, in the o rd er of t h e i r com plexity and a b s tra c tn e s s, and the sequence of c o g n itiv e p ro cesses in the o rder of in c re a s in g ly demanding i n t e l l e c t u a l r ig o r. The a ffe c tiv e domain is the second p a r t of Bloom's (1956: 7) taxonomy of ed u c a tio n a l o b je c ts. The major c la s se s a r e : (1 ) re c e iv in g (a tte n d in g ), (2 ) responding, (3 ) v a lu in g, (I4.) o rg a n iz a tio n, and (5 ) c h a r a c te r iz a tio n by a value or value complex. The a f fe c tiv e domain r e p re se n ts in c re a sin g i n t e r n a li z a ti o n or commitment to a f e e lin g, thus also re q u irin g more complex behavior a t high le v e ls (Krathwohl, Bloom, and Mas is 1961j.: 95). R eceiving is the in d iv id u a l being s e n s itiz e d to the e x isten c e of c e r ta in phenomena and is the f i r s t and c r u c ia l s te p. Responding is a c tiv e ly a tte n d in g. Acquiescence in responding o r compliance in v o lv es r e a c tin g to a su g g estio n,

22 12 w h ile w illin g n e s s to respond im p lie s th e c a p a c ity fo r v o lu n ta ry a c t i v i t y. S a t is f a c t io n in resp o n se im p lie s th a t the b eh a v io r i s accompanied by a f e e lin g o f s a t i s f a c t i o n or enjoyment (Krathwohl e t a l : 1?8). V alu in g in v o lv e s th e in t e r n a liz a t io n o f a s e t of s p e c if ie d, id e a l v a lu e s. A cceptance of a v a lu e, p r e fe r ence fo r a v a lu e, and commitment fu r th e r d e sc r ib e v a lu in g b eh avior (Krathwohl e t a l. 1964: 180). As the le a r n e r s u c c e s s f u lly in t e r n a liz e s v a lu e s, he en cou n ters s it u a t io n s fo r which more than one value i s r e le v a n t. N e c e s s it y a r is e s f o r th e o r g a n iz a tio n o f the v a lu e s in to a system, the d eterm in a tio n o f the in t e r r e la t io n s h ip s among them, and th e e sta b lish m e n t o f the dominant ones (Krathwohl e t a l. 1964: 182). C h a r a c te r iz a tio n by a v a lu e or va lu e complex i s th e f i n a l c l a s s of the a f f e c t i v e domain. The in d iv id u a l a c ts c o n s is t e n t ly in accordance w ith the v a lu e s he has in t e r n a liz e d at t h is l e v e l. There i s g e n e r a liz a t io n o f t h is c o n tr o l so th a t the in d iv id u a l i s d e sc r ib e d and c h a r a c te r iz e d as a person by th e se p erv a siv e c o n t r o llin g te n d e n c ie s as w e ll as in te g r a tio n of th e se b e l i e f s in to a t o t a l p h ilo so p h y or w orld view (Krathwohl 1964: 184). These le a r n in g th e o r ie s h e lp to e x p la in the a cq u i s i t i o n o f knowledge and u n d erstan d in g by th e p a tie n t and the ap p rop riate perform ance or com pliance th a t i s

23 expected w ith the a c q u is itio n of knowledge. A p a tie n t le a rn s to understand (c o g n itiv e domain) how h y p e rte n sio n a f fe c ts h is body and how a d ecreased in ta k e of s a l t, o p timum w eight, and a n tih y p e rte n siv e m edication h elp to c o n tro l h is blood p re ssu re. Most im portant to t h i s goal is an a ttitu d e of acceptance ( a f fe c tiv e domain) of h is d isea se and of r e s p o n s i b il i t y in carin g f o r h im self.

24 CHAPTER I I REVIEW OF THE LITERATURE The l i t e r a t u r e rev iew i s d iv id e d in to two s e c t io n s. outcom e. The f i r s t s e c tio n d e a ls w ith knowledge and i t s The second s e c t io n d e a ls w ith com p lian ce. Knowledge A rev iew o f the l i t e r a t u r e r e v e a le d s e v e r a l s tu d ie s d e a lin g w ith h y p e r te n siv e p a t i e n t s knowledge, com pliance, and c o n tr o l of t h e ir d is e a s e. Me Kenney e t a l. (1973: H O ij.) conducted a study among 25 noncom pliant h y p e r te n siv e s to i d e n t i f y the h e a lth care n eed s o f th e am bulatory p a t ie n t s, to i n i t i a t e c l i n i c a l pharmacy s e r v ic e s which would respond to th e se n e e d s, and to e v a lu a te the e f f e c t o f th e se s e r v ic e s. The pharmac i s t d isc u s se d the d ise a s e and in v e s t ig a te d adverse drug r e a c tio n s w ith th e p a t ie n t s. P a tie n ts were found to know v ery l i t t l e about h y p er ten sio n and the s ig n if ic a n c e and r e la t io n s h ip o f b lood p ressu re to h y p e r te n sio n. R e su lts showed a s i g n i f i c a n t improvement in t h e ir knowledge o f h y p e r te n sio n and i t s trea tm en t, an in c r e a se in com pliance w ith p r e sc r ib e d th erap y, and an in c r e a se in c o n tr o l o f b lood p r e s s u r e. U n fo r tu n a te ly, th e s e p a t ie n t s re v e r te d back to the noneom pliant s ta t e a f te r the stu d y. The 25 llj-

25 c o n tro l h y p e rte n siv e s rem ained noneom pliant b e fo re, d u ring and a f t e r the stu d y. I t i s im portant to note th a t s e r v i ces must be continued i n d e f in i t e l y to be most e f f e c tiv e, since these p a tie n ts did no t rem ain com pliant a f te r the study p e rio d. A stu d y done by P e rg rin (19714-) d e a lt w ith hyp erte n siv e and d ia b e tic p a t i e n t s 1 knowledge, adherence to th e ra p e u tic regim en, and d ise a se c o n tro l. A cceptable knowledge was shown by 50 p e rc e n t of the 69 p a tie n ts in terv iew ed and te s te d. The fo u r areas of adherence th a t were in v e s tig a te d were m ed icatio n in ta k e, s a l t in ta k e, weight c o n tro l, and appointm ent keeping. Although m edicatio n was determ ined as most im portant in c o n tro l, h ig h e st compliance was found in the a re a of p a tie n ts keeping t h e i r appointm ents. Free tr a n s p o r ta tio n to the c l i n i c was one p o s sib le ex p la n a tio n. Another e x p la n a tio n was th a t only p a tie n ts who re tu rn e d fo r th re e c li n i c v i s i t s were s e l e c t ed and th is e lim in a ted those p a tie n ts who d id not r e tu r n a f te r the f i r s t or second appointm ent. W eight showed the second h ig h e st in com pliance, although o th e r stu d ie s have shown th a t a change in h a b it i s o fte n the most d i f f i c u l t to change. In the two areas of s a l t in tak e and weight cont r o l, some re p o rte d th ey had not receiv ed any in s tr u c tio n. Of those p a tie n ts w ith accep tab le knowledge, 71 p erc e n t had accep tab le compliance w hile f o r p a tie n ts w ith

26 16 unaccep tab le knowledge, 52 p e rc e n t had accep tab le com pliance s c o r e s. Those who had g o o d -fa ir c o n tro l had more knowledge about t h e i r d isease than those in poorer c o n tro l. D iab e tic s have been the focus of many knowledge and compliance s tu d ie s, since d ia b e te s is a d ise a se r e q u ir ing re g u la r o u tp a tie n t follow -up as w ell as d a ily s e l f - c a r e. W atkins e t a l. (1967: ^57), W illiam s e t a l. (1967: and P e rg rin ( : ) have s tu d ie d d ia b e tic s* knowledge about t h e i r d ise a se, t h e i r com pliance, and t h e i r le v e l of d isea se c o n tro l. S u rp ris in g ly, in a l l th re e s tu d ie s, p a tie n ts* knowledge about d ia b e te s was shown to be in v e rs e ly c o rre la te d w ith t h e i r le v e l of d ise a se c o n tro l. One p o ssib le e x p la n a tio n fo r high knowledge among p o o rly -c o n tro lle d p a tie n ts is th a t because they are in poor c o n tr o l, they have had more experience w ith problems and have learn ed more; b u t d e s p ite t h is, o th e r f a c to rs continue to i n t e r fe re w ith t h e i r c o n tro l. However, Watkins e t a l. (1967: ) d id fin d a p o s itiv e c o r r e la tio n between d iab etics* knowledge and t h e i r com pliance. S ev eral in v e s tig a to r s have considered p a tie n ts* knowledge about t h e i r m edications an im portant v a ria b le in s e lf-m e d ic a tio n p r a c tic e. Cole and Emmanuel (1971: ) in s tr u c te d d ischarged h o s p ita l p a tie n ts about t h e i r m edications and the im portance of follow ing drug regimens in d e t a i l. They took th re e groups of 25 p a tie n ts each; one re c e iv e d pharmacy c o n s u lta tio n p r io r to d isch a rg e.

27 one had pharmacy c o n s u lta tio n and s e lf-m e d ic a tio n p ra c tic e during h o s p ita liz a tio n, and the th i r d re c e iv e d no c o n s u lta tio n. Those p a tie n ts who had pharmacy c o n s u lta tio n p r io r to disch arg e were found to be 92 p erc en t com pliant, those who had both c o n s u lta tio n and p r a c tic e during h o s p it a l i z a tio n were 88 p erce n t com pliant, w hile those who receiv ed n e ith e r were 2l\. p e rce n t com pliant. Leary, V e s s e lla and Yeaw (1971: 1193) conducted 26? p a tie n t in te rv ie w s. Pat i e n t s rec e iv e d low scores on knowledge o f drug a ctio n, dosage, tim ing, and side e f f e c t s. Seventy-tw o p ercen t did not know any symptoms which might in d ic a te harm ful side e f f e c ts of t h e i r m ed icatio n. They were a lso vague, confused, or ig n o ra n t about the purpose f o r which they were ta k in g th e ir m ed ication. M alahy s (1966: 291) study attem pted to show th a t knowledge of m edications would decrease the number of medic a tio n e r ro r s made by p a t i e n t s. The sample c o n s is te d of tak in g fo u r groups of te n p a tie n ts, in tro d u c in g two v a r i a b les, te ac h in g and la b e lin g of m ed icatio n s, and then observing the number of m ed icatio n e r r o r s. I t was alarm ing to n o te th a t 90 p ercen t of the I4.O p a tie n ts made some kind of m edicatio n e r ro r. The g r e a te s t number of e rro rs occurred in the categ o ry of tim ing or sequence, w hile the second most fre q u e n t e r ro r was in not knowing th e purpose of th e drug. Although evidence in th i s study d id not

28 18 support the h y p o th esis th a t teaching p a tie n ts about drugs r e s u l t s in fewer e r r o r s, th e in v e s tig a to r b e lie v e d th a t teach in g must s t i l l make a d if f e r e n c e. H ypertensive p a t i e n t s T knowledge of i l l n e s s was p o s itiv e ly r e la te d to c lin ic attendance as shown in a study done by Tagliocozzo and Ima (1970: 773). A knowledge t e s t was ad m in istered to 159 o u tp a tie n ts. The t e s t focused on fo u r d ise a se s: h y p e rte n sio n, a r t h r i t i s, d ia b e te s, and can cer. For each p a tie n t at l e a s t one of these illn e s s e s was im p lica te d in h is c u rre n t d iag n o sis so th a t the fo u r d ise a se s were not com pletely unknown e n t i t i e s to the resp o n d en t. A s t a t i s t i c a l l y s ig n if ic a n t r e la tio n s h ip between knowledge and attendance behavior was shown. P a tie n ts w ith low knowledge sco res were more prone to term in ate care p r io r to the fo u rth v i s i t. Cross tabula tio n s of knowledge and s e le c t v a ria b le s re v e a le d stro n g a s s o c ia tio n of knowledge w ith ed u catio n and experience w ith i l l n e s s. The fin d in g s suggested th a t p ro p e rtie s of p a tie n ts may v ary in t h e i r s ig n ific a n c e fo r compliance behav io r, depending on the n a tu re of the i l l n e s s. Knowledge of i l l n e s s and i t s consequences appeared to be r e l e vant in an il l n e s s c h a ra c te riz e d by few problem s in s e lf management, le s s p a s t i l l n e s s ex p erien ce, and le s s demanding tre a tm e n t. The ro le of knowledge in p a tie n t behavior was reduced fo r d ia b e tic s and markedly pronounced fo r h y p e rte n s iv e s.

29 Compliance Low c o r re la tio n s have been found on p a t i e n t s 1 compliance reg ard in g re tu rn appointm ents, t e s t s, medicatio n s, tre a tm e n ts, r e f e r r a l s, and r e s t r i c t i o n s (Berkowitz e t a l. 1963: 22). I t seemed th a t the le v e ls of p a tie n t compliance was a ffe c te d by the n atu re of the req uirem ent. Follow -through was low est in areas which a p a tie n t has ex clu siv e r e s p o n s i b il i t y fo r h is own care a t home, s p e c if ic a lly h is m ed icatio n s, tre a tm e n ts and r e s t r i c t i o n s. Follow -through was h ig h e r on r e tu r n appointm ents, r e f e r r a l s and t e s t s ; th a t is, item s which were im portant to the in te r n a l fu n c tio n in g of the o rg a n iz a tio n but re q u ire d minimum p a tie n t e f f o r t or change. Davis (1966: 2l}.9) found th a t the la r g e s t number of p a tie n ts in h is study complied w ith two out of th re e regim ens, adhering to advice which involved the l e a s t amount of d i f f i c u l t y in a f fe c tin g a ch ange. The dropout problem in a n tih y p e rte n siv e tre atm e n t i s an im portant asp ect of management. To study reasons why p a tie n ts drop out of tre a tm e n t, C aldw ell e t a l. (1970: e v alu ated 66 p a tie n ts in term s of m edical care and s o c ia l- em otional f a c t o r s. A group of lj.2 p a tie n ts had had a h y p erte n siv e emergency a f te r d isc o n tin u in g tre a tm e n t, w hile a c o n tro l group of 2!j. p a tie n ts had had prolonged c o n s is te n t tre atm en t w ith good c o n tro l of t h e i r d is e a s e. The fo llo w ing reasons were given fo r d isc o n tin u in g tre a tm e n t: 39

30 p erc e n t f e l t w e ll, 36 p erc e n t f e l t they had poor in s t r u c 20 tio n, and 35 p ercen t c ite d f in a n c ia l need. In c o n tra s t the c o n tro l group had the fo llo w in g reasons f o r stay in g in tre atm e n t: 71 p erc en t had good knowledge of the d ise a se,. 50 p ercen t had knowledge of harm ful e f f e c ts of inadequate tre a tm e n t, and 50 p ercen t c ite d evidence of harm ful e f f e c ts of h y p e rte n sio n in the fam ily. The dropout group showed s t a t i s t i c a l l y s ig n if ic a n t d iffe re n c e s from the c o n tro l group. They were younger, had t h e i r d isea se f o r a s h o rte r tim e, had le s s ed u catio n and income, and were more l i k e l y to be black, blue c o lla r w o rk ers. Socio-economic f a c to r s, le a rn e d re sp o n s e s, and ed u catio n of the p a tie n t about h is d ise a se were found to in flu e n c e a p a t i e n t 1s a b i l i t y to fo llo w an a n tih y p e rte n siv e program. An approach to keep p a tie n ts in treatm e n t was p re se n te d, in v o lv in g education of the p a tie n t and spouse, s p e c ia l e f f o r ts a t the i n i t i a tio n o f tre atm e n t fo r the p o o rly educated and fo r those who f e e l w e ll. E ducation of the p a tie n t was named of g r e a te s t im portance to th e success of the th e ra p e u tic regim en. To determ ine reasons f o r noncompliance of hyperte n siv e p a tie n ts, P in n e rty, M a ttie, and P in n e rty (1973: 7 3 ) in terv iew ed 60 dropouts from fo u r h y p e rten siv e c l i n i c s. A q u e stio n n a ire was used to a sse ss three o b je c tiv e s : p a tie n t a t t i t u d e toward the p r o fe s s io n a l r e la tio n s h ip.

31 21 p a tie n t knowledge of d ise a se, and p a tie n t a t titu d e s toward economic f a c to r s. They found th a t th e time expended by p a tie n ts to o b ta in ca re, p a t i e n t s ' in te llig e n c e and understanding of th e ir d isea se, and the d o cto r/p a ram e d ica l- p a tie n t r e la tio n s h ip were the i n f l u e n t i a l f a c to r s a f fe c tin g the p a t i e n t s ' a t t i t u d e s. F if ty - f o u r p ercen t of p a tie n ts r e a d ily accepted care by a h e a lth a id e. Long w aitin g time and a poor d o c to r-p a tie n t r e la tio n s h ip were m ajor reasons fo r dropping out of the c l i n i c. C onsequently, the c lin ic was re o rg an ized to provide 2l(.-hour comprehensive serv ice and a p e rso n al d o c to r/p a ra m e d ic a l-p a tie n t r e la tio n s h ip. This reduced the dropout r a te from 1l2 p ercen t to 8 p e rc e n t. T u cso n 's V eterans H o s p ita l was the s i t e f o r a study of h y p e rten siv e p a t i e n t s c l i n i c attendance (Rezac 197b* lt-9). F ifte e n a tte n d e rs and 15 dropouts were in terv iew ed. P erso n n el, f re e care, and good q u a lity h e a lth care had p o s itiv e in flu en c e on c lin ic attendance b eh av io r. F ee lin g w e ll, u n p leasan t side e f f e c ts of m ed icatio n s, long w aitin g tim es, and job r e s p o n s i b i l i t i e s c o n f lic tin g w ith c lin ic hours had d e te r re n t in flu en c e on attendance and com pliance. Knowledge was not g e n e ra lly a s so c ia te d w ith com pliant b eh av io r. S tu d ie s on m edicatio n compliance are volum inous. I r r e g u la r s e lf - a d m in is tr a tio n of m edications is a s i g n i f i can t problem in the o u tp a tie n t management o f many i l l n e s s e s.

32 22 Mclnnis ( : ) found th a t only 57 p erc e n t of tu b e rcu lo s is p a t i e n t s f u rin e s were p o s itiv e f o r t h e i r a n titu b e r c u lo sis m ed icatio n. M oulding, Onstad and Sbarbaro (1970: ) re v e a le d th a t 31 p erc e n t of the group of supposedly r e l ia b le p a tie n ts took le s s than 70 p erc e n t of t h e i r medic a tio n s. Studies by Mohler, W allin, and D reyfus (1955: 1116), C ham ey e t a l. (1967: 190), and Bergman and Werner ( : ) rev ealed th a t only about h a lf of the p a tie n ts complied w ith t h e i r m edication tre a tm e n t. Summary In a review of the l i t e r a t u r e, two stu d ie s were found th a t d e a lt w ith the th re e v a ria b le s of h y p erten siv e p a tie n ts* knowledge, com pliance, and c o n t r o l. A p o s itiv e r e la tio n s h ip among h y p e rte n siv e p a tie n ts* knowledge of t h e i r d ise a se, com pliance w ith p re s c rib e d th erap y, and blood p r e s sure c o n tro l was found. Although d ia b e tic s did not show a p o s itiv e r e la tio n s h ip between knowledge and d ise a se cont r o l, h y p e rte n siv es did show t h i s p o s itiv e r e la tio n s h ip. P a t i e n t s knowledge about t h e i r m edication was no t cons i s t e n t l y r e la te d to in c re a se d com pliant m ed icatio n in tak e b eh av io r. H ypertensive p a tie n ts * knowledge of il l n e s s was p o s itiv e ly r e l a t e d to c lin ic attendance in one study. Knowledge of h y p e rte n sio n and of harm ful e f f e c ts of inadequate tre atm e n t was found r e la te d to in c re ase d com pliance. Long w a itin g tim e, inadequate u n d erstan d in g

33 23 of h y p e rte n sio n, and a poor d o c to r-p a tie n t r e la tio n s h ip e ffe c te d noneompliance w ith tre a tm e n t regim en. M edication com pliance s tu d ie s showed th a t only about h a lf of the p a t i e n t s complied w ith t h e i r m edication tre atm e n t at home. P a tie n t ed u catio n about h is d is e a s e, tre a tm e n t, or m edicatio n had not c o n s is te n tly shown p o s itiv e r e s u l t s in term s of com pliant b eh av io r or d ise a se c o n tro l.

34 CHAPTER I I I METHODOLOGY This stu d y was designed to answer the fo llo w in g two q u e stio n s: (1) Is th ere a r e la tio n s h ip between hyp erte n siv e p a t i e n t s ' knowledge of t h e i r d ise a se and t h e ir compliance r e la te d to tak in g m edication, u sin g s a l t, cont r o l l i n g w eight, and keeping appointm ents, and (2 ) is th e re a r e la tio n s h ip between p a t i e n t s 1 compliance w ith t h e i r treatm en t regim en and t h e i r le v e l of d ise a se cont r o l as measured by blood p re ssu re and w eight? The q u e stio n n a ire was adapted from th e one used by P e rg rin (1974). Design of the Study P a tie n ts who atten d ed e ith e r a G eneral Medicine or Endocrine C lin ic of a U n iv e rsity M edical C enter were sele c te d as the p a tie n t p o p u la tio n. P erm ission to conduct the study was o b tain ed from The U n iv e rsity of A rizona Human S u b jects Committee and from the two p h y sic ia n s at each C lin ic (Appendix A ). A l i s t of a l l h y p erte n siv e p a t i e n t s who were under the care of th e se p h y sic ia n s and who atten d ed e ith e r the G eneral Medicine or Endocrine C lin ic in 1974 or 1975 was ob tain ed from the M edical In fo rm atio n Service of the M edical C enter. From th i s l i s t, in 24

35 sequence, the re se a rc h e r s e le c te d as p o ssib le su b je c ts 25 those p a tie n ts who met the c r i t e r i a e s ta b lis h e d f o r th e study. F o rty -e ig h t s u b je c ts met the c r i t e r i a of the study. A phone c a l l was made to each p a tie n t, asking him i f he would agree to p a r tic ip a te in the study. The r e se arch e r i d e n tif ie d h e r s e lf as a graduate stu d en t at The U n iv e rsity of A rizona, C ollege of N ursing. A b r ie f ex p la n a tio n of the study was given to the p a tie n t, w ith in fo rm atio n th a t p a r t ic ip a ti o n was v o lu n tary, th a t no hazards were involved, and th a t h is p a r t ic ip a ti o n or r e f u s a l would in no way a f f e c t h is usu al m edical care at the C lin ic. The p a tie n t was inform ed th a t the q u e stio n n a ire would take approxim ately 30 m inutes of h is tim e. I f he agreed to p a r t ic ip a te in the study, he was assured of in d iv id u a l anonymity and c o n f id e n tia lity o f r e p l i e s. An attem pt was made to c o n ta c t each of the I4.8 p a tie n ts on the l i s t. The re se a rc h e r was unable to lo c a te 11 of the p a tie n ts. S ix teen re fu s e d to p a r t ic ip a te, which l e f t a t o t a l of 21 p a tie n ts who agreed to p a r t ic ip a te in the study. Once p erm issio n was o b tain ed, the re se a rc h e r arranged an appointm ent fo r a home v i s i t at th e p a t i e n t s convenience. E l i c i t i n g in fo rm atio n in the home ra th e r than the C lin ic w aitin g area was thought to be more conducive to a p a t i e n t s freedom in responding. W ritte n

36 26 p erm issio n was o b tain ed from each s u b je c t at the time of the in terv ie w (Appendix B). The s tr u c tu r e d q u e stio n n a ire was ad m in istered o r a lly to the s u b je c t to ensure th a t read in g a b i l i t y did not n e g a tiv e ly in flu en ce the outcome. Each su b je c t was inform ed th a t a f t e r the q u e stio n n a ire was com pleted, the re se a rc h e r would c l a r i f y any m issed item s and answer any q u estio n s he might have. Demographic in fo rm atio n was e l i c i t e d v e rb a lly from the s u b je c t during the in te rv ie w. A fter th e q u e stio n n a ire was ad m in istered to a l l of the s u b je c ts, the re se a rc h e r review ed each of the subj e c t s ' m edical re c o rd fo r in fo rm atio n on the l a s t th ree blood p ressu re and w eight read in g s at the C lin ic, number of C lin ic v i s i t s in the l a s t 12 months, and the name, dosage, and stre n g th of each an tih y p e rte n siv e m edication p re sc rib e d by the p h y sic ian. Study Sample The s u b je c ts f o r the study were s e le c te d from the case load of e ith e r the G eneral Medicine or Endocrine C lin ic of a U n iv e rsity M edical Center and met the fo llo w in g c r i t e r i a : 1. Lived w ith in the Tucson c i t y lim its. 2. Spoke E n g lish. 3. Were 18 years of age or o ld er.

37 27 1 _. Had a d iag n o sis of h y p e rte n sio n f o r at l e a s t th re e months. 5. Had been seen by a p h y sic ia n or nurse at e ith e r C lin ic at le a s t th re e times in the prev io u s tw elve months, w ith the most re c en t appointm ent w ith in the p a st six months. Data C o lle c tio n Instrum ent The q u e stio n n a ire was adapted from the one used by P e rg rin (1974-) in h er d o c to ra l d is s e r ta tio n. The q u e stio n n a ire (Appendix C) was d iv id ed in to fo u r p a r ts. The f i r s t p a r t d e a lt w ith s u b je c t demographic d ata. The second p a rt d e a lt w ith th e s u b je c t s knowledge of h y p e rte n sio n. The th i r d p a r t d e a lt w ith compliance r e la te d to tak in g medicatio n, u sin g, s a l t, c o n tr o llin g w eight, and keeping ap p o in t m ents. The fo u rth p a rt d e a lt w ith le v e l of d isea se c o n tro l as measured by blood p ressu re and w eight. Demographic Data The f i r s t p a r t of the q u e stio n n a ire d e a lt with su b je c t demographic d ata. The s u b je c t s ed u catio n and occupation were a s c e rta in e d to compute H ollingshead Two- F acto r Index of S o c ia l P o s itio n Scores (1957). To calcu la te the Index of S o c ia l P o s itio n fo r an in d iv id u a l, the scale value fo r occupation was m u ltip lie d by the fa c to r weight of seven fo r occupation, and the scale v alu e fo r ed u catio n was m u ltip lie d by th e fa c to r w eight of fo u r fo r

38 28 e d u catio n. Score values fo r occu p atio n ranged from one to seven, as shown below: Score V alues; 1. Higher ex ec u tiv e s, p r o p rie to r s of la r g e r concerns, and major p ro fe s s io n a ls. 2. B usiness managers, p r o p rie to r s of medium -sized b u sin e sse s, and le s s e r p r o f e s s io n a ls. 3. A d m in istratio n p erso n n el, sm all independent b u sin e sse s, and minor p r o f e s s io n a ls. I].. C le r ic a l and s a le s w orkers, te c h n ic ia n s, and owners of l i t t l e b u sin e sse s. 5. S k ille d manual em ployees. 6. Machine o p e ra to rs and s e m i-s k ille d employees. 7. U n sk ille d employees. as shown below: Score v alu es f o r ed u catio n ranged from one to seven, Score V alu es; 1. G raduate p ro fe s s io n a l tr a in in g. 2. Standard co lleg e or u n iv e r s ity g rad u a tio n. 3. P a r t i a l c o lleg e tr a in in g. Ij,. High school g rad u ate s. 5. P a r t i a l high school. 6. Ju n io r high school. 7. Less than seven years of school. The range of scores on a continuum was from a low of 11 to a high of 77. S o c ia l c la ss p o s itio n s were d iv id ed in to f iv e d i s t i n c t groups, w ith S o cial Class I r e f e r r in g to

39 29 high s o c ia l c la s s and S o cial C lass V r e f e r r in g to low s o c ia l c la s s. Scores are d iv id ed by H o llin g sh ead (1957: 1 0 ) in the fo llo w in g manner: S o c ia l C lass Range of Computed Scores I I I I I I IV V Other demographic d a ta th a t were asked concerned s u b je c ts age, ra c e, sex, m a r ita l s ta tu s, source of income, annual income, number of y ears w ith a d ia g n o sis of hyperte n sio n, and fam ily h is to r y of h y p erte n sio n. Knowledge The second p a rt of the q u e stio n n a ire d e a lt w ith the s u b je c t s knowledge about h is d ise a se. The s u b je c ts le v e l of knowledge was measured by a 1 6 -item q u e s tio n n a ire, with content areas in c lu d in g d e f in itio n of h y p erte n sio n, a s s o c ia tio n of r i s k f a c to r s, tre a tm e n t, and m ed ication. Responses to each of the q u e stio n s were c a te g o riz e d c o r r e c t, in c o r re c t, and don t know. In c o rre c t responses and don t know responses were c l a s s i f i e d as in c o r re c t answ ers. The p o s sib le range of knowledge score was from zero fo r no q u estio n s answered c o r re c tly to six te e n f o r a l l qu estio n s answered c o rre c tly.

40 30 Compliance The th ir d p a r t of the q u e stio n n a ire d e a lt with treatm en t com pliance. The s e le c te d components of com pliance th a t were in v e s tig a te d were ta k in g m edication, u sing s a l t, c o n tr o llin g w eight, and keeping appointm ents. Score v alues in th e se four areas of compliance were dichotom ized by the re se a rc h e r, w ith a score value of one to two d e sig n a tin g accep tab le compliance and a score value of th re e to fiv e d e sig n a tin g unacceptable com pliance. Seven q u estio n s were asked about the s u b je c t's m edication com pliance. The s u b je c t was also asked to show the re s e a rc h e r h is cu rre n t p i l l c o n ta in e rs so th a t a reco rd could be made of th e name, s tre n g th, and dosage of each of h is a n tih y p e rte n siv e m edication. Score values f o r medicatio n compliance ranged from one to f iv e, w ith the re se a rc h e r d e sig n a tin g a score value of one to two as accep tab le medic a tio n com pliance and a score v alu e of th re e to fiv e as u n acceptable m edication com pliance. I f the s u b je c t was on more than one m ed ication, the h ig h e st score re c e iv e d fo r a sin g le m edication was used. Score V a lu es; 1. Takes a l l m ed ication as recommended. 2. Takes a l l m ed icatio n as recommended most of the tim e. 3. Takes a l l m ed ication as recommended about h a lf of th e tim e.

41 31 4. Takes a l l m ed icatio n as recommended some of the tim e. 5. Takes a l l m edicatio n as recommended r a r e ly, i f e v e r. Compliance to s a l t in ta k e was determ ined by six q u e s tio n s. The s u b je c t's c u rre n t in tak e of s a l t was compared to h is s a l t in tak e before a d iag n o sis of hyperte n sio n was made. Four c a te g o rie s were used, w ith a possib le score value ranging from one to f iv e. The re se a rc h e r desig n ated a score value of one to two as a ccep tab le s a l t compliance and a score value of fo u r to fiv e as u n acceptable s a l t com pliance. Score V alu es; 1. Follow ing recommendations as to use of s a l t. 2. Using more s a l t than should but le s s than before had h y p erten sio n. ij.. Using more s a l t than recommended and about same as before had h y p e rte n sio n. 5>. Not r e s t r i c t i n g s a lt a t a l l although recommended. Six q u estio n s determ ined compliance to w eight cont r o l. The s u b je c t's w eight a t the time of d ia g n o sis and h is c u rre n t w eight were determ ined. Score v alu es fo r comp lian ce to w eight c o n tro l ranged from one to f i v e, with the re s e a rc h e r d e sig n a tin g a score value of one to two as accep tab le weight compliance and a score value of th ree to fiv e as u n accep tab le w eight com pliance.

42 Score V alu es; 1. Recommended w eight g ain, lo s s or m aintenance; conforming to recommendations. 2. Recommended w eight g ain or lo ss ; m ain ta in in g w eight. 3. Recommended w eight gain; p a tie n t lo s in g. 1}.. Recommended w eight lo s s ; p a tie n t g a in in g. 5. Recommended w eight m aintenance; p a tie n t g ain in g or lo s in g. Two q u estio n s were asked reg ard in g the s u b je c t s compliance to keeping appointm ents. Score v alu es ranged from one to five, w ith the re s e a rc h e r d e sig n a tin g a score value of one to two as accep tab le appointm ent compliance and a score value of th re e to fiv e as u n accep tab le ap p o in t ment com pliance. Score V a lu est 1. Always keeps appointm ents. 2. Keeps appointm ents most of the tim e. 3. Has m issed two or more of l a s t w ithout inform ing C lin ic. fo u r appointm ents b. Time p e rio d of more th an six weeks w ith o u t making another appointm ent. 5. G reater d iffe re n c e than any of above. C ontrol The fo u rth p a r t of the q u e stio n n a ire d e a lt w ith the s u b je c t s le v e l of d ise a se c o n tro l as determ ined by w eig h t and b lood p r e s s u r e. Three score v a lu e s com prised

43 33 each s u b je c t s le v e l of d isea se c o n tro l score: h is w eight c o n tro l sco re v alue, h is s y s to lic blood p re ss u re score v alu e, and h is d i a s t o l i c blood p ressu re score v a lu e. The s u b je c t s s y s to lic and d ia s to lic blood p re ss u re score v alu es were added to determ ine a blood p re ss u re c o n tro l s c o re. The M etro p o litan L ife In su ran ce Company's S t a t i s t i c a l B u lle tin (I960) fo r n a tio n a l average fo r w eight according to h e ig h t, sex, and age was used to determ ine each s u b je c t s w eight c o n tro l sco re. This n a tio n a l average fo r w eight was then compared to the average of the subj e c t s w eights fo r th e l a s t th re e c lin ic v i s i t s. P erg rin (197^) found no d iffe re n c e in averaging the s u b je c t s w eights fo r the l a s t th ree c l i n i c v i s i t s as opposed to the s u b je c t's w eight on the l a s t c lin ic v i s i t and then comparing th e se W ow eights w ith the s u b je c t s id e a l w eight. T h erefo re, th e re se a rc h e r decided to u t i l i z e the average of the s u b je c t's w eights fo r the l a s t th ree c li n i c v i s i t s. The score v alu es fo r w eight c o n tro l ranged from one to f iv e, w ith th e re s e a rc h e r d e sig n a tin g a score value of one to two as acceptable weight c o n tro l and a score value of fiv e as u n acceptable w eight c o n tr o l. As determ ined by P e rg rin (1974)* the score v alu es are shown below. Score V alu es* 1, W eight no more than 10^ above or 20^ below n a tio n a l average f o r h e ig h t, sex and age.

44 2. W eight no more than 10^ above n a tio n a l average f o r h e ig h t, sex and age but p a tie n t g ain in g w eight r a th e r than m ain tain in g w e ig h t Weight g re a te r than s ta te d l i m i t, but moving toward average a t the r a te of at l e a s t two pounds p er month. 5>. Weight g r e a te r than 10^ above or 2.0% below average and not changing toward normal a t le a s t by two pounds per month. Each s u b je c t's s y s to lic blood p re ssu re score value and d ia s to lic blood p ressu re score value com prised the blood p ressu re c o n tro l s c o re. A score value of two to fo u r was d e sig n a ted by the re s e a rc h e r as accep tab le blood p re ssu re c o n tro l w hile a score value of fiv e to tw entye ig h t was d esig n ated as un accep tab le blood p re ssu re c o n tro l. The re s e a rc h e r averaged th e s u b je c t's blood p re ssu re s f o r the l a s t th re e c lin ic v i s i t s when no e s s e n t i a l d iffe re n c e was found in t h i s blood p re ssu re as compared to the subj e c t 's blood p re ssu re on the l a s t c lin ic v i s i t. One s u b je c t moved from accep tab le to u n accep tab le blood p re s sure c o n tro l when the com parison was made. Scoring fo r blood p re ssu re c o n tro l ranged from one to fo u rte e n p o in ts as determ ined by P e rg rin (1974) and is shown below. Score V alues Blood P re ssu re L ess than or equal Over 5>0 y ears to gq y e a r s o f age o f - ^ e S y s to lic 140 D ia s to lic 90 S y s to lic D ia s to lic

45 35 5 S y sto lic D ia s to lic ll{. S y sto lic llj. D ia s to lic Each s u b je c t!s w eight c o n tro l score and h is blood p re ssu re c o n tro l score were added to determ ine a le v e l of d isease c o n tro l sco re, which ranged from th re e to t h i r t y - th re e p o in ts. L evels of c o n tro l were c l a s s i f i e d as good, f a i r, poor, and very poor as determ ined by P e rg rin (1974) Score V alues; Levels of C ontrol 3 Good Ip-6 P a ir 7-15 Poor Very Poor For purpose of t h i s study the re se a rc h e r d esig n a te d a score v alu e of th re e to s ix as an acceptable le v e l of c o n tro l and a score value of seven to t h i r t y - t h r e e as an u n accep tab le le v e l of c o n tro l.

46 CHAPTER IV PRESENTATION AND ANALYSIS OF DATA This study was designed to answer the follo w in g two q u estio n s: (1) Is th e re a r e la tio n s h ip between hyp erten siv e p a t i e n t s knowledge of t h e i r disease and th e ir compliance r e la te d to ta k in g m edication, u sin g s a l t, cont r o l l i n g w eight, and keeping appointm ents; and (2) is there a r e la tio n s h ip between p a t i e n t s compliance with th e i r treatm en t regimen and t h e ir le v e l of d ise a se c o n tro l as measured by blood p re ssu re and weight? T his chapter w ill p re se n t th e fin d in g s and s t a t i s t i c a l a n a ly s is of the d ata c o lle c te d. C h a r a c te r is tic s of the Sample The sample c o n siste d of 21 su b je c ts who atten d ed e ith e r a G eneral Medicine or Endocrine C lin ic of a University M edical Center and who met the c r i t e r i a e s ta b lis h e d fo r the study. Tables 1 through 11 p rese n t frequency d is tr ib u tio n s of s e le c te d p a tie n t c h a r a c t e r i s t i c s. Table 1 p re se n ts th e d i s t r i b u t i o n of s u b je c ts by age. Twelve s u b je c ts (57.6 p ercen t) were over 60 years of age, w hile only two s u b je c ts (9.6 percen t) were under 50 y ears of ag e. 36

47 37 Table 1. D is tr ib u tio n of S u b je cts by Age Over 71 T otal Number P ercent 4* S u b je c ts' race is p re se n te d in Table 2. Twenty su b je c ts (95.2 p e rce n t) were White and one s u b je c t (1}..8 p ercen t) was B lack. No o th e r races were re p re se n te d. Table 2. D is tr ib u tio n of S ubjects by Race White Black T o tal Number Percent Table 3 p re se n ts the sex of the s u b je c ts. There were s ix males (28.6 p ercent) and f if t e e n fem ales (71.4 p ercen t) re p re se n te d in the sample. Table 3. D is tr ib u tio n of S ubjects by Sex Males Females T o tal Number P ercent

48 38 Table l\. p re se n ts the d i s t r i b u t i o n of s u b je c ts by t h e i r m a r ita l s ta tu s. There were no div o rced or sep arated s u b je c ts. E ig h teen s u b je c ts (85.7 p ercen t) were m arried, two (9.5 percen t) were widowed, and one (1.8 p ercen t) had never been m arried. Table 4. D is tr ib u tio n of S u b jects by M a rita l S ta tu s M arried Widowed Never M arried T o ta l Number P ercen t As shown in Table 5, the d i s t r i b u t i o n of su b je c ts by y e a rs of schooling ranged from le ss than e ig h t years to n in e te e n y e a rs. Three s u b je c ts (ll _.3 p e rc e n t) had 17 to 19 years of scho o lin g. The mean years of schooling was 12.5 y e a rs. Table 5. D is tr ib u tio n of S u b jec ts by Years of Schooling T o ta l Number P ercen t

49 39 Table 6 p re s e n ts the d i s t r i b u t i o n of s u b je c ts by source of income. None of th e s u b je c ts were re c e iv in g d i s a b i l i t y o r w e lfa re. Seven su b je c ts (33.3 p e rc e n t) r e ceived t h e i r income from g a in fu l employment, fiv e (2 3.8 p ercen t) from p en sio n s, and two (9.5 p ercen t) from S o cial S e c u rity. Six o th e rs (28.6 p e rc e n t) re c e iv e d income from more than one source, such as a job and a p en sio n, or a pension and S o cial S e cu rity. Table 6. D is tr ib u tio n of S u b je c ts by Source of Income Job Pension S o c ia l S e c u rity Other Combin a tio n T o ta l Number P ercen t ^ it As p resen ted in Table 7, the average annual in comes of the su b je c ts ranged from le ss th an $^,999 to over $20,000. C onsidering th a t twelve s u b je c ts (57.6 p ercen t) were over 60 years of ag e, i t is of i n t e r e s t to n ote the high average annual income. E ight s u b je c ts (38.2 p ercen t) re p o rte d an income of over $10,000.

50 Table 7. D is tr ib u tio n of S u b je c ts by Average Annual Income ko 5, , , 000-4,999 9, ,999 19, ,0 0 0 T o tal Number P ercen t llj The len g th of time the su b je c ts in the study had been diagnosed as having h y p e rte n sio n ranged from one to th irty - s e v e n y e a r s. The la r g e s t number of s u b je c ts, th i r t e e n (6 1.9 p e r c e n t), had been diagnosed as having h y p erte n sio n fo r a p e rio d of one to eig h t y e a rs. Six su b je c ts (2 8.6 p ercen t) had had h y p e rten sio n from nine to six te e n y e a rs. One su b je c t (I4..8 p e rce n t) had h y p e rten sio n fo r tw e n ty -fiv e y e a r s, w hile another (I4..8 p ercen t) had i t fo r th irty - s e v e n y e a rs. Table 8 p re se n ts the d i s t r i b u t i o n of s u b je c ts by y ears w ith h y p e rte n sio n. Table 8. D is tr ib u tio n of S u b je c ts by Years With Hyperte n sio n T o tal Number P ercent

51 4% Table 9 p re se n ts the d i s t r i b u t i o n of s u b je c ts by fam ily h i s t o r y of h y p e rte n sio n. Twelve s u b je c ts (57.1 p ercen t) s a id th ere was a fam ily h is to r y of h y p erte n sio n, w hile e ig h t s u b je c ts ( p e r c e n t) sa id th e re was none. One su b je c t (4*8 p e rce n t) did n o t know. Table 9. D is trib u tio n of S u b jects by Family H is to ry of H ypertension Yes No Don' t Know T o ta l Number P ercen t In a d d itio n to th e above demographic d ata, subj e c t s ' occupation and ed u catio n were a s c e rta in e d in order to compute H ollingshead Two-Factor Index of S ocial P o sitio n Scores (1997). Table 10 p re se n ts the d is tr ib u tio n of s u b je c ts by H o llingshead S o cia l C la ss. I t is of i n t e r e s t th a t su b je c ts were re p re se n te d in a l l fiv e S o cial C lass c a te g o rie s. Ten s u b je c ts (47.6 p e r c e n t) were c la s s if i e d in S o c ia l C lass I, I I, and I I I ; w hile eleven subje c ts (52.3 p e rce n t) were c l a s s i f i e d in S o c ial C lass IV and V.

52 42 Table 10. D is tr ib u tio n of S u b je cts by H ollin g sh ead S o c ia l C lass I II III IV V T o ta l Number P ercen t The number of time s the su b jec ts were seen in the C lin ic fo r t h e i r h y p e rten sio n during the p a s t twelve months is p re se n te d in Table 11. The number of C lin ic v i s i t s during th e p a s t twelve months ranged from th ree to n in e. Seventeen s u b je c ts (80.9 p ercent) had fiv e or fewer C lin ic v i s i t s during the p a s t twelve months. Table 11. D is tr ib u tio n of S u b je c ts by Number of C lin ic V is its in P ast Twelve Months T o tal Number P ercent i Knowledge A t o t a l of s ix te e n q u estio n s were asked to determ ine the s u b je c ts ' knowledge of h y p e rten sio n. The p o ssib le range of knowledge score was from zero fo r no q u estio n s answered c o r re c tly to s ix te e n f o r a l l q u estio n s

53 answered c o r re c tly. In c o rre c t responses and d o n lt know responses were c l a s s i f i e d as in c o r re c t answers. As shown in Table 12 the c o rre c t responses ranged from a low of seven (one su b jec t) to a high of six te e n (fiv e s u b je c ts ). Ten su b je c ts (I4.7.6 p ercen t) re c e iv e d a knowledge score of 15 or 16. The mean knowledge score was Twenty su b je c ts (9 5.2 p e rce n t) answered at l e a s t $0 p e rc e n t of the q u e stio n s c o r re c tly. Table 12. D is tr ib u tio n of S u b jects by C orrect Responses to Knowledge Q uestions T otal Number P ercen t 1..8 I Knowledge and Demographic D ata Table 13 p re se n ts the r e s u l t s of a m u ltip le r e - g re ssio n a n a ly sis of s u b je c ts ' knowledge w ith s e le c te d demographic d ata. When the o th e r six independent v a r i ab les were c o n tro lle d, the v a r ia b le of y ea rs of schooling was found to be s ig n if ic a n tly r e l a t e d to the dependent v a ria b le of knowledge at the.029 s ig n ific a n c e le v e l. This means th a t more y ears of schooling was r e l a t e d to a h ig h er knowledge sco re. A h ig h e r Social C lass p o s itio n was also r e l a t e d to a h ig h er knowledge sco re, although

54 Table 13. M ultiple R egression A nalysis of Knowledge and S ele cte d Demographic Data V ariable F to E n ter or Remove P Values M ultiple R R2 In crease in R Zero Order r Age Sex Years w ith H ypertension C lin ic V is its in 12 Months S o cial C lass Score Family H isto ry of H ypertension Years of Schooling O verall F (7, 13) = P =.009 ^ S ig n ific a n t at.029

55 not a s ig n if ic a n t le v e l. I t is of i n t e r e s t to note th a t k5 knowledge was in v e rs e ly r e l a t e d to the number of C lin ic v i s i t s in a 12-month p e rio d. Although th is was not s ig n i f i c a n t (P = )y a tre n d was shown th a t h ig h er knowledge was r e la te d to few er C lin ic v i s i t s. Medication Compliance The se le c te d components of compliance that were in v estig a ted were taking m edication, using s a lt, co n tro l- ing w eight, and keeping appointments. Seven questions were asked each su b ject to determine h is compliance to taking a prescribed antihypertensive medica tio n. One sub ject, although diagnosed as h y p erten siv e, was not taking any prescribed antihypertensive m edication. I t was observed that for the twenty subjects taking medication, s ix d iffe r e n t m edications were prescribed by the p h ysician s. They were potassium ch lorid e, hydrochloroth ia zid e, propranalol, methyldopa, hydralazine hydroch lorid e, and reserp in e. Table 11]. shows the d istr ib u tio n of sub jects by the number of m edications being taken. F ifte e n su b je c ts (71 p ercen t) were ta k in g e i t h e r one or two m ed icatio n s.

56 46 Table llj.. D istrib u tio n of Subjects by Number of Medications Taken b 5 Total Number i i 20 Percent 35 ko M edication com pliance was determ ined by the re se a rc h e r in accordance to the answers given by the subje c ts re g a rd in g t h e i r in ta k e of p re sc rib e d a n tih y p e rte n sive m edicatio n compared to th e n o ta tio n s on t h e i r m edical re c o rd s. S ix teen su b je c ts (80 p e r c e n t) had acceptable m ed ication compliance w hile fo u r (20 p ercen t) had unaccep tab le m edication com pliance. Table 15> p re s e n ts the d is t r i b u t i o n of s u b je c ts by m ed icatio n com pliance, or the manner in which th ey took t h e i r a n tih y p e rte n siv e medicatio n s. Table 15>. D is tr ib u tio n of S u b jects by M edication Compliance Acceptable Unacceptable Amount of Time Amount of Time A ll Most Half Some Rare Total Number Percent

57 k7 If sub jects were not taking th eir m edication as prescribed, they were each asked to give a reason. Nine subjects (ijj) percent) were not taking th eir m edication as prescribed. One subject who was not taking h is potassium ch lorid e, gave the reason of "not lik in g the ta ste and n au sea. Four subjects said fo r g e ttin g was the main reason for not taking th e ir m edications as prescribed. Three subjects said they did not take th eir m edications reg u la rly because i t was not im portant. One subject said that not having enough money to buy h is m edications was the reason why he was not able to take h is m edications regu larly. Salt Compliance Five questions were asked to determine the subjects T compliance to use of s a lt. Nineteen subjects (90.5 percent) were to ld by th eir physician or nurse not to add any s a lt to th eir food. Nineteen su b jects (90.5 percent) said they ate foods that contained s a lt, such as bacon, potato chips, p ic k les, canned fis h and/or canned v eg eta b les. Thirteen subjects (61.9 p ercen t) sa id s a lt was added to th e ir food when i t was being prepared. Table 16 p re se n ts the d i s t r i b u t i o n of s u b je c ts by s a lt com pliance. F ifte e n su b jects (7 1.4 p ercen t) had

58 48 accep tab le s a l t compliance w hile s ix su b je c ts (28.6 p e r cent) had unacceptable s a lt com pliance. Table 16. D is tr ib u tio n of S u b jects by S a lt Compliance A cceptable U nacceptable Follow ing Using more Using More Not Re Recommen S a lt Than S a lt Than s t r i c t i n g d a tio n Should - Should - Use of Less Than Same As S a lt Before Before Number P ercen t Weight Compliance Five q u estio n s were asked to determ ine compliance to c o n tr o llin g w eight. S ix tee n s u b je c ts (76.2 p ercen t) sa id t h e i r p h y sic ia n suggested they lo se w eight and fiv e s u b je c ts ( ) p erc en t sa id th e y were not to ld to lose w eight. Of the s ix te e n s u b je c ts to ld to lo se w eight, th i r t e e n su b je c ts (8 l p e r c e n t) sa id they had l o s t weight since th ey were diagnosed as being h y p e rte n s iv e. Table 17 p re s e n ts the d i s t r i b u t i o n of s u b je c ts by amount of w eight l o s t. The score value fo r w eight compliance was determ ined by the re se a rc h e r in accordance to the responses of the s u b je c ts re g a rd in g t h e i r a b i l i t y to m a in tain, gain, or lo se w eight as recommended by th e ir p h y sic ia n. Table

59 18 p re se n ts the d i s t r i b u t i o n of s u b je c ts by compliance to c o n tro l w eight. Seventeen s u b je c ts (8l p e rc e n t) had accep tab le w eight compliance w hile fo u r s u b je c ts (19 p e r cent) had unacceptable w eight com pliance. Table 17. D is tr ib u tio n of S u b jec ts by Number of Pounds Lost ij.O Over I4I T o ta l Number 4 ti- i P ercent Table 18 D is tr ib u tio n of S u b jects by Weight Compliance A cceptable Conforming Recommended to G ain, Gain or Loss or Loss - Main- M aintenance ta in in g U nacceptable Recommended Loss - Gaining T otal Number P ercent oo H J Appointment Compliance Two q u e stio n s were asked the su b je c ts reg ard in g t h e ir a b i l i t y to keep m edical appointm ents f o r t h e i r h y p e rte n sio n. A ll of the twenty-one s u b je c ts (100 p e r c e n t) had accep tab le appointm ent com pliance. F if te e n su b je c ts

60 50 (7 1.4 p e r c e n t) were always able to keep t h e i r appointm ents fo r th e day and time when they had been g iv en, and six s u b je c ts (2 7.6 p e r c e n t) were able to keep t h e i r ap p o in t ments most of the tim e. Knowledge and Compliance A s e r ie s of t - t e s t s were done to compare the d i f feren ce between th e mean knowledge scores and each of the four compliance v a ria b le s to ta k in g m ed ication, using s a l t, c o n tro llin g w eight, and keeping appointm ents. The r e s u l t of the t - t e s t of s u b je c ts knowledge of hyperte n sio n and t h e i r m edication compliance is shown in Table 19. Knowledge sco res of s u b je c ts w ith accep tab le medic a tio n com pliance compared to knowledge sco res of those w ith unacceptable m ed ication compliance re v e a le d a t - t e s t value of 2.03, which is s ig n if ic a n t a t the.058 le v e l. In o th e r words, those s u b je c ts w ith accep tab le m edication compliance had a h ig h e r degree of knowledge about hyperte n sio n than those w ith unacceptable m ed ication com pliance. The r e s u l t of the t - t e s t o f s u b je c ts knowledge of h y p e rten sio n and th e ir s a l t com pliance was n o t found to be s t a t i s t i c a l l y s ig n if ic a n t (P = ), as shown in Table 20. However, the r e s u l t was in the expected d ir e c tio n in th a t those s u b je c ts w ith accep tab le s a l t compliance had a h ig h er degree of knowledge about h y p e rten sio n as compared to those w ith unacceptable s a l t com pliance.

61 51 Table 19. Knowledge by M edication Compliance Number Mean Knowledge t Value Score df P Value A cceptable Compliance * U nacceptable Compliance T o ta l 1 C\J * P =.058 pooled v aria n ce e stim a te. -x-x- One s u b je c t no t tak in g m ed ication Table 20. Knowledge by S a lt Compliance Number Mean Knowledge Score t V alue df P Value A cceptable Compliance U nacceptable Compliance T o ta l 21 P =.llj-9

62 52 T - te s ts were done to determ ine the r e la tio n s h ip between s u b je c ts knowledge of h y p e rte n sio n and both t h e i r weight compliance and appointm ent com pliance. The computed P value fo r knowledge compared to w eight comp lia n c e was.283 and the P value f o r knowledge compared to appointm ent compliance was.839. N eith er of the r e l a tio n s h ip s were found to be s t a t i s t i c a l l y s ig n if ic a n t. Table 21 p re se n ts a summary of the number and p e r cent of s u b je c ts by com pliance le v e l and the fo u r s e le c te d areas of the treatm en t regimen. C ontrol Three score values com prised each s u b je c t's le v e l of d isea se c o n tro l score; h is w eight c o n tro l score v alu e, h is s y s to lic blood p re ssu re score value, and h is d ia s to lic blood p ressu re score v alu e. Weight and blood p ressu re score values were computed fo r each su b je c t. W eight c o n tro l scores ranged from one to f iv e. Twelve s u b je c ts (57.1 p e r c e n t) weighed no more th an ten p ercen t above, or twenty p e rc e n t below n a tio n a l average fo r h e ig h t, sex, and age according to the M etro p o litan L ife Insurance Company's S t a t i s t i c a l B u lle tin (I960). Table 22 p re se n ts the d i s t r i b u t i o n of su b je c ts by weight c o n tro l s c o re s. T h irte e n s u b je c ts (61.9 p e r c e n t) had

63 Table 21. Number and P ercen t of H ypertensive P a tie n ts by Compliance Level and Area of Treatm ent Regimen (N = 21) Area of Treatment Regimen M edication S alt In t alee Weight Appointments Compliance Level T o tal No. P a tie n ts Seen P ercent of Comp lian ce T o tal No P a tie n ts Seen. Percent of Comp lian ce T o tal No P a tie n ts Seen. Percent of Complian ce T o tal No. P a tie n ts Seen Percent of Comp lian ce Acceptable U nacceptable k ! T o tal 20-:: x-one su b ject n o t talcing m edication

64 accep tab le w eight c o n tro l w hile e ig h t s u b je c ts (3 8.1 p e r cent) had unacceptable weight c o n tro l. Table 22. D is tr ib u tio n of S u b jects by W eight C ontrol Scores Acceptable Unacceptable Total Number Percent Blood p re ssu re c o n tro l sco res were computed fo r each s u b je c t by adding the s y s to lic score value and the d ia s to lic score v alu e. A range from two to tw en ty -e ig h t was p o s s ib le. As shown in Table 23 the d i s t r i b u t i o n of su b je c ts by blood p ressu re c o n tro l scores ranged from two to te n. Seventeen su b je c ts (8l.O percen t) had acceptable blood p re ssu re c o n tro l while fo u r su b je c ts (19.0 percen t) had unacceptable blood p re ssu re c o n tro l. Levels of d isea se c o n tro l scores ranged from a p o ssib le th ree to t h i r t y - t h r e e p o in ts. Table 2lj. p re se n ts the d i s t r i b u t i o n of su b je c ts by le v e ls of d ise a se c o n tro l The range was from th re e to f i f t e e n p o in ts. Twelve subje c ts (5 7.1 p e r c e n t) had accep tab le le v e l of d ise a se cont r o l w hile nine su b je c ts (4 2.9 p ercen t) had unacceptable le v e l of d isea se c o n tro l.

65 Table 23. D is tr ib u tio n of S u b jects by Blood P ressure C ontrol Scores 55 Score Value Number of S u b jects Percent of Sub je c ts A cceptable k U nacceptable T o ta l Table 2l+. D is tr ib u tio n of D isease C ontrol S u b jects by Levels of A cceptable U nacceptable Good P a ir Poor Very Poor T o tal Number P e rc en t

66 Knowledge and C ontrol A s e r ie s of t - t e s t s were done to determ ine i f those p a tie n ts who had more knowledge about h y p e rte n sio n were in a b e t t e r le v e l of c o n tro l. Knowledge scores were compared to the c o n tro l v a ria b le s of weight and blood p re ssu re s e p a ra te ly and then in com bination fo r a t o t a l le v e l of d isease c o n tro l. None of the fin d in g s were s ig n if ic a n t. T h erefo re, those su b je c ts w ith accep tab le w eight and blood p re ssu re c o n tro l did not have more knowledge about h y p erte n sio n than those w ith unacceptable w eight and blood p ressu re c o n tro l. Compliance and C ontrol A s e rie s of F is h e r 's Exact T ests were computed fo r the fo u r compliance v a ria b le s of tak in g m ed icatio n, u sing s a l t, c o n tr o llin g w eight, and keeping appointm ents by the c o n tro l v a ria b le s of weight and blood p re ssu re s e p a ra te ly and then in com bination fo r a t o t a l le v e l of d isease cont r o l. The only s ig n if ic a n t fin d in g r e la te d to medicatio n compliance and blood p re ssu re c o n tro l. As shown in Table 25, the F is c h e r 's Exact T est was s ig n if ic a n t at the.013 le v e l. F ifte e n su b jec ts (75 p ercen t) had both accep tab le m edication compliance and accep tab le blood p re s sure c o n tro l. In o th e r words, those s u b je c ts who had

67 acceptable medication compliance were in better blood pressure control. S i Table 25. Blood Pressure Control Rates by Medication Compliance Blood Pressure Control Acceptable Unacceptable Number Percent Number Percent Medication Compliance Acceptable Unacceptable i Total b 20 Fischer s Exact Test P = None of the other computations were found to be statistically significant. Compliance to using salt, controlling weight, and keeping appointments were not found to be related to the control variables of weight and blood pressure separately or in combination for a total level of disease control.

68 CHAPTER V DISCUSSION OF FINDINGS T his ch apter d isc u sse s the r e la tio n s h ip of the conceptual framework and the fin d in g s of the study to the review of the l i t e r a t u r e. The conclusions and the recomm endations are also p re se n te d. The study was designed to answer the follow ing two q u e s tio n s : (1) Is th ere a r e la tio n s h ip between hyperte n siv e p a t i e n t s knowledge of t h e i r d ise a se and t h e i r compliance r e la te d to ta k in g m edication, u sin g s a l t, cont r o l l i n g w eight, and keeping appointm ents; and (2) is th ere a r e la tio n s h ip between p a t i e n t s ' compliance w ith th e ir tre atm e n t regimen and t h e i r le v e l of d ise a se c o n tro l as measured by blood p re ssu re and weight? Learning th eo ry combined w ith e d u c a tio n a l o b jectiv e s of the co g n itiv e and a f f e c tiv e domain comprise the th e o r e tic a l framework. These le a rn in g th e o rie s h elp to e x p la in the a c q u is itio n of knowledge and u n d erstan d in g by the p a tie n t and the ap p ro p ria te perform ance or compliance th a t is expected w ith th is a c q u is itio n of knowledge. The p a tie n t le a rn s to u n d erstan d (co g n itiv e domain) how hyperte n sio n a f f e c ts h is body and how a decreased s a l t in ta k e, optimum w eight, and the in tak e of p re sc rib e d a n tih y p e r te n siv e m ed ication h elp to c o n tro l h is blood p ressu re and 58

69 59 weight. Important to this goal of blood pressure and weight control is the patient s attitude of acceptance (affective domain) of hypertension and of responsibility in caring for himself. The questionnaire was adapted from the one used by Pergrin (1974) in her doctoral dissertation. The questionnaire was divided into four parts with questions seeking information about subjects demographic data, knowledge of the disease, compliance to their treatment regimen, and level of disease control. Findings in R elation to L iterature Review McKenney et al. (1973) found that teaching the patient about his disease and a planned follow-up program improved the patient s knowledge of hypertension, increased his compliance with the prescribed treatment regimen, and improved his blood pressure control. Their patients were initially found to know very little about hypertension, as contrasted to this study where the subjects had essentially high knowledge scores. Comparing the results of this study with Pergrin s (1974) study revealed that the subjects of this study had higher knowledge scores using the same knowledge test. The mean knowledge score of the subjects of this study was 13.7 (76.2 percent) as contrasted to 11.2 (62 percent) in Pergrin s study. As in Pergrin s study, the highest

70 le v e l of compliance was found in the are a of p a t i e n t s keeping t h e i r c lin ic appointm ents. Although th is sample of p a tie n ts were n o t provided w ith fre e tra n s p o r ta tio n to the c l i n i c as in P ergr i n s study, ap p aren tly tr a n s p o r ta tio n, money, or i l l n e s s did not in te r f e r e w ith t h e i r a b i l i t y to comply w ith keeping c lin ic appointm ents. The s u b je c ts in th is stu d y w ith accep tab le m edicatio n com pliance had a h ig h er degree of knowledge about h y p erten sio n than those w ith unacceptable m edication com pliance. H igher knowledge was found to be r e la te d to m ed icatio n compliance a t the.058 sig n ific a n c e le v e l. A tre n d was also found in t h i s study whereby h ig h er knowledge was r e la te d to accep tab le m ed ication and s a l t com pliance. Hyperte n siv e p a t i e n t s ' knowledge of th e ir i l l n e s s was p o s itiv e ly r e la te d to c lin ic attendance as shown in a study done by Tagliocozzo and Ima (1970), bu t th is study d id not re v e al such a r e la tio n s h ip. Berkowitz e t a l. (1963) found low c o r re la tio n s on p a t i e n t s ' com pliance to r e tu r n appointm ents, t e s t, medic a tio n s, tre a tm e n ts, r e f e r r a l s, and r e s t r i c t i o n s. They found compliance to be low est in the areas of m ed icatio n s, tre a tm e n ts, and r e s t r i c t i o n s, w hile com pliance was higher on r e tu r n appointm ents and r e f e r r a l s. S im ilar r e s u l t s were shown in t h i s study. S ix tee n s u b je c ts (80 percen t) had accep tab le m edication com pliance, f i f t e e n su b je c ts (71 4 p ercen t) had accep tab le s a l t com pliance, and

71 61 seventeen s u b je c ts (80 p erce n t) had accep tab le w eight com pliance. As in the Berkow itz e t a l. (1963) study, the r e s u l t s of th is study re v e a le d th a t compliance was h ig h e r on su b je c ts keeping appointm ents. A ll tw enty-one s u b je c ts (100 p ercen t) had acceptable appointm ent com pliance as c o n tra ste d to low er compliance r a te s in the o th e r areas. Numerous stu d ie s on m ed icatio n com pliance re v e a led th a t ir r e g u la r s e lf - a d m in is tr a tio n of m ed ications is a s ig n if ic a n t problem in the o u t- p a tie n t management of many i l l n e s s e s. The r e s u l t s of th is stu d y showed th a t s ix te e n s u b je c ts (80 p ercen t) took a l l t h e i r m edications as recommended a l l th e time or a t l e a s t took them as recommended most of the tim e. As shown in the stu d ie s done by MeKenney e t a l. (1973) and P e rg rin (1974), p a tie n t ed u catio n about h is disease, tre a tm e n t, and m edication has not c o n s is te n tly shown p o s itiv e r e s u lts in terms of com pliant behavior or d isease c o n tro l. T his study also rev ealed s im ila r r e s u lts of no s ig n if ic a n t r e la tio n s h ip between knowledge and compliance to u sing s a l t, c o n tr o llin g w eight, and keeping appointm ents. D iscu ssio n Quite a few of the comments the r e s e a rc h e r r e ceived w hile v e rb a lly a d m in iste rin g the s tr u c tu r e d q u e stio n n a ire were th a t the q u e stio n s r e l a t i n g to

72 62 knowledge were "too easy" or that i f these were " trick q u estio n s. " Ten subjects (I p ercen t) were able to answer a ll of the knowledge questions c o r r e c tly or missed one question. A larger sample of subjects might have produced a wider range of knowledge sc o r e s. A m ultiple regression analysis of knowledge with se le cted demographic data revealed that years of schooling were re la ted to knowledge at the.029 sig n ific a n c e le v e l. A higher educational le v e l might make i t ea sier for a p a tien t to understand how hypertension a ffe c ts h is body and the ram ification s of s a lt intake, optimum w eight, and intake of antihypertensive m edication. But educational le v e l does not take into account personal circumstances which may prevent a person from continuing h is education. A m ultiple regression analysis of knowledge with sele cted demographic data a lso revealed a trend showing that knowledge was rela ted to fewer c lin ic v i s i t s for hypertension in the past twelve months (P = ). The number of c lin ic v i s i t s may be rela ted to m edication compliance and blood pressure c o n tr o l. The r e s u lts of th is study showed that those subjects who had acceptable compliance were in b etter blood pressure co n tro l. This was sig n ific a n t at the.013 le v e l. Those su b jects who had fewer number of c lin ic v i s i t s were probably under b etter blood pressure con trol, and they were under b etter

73 63 blood p re ssu re c o n tro l because th ey com plied w ith t h e i r p re sc rib e d a n tih y p e rte n siv e m ed icatio n in t a k e. T herefore, poorer blood p ressu re c o n tro l p o s sib ly n e c e s s ita te d a h ig h e r number of c lin ic v i s i t s in a y ear. A s e r ie s of t - t e s t s were done to analyze knowledge sco res w ith the fo u r compliance v a ria b le s of ta k in g medic a tio n, u sin g s a l t, c o n tr o llin g w eight, and keeping ap p o in t m ents. H igher knowledge was found to be r e l a t e d to acceptable m edication compliance at the. 05,8 s ig n ific a n c e le v e l. No r e la tio n s h ip was found between p a t i e n t 's knowledge of t h e i r d isease and t h e i r compliance to keeping appointm ents because no v a r ia tio n was found in ap p o in t ment com pliance. A ll twenty-one su b je c ts (100 p ercen t) had accep tab le appointm ent com pliance. A t o t a l knowledge score was used by the re se a rc h e r ra th e r than s p e c ific knowledge r e la te d to s a l t in ta k e, m edication in ta k e, appointm ent keeping, and w eight c o n tro l. This t o t a l knowledge score was compared to the s p e c ific v a ria b le s of compliance with no s ig n if ic a n t f in d in g s. S ig n ific a n t fin d in g s may have been shown i f the re se a rc h e r had in v e s tig a te d s p e c ific knowledge scores to the s p e c ific compliance v a r i a b l e s. Conclusions The s ix te e n -ite m s tr u c tu r e d q u e stio n n a ire on knowledge was adm in istered o r a lly to the tw enty-one

74 subjects of the sample. A mean knowledge score of 13.7 was found. 64 A m u ltip le re g re s sio n a n a ly sis of knowledge w ith s e le c te d demographic d ata re v e a le d th a t more y e a rs of schooling were r e l a t e d to a h ig h e r degree of knowledge about h y p e rten sio n a t the.029 s ig n ific a n c e le v e l. A s e r ie s of t - t e s t s were done to compare knowledge sco res w ith the fo u r compliance v a ria b le s of ta k in g medic a tio n s, u sing s a l t, c o n tr o llin g w eight, and keeping appointm ents. H igher knowledge was found to be r e la te d to accep tab le m edication com pliance at the.058 s i g n i f i cance le v e l. Those s u b je c ts who took th e ir p re sc rib e d a n tih y p e rte n siv e m edication as ordered had a h ig h e r degree of knowledge about h y p e rte n sio n. A s e r ie s of F is c h e r 's Exact T ests were computed fo r the fo u r compliance v a r ia b le s of tak in g m edication, u sin g s a l t, c o n tr o llin g w eight, and keeping appointm ents by the c o n tro l v a ria b le s of w eight and blood p ressu re s e p a ra te ly and in com bination fo r a t o t a l le v e l of d isea se c o n tro l. A cceptable m edicatio n compliance was found to be r e l a t e d to accep tab le blood p re ssu re c o n tro l at the.013 s ig n ific a n c e le v e l. Those s u b je c ts who took t h e i r p re s c rib e d a n tih y p e rte n siv e m ed icatio n as o rd ered were in b e t t e r blood p re ssu re c o n tro l.

75 Recommendations The study may be r e p lic a te d w ith a la rg e r sam ple, w ith v a ria b le s in S o c ia l C lass P o s itio n, age, sex, and e th n ic group. 2. The study may be r e p lic a te d comparing d if f e r e n t c l i n i c p o p u la tio n s. 3. An experim ental stu d y may be done w ith the knowledge v a ria b le s being g iven and comparing knowledge to compliance and le v e l of d ise a se c o n tro l. 1 _. S u b je c ts ' p e rc e p tio n of h e a lth and i t s r e l a tio n sh ip to compliance may be in v e s tig a te d. 5. The r e la tio n s h ip between s u b je c ts ' p e rc e p tio of t h e i r w eight and t h e i r compliance to w eight co n tro l may be another area f o r in v e s tig a tio n.

76 66 CHAPTER VI SUMMARY This stu d y was designed to answer the follow ing two q u e s tio n s : (1) Is th e re a r e la tio n s h ip between hyp erten siv e p a t i e n t s ' knowledge of t h e i r d isea se and t h e i r compliance to the p re sc rib e d tre a tm e n t regimen; and (2) i s th e re a r e la tio n s h ip between p a t i e n t 's com pliance w ith t h e i r tre atm en t regimen and t h e i r le v e l of d ise a se cont r o l as measured by blood p re ss u re and w eight? Because of the chronic n a tu re of h y p e rten sio n i t is the p a tie n t h im se lf, n o t the h e la th care p r o fe s s io n a l who has the r e s p o n s i b il i t y fo r the day to day management of the d is e a s e. I t is suggested th a t the in d i v id u al must have knowledge of h is d isea se and an a ttitu d e of acceptance of h is d isease in ord er to make resp o n sib le d e c isio n s about d a ily management. Learning th eo ry combined w ith e d u ca tio n a l o b je c tiv e s of the c o g n itiv e and a f fe c tiv e domain com prise the t h e o r e tic a l framework fo r the stu d y. A review of the l i t e r a t u r e re v e a le d s e v e ra l s tu d ie s d ealin g w ith the outcomes of h y p e rten siv e pat i e n t s ' knowledge of th e ir d is e a s e, compliance to a t r e a t ment regim en, and le v e l of d ise a se c o n tro l. M edication compliance s tu d ie s showed th a t p a t i e n t s ' knowledge about

77 t h e i r m edication was not c o n s is te n tly r e la te d to in creased com pliant b eh av io r. P a tie n t ed u catio n about h is d isea se, tre a tm e n t, or m edication had not c o n s is te n tly shown p o s i tiv e r e s u l t s in term s of com pliance or d ise a se c o n tro l. The sample was chosen from a l i s t of p a tie n ts who were being follow ed in e ith e r a G eneral M edicine or 67 Endocrine C lin ic of a U n iv e rsity M edical C enter. The fin d in g s are based on the tw enty-one com pleted q u e stio n n a ir e s. Twenty of the s u b je c ts were White and one su b je c t was B lack. Six males and f i f t e e n fem ales re p re s e n te d the sample. S u b jects were re p re se n te d in a l l fiv e c l a s s i f i c atio n s o f H o llingshead (1957) S o cial C lass. The measurement to o l was a s tr u c tu r e d q u e stio n n a ire adapted from the one developed by P erg rin (1974) The s tru c tu re d q u e stio n n a ire was ad m in istered o r a l ly to the su b je c ts by the re se a rc h e r du rin g a home v i s i t. The q u e stio n n a ire was divided in to fo u r p a rts w ith q u estio n s seeking in fo rm atio n about demographic d a ta, knowledge of the d ise a se, compliance to the p re sc rib e d tre a tm e n t r e g i men, le v e l of d ise a se c o n tro l. A s e r ie s of t - t e s t s and F i s c h e r 1s E xact T ests were used to analyze the d a ta. A m u ltip le re g re s s io n a n aly sis of knowledge w ith s e le c te d demographic d a ta re v ea le d th a t more y ears of schooling were r e l a t e d to a h ig h e r degree of knowledge about h y p e rte n sio n at th e.029 s ig n ific a n c e le v e l.

78 68 A s e r ie s of t - t e s t s were done to compare knowledge sco res w ith the four compliance v a ria b le s o f tak in g medic a tio n s, u sing s a l t, c o n tr o llin g w eight, and keeping appointm ents. Higher knowledge was found to be r e la te d to accep tab le m edication com pliance at the.058 s i g n i f i cance le v e l. Those su b je c ts who took t h e i r p re sc rib e d a n tih y p e rte n siv e m edication as ordered had a h ig h e r degree of knowledge about t h e i r d ise a se. A s e rie s of F is c h e r s Exact T ests were computed f o r the four compliance v a r ia b le s of tak in g m edication, u sin g s a l t, c o n tr o llin g w eig h t, and keeping appointm ents by the c o n tro l v a r ia b le s of w eight and blood p re ssu re s e p a ra te ly and in com bination fo r a t o t a l le v e l of d isease c o n tr o l. A cceptable m ed ication compliance was found to be r e la te d to accep tab le blood p re ssu re c o n tro l at the.013 sig n ific a n c e le v e l. Those s u b je c ts who took t h e i r p re sc rib e d a n tih y p erte n siv e m edication as o rd ered were in b e tte r blood p re ssu re c o n tro l.

79 APPENDIX A CONSENT FORM FOR PHYSICIAN I have given my p erm issio n to E lain e Watanabe, R. N., to c o n ta c t my h y p e rten siv e p a tie n ts at the C lin ic as p o ssib le p a r tic ip a n ts in h er re se a rc h study. I r e a liz e th a t a c h a rt review w i l l be done and a s tr u c tu re d q u e s tio n a ire w ill be ad m in istered during a home v i s i t to determ ine p a t i e n t s le v e l of knowledge and t h e i r compliance to the treatm en t regim en. I n a d d itio n, th e re s e a rc h e r must o b ta in w r itte n p erm issio n from the in d iv id u a l p a tie n t. S ignature of P h y sician Date 69

80 APPENDIX B CONSENT FORM FOR PARTICIPATION IN A STUDY MEASURING KNOWLEDGE, COMPLIANCE TO TREATMENT REGIMEN AND LEVEL OF DISEASE CONTROL I, E lain e Watanabe, R. N., am conducting a study to determ ine h y p erten siv e p a t i e n t s 1 knowledge of th e ir d ise a se, t h e i r compliance to s e le c te d asp ects of t r e a t ment, and t h e i r le v e l of d isease c o n tro l. I have re c e iv e d perm ission from your p h y sic ia n to c o n ta c t you as a p o s sib le p a r tic ip a n t in t h i s study. A v e rb a l q u e stio n n a ire w i l l be ad m in istered which should take approxim ately I4.5 m inutes. I would lik e to ask you some b io g ra p h ic a l and p erso n al in fo rm atio n f i r s t. Then I have some q u estio n s about high blood p re ssu re and how you are fo llow ing your tre a tm e n ts. Your m edical reco rd s w ill be review ed to g a th e r b asic in fo rm atio n as w e ll as your blood p ressu re and w eight read in g s at the c l i n i c. Your p a r tic ip a tio n in t h i s study is v o lu n ta ry. Your p a r t ic ip a ti o n or your r e f u s a l to p a r tic ip a te w ill in no way a f f e c t your m edical care nor w i l l i t be known to the c l i n i c s t a f f. A ll c o n f i d e n t ia li t y w ill be assured. Your name w ill not be put on the q u e s tio n n a ire, but an i d e n t i f i c a t i o n number w i l l be used. This number w ill enable me to correspond your q u e stio n n a ire w ith your m edical re c o rd. At no time w i l l your name be re v e a le d, as a l l d ata w i l l be coded in to numbers and computer an a ly sis c a r rie d out on grouped d ata. You are fre e no t to answer p a r t ic u la r q u estio n s or to withdraw from the study a t any tim e. The r e s u lts of the study w ill be made a v a ila b le to you upon re q u e st. Although you w ill not b e n e fit p e rs o n a lly from t h i s study, i t is hoped th a t t h i s in fo rm atio n w i l l be of h elp to n u rses and o th e r h e a lth p r o fe s s io n a ls in th e ir teach in g and p ro v id in g care to p a tie n ts. 70

81 71 I f you agree to p a r tic ip a te in t h i s study, your sig n a tu re is needed. S ignature of P a tie n t Date

82 APPENDIX C QUESTIONNAIRE Demographic Data ID Number F i r s t of a l l, I would lik e to ask you a few q u estio n s about y o u rse lf. 1. What is your p resen t age? 2. Race of p a tie n t: (by o b serv atio n ) 1. White 2. Black 3. Me x i c an - Arne r i c an 4. In d ian 5. O rie n ta l 6. Other 3. Sex of p a tie n t: (by o b se rv atio n ) 1. Male 2. Female Lj.. Are you now m srried, widowed, se p a ra te d, divorced, or n ever m arried? 1. M arried 2. Widowe d 3. S ep arated k. D ivorced 5. Never m arried 5. What is the h ig h e st grade of school you have completed None 0 Elem entary k High School College k Advanced Degree k Technic al 1 2 Years of Schooling^

83 73 1. Graduate P ro fe s s io n a l T rain in g 2. S tandard C ollege of U n iv e rsity G raduation 3. P a r t i a l C ollege T rain in g 4. High School G raduates 5. P a r t i a l High School 6. Ju n io r High School 7. Less Than Seven Years of School H ollingshead E d u catio n Score 6. What is your occupation? 1. H igher e x e c u tiv e s, p ro p rie to r s of la rg e concerns, and major p r o f e s s io n a ls. 2. B usiness m anagers, p r o p rie to r s of m edium -sized b u sin e sse s, and l e s s e r p r o f e s s io n a ls. 3. A d m in istratio n p e rso n n el, sm all independent b u sin e sse s, and minor p r o f e s s io n a ls. C le r ic a l and sa le s w orkers, te c h n ic ia n s, and owners of l i t t l e b u sin e sse s. 5. S k ille d manual employees. 6. Machine o p e ra to rs and s e m i-s k ille d employees. 7. U n sk illed employees. H ollingshead O ccupation Score S o c ia l Class Score 7. What is your source of income? 1. Job 2. D is a b ility 3. P ension S o cial S e c u rity _5. 6. W elfare O ther 7. Combined 8. What is your average annual income? 1. "2. "3. Less than $ 5,ooo - 810,000 - $15,000 - $20, %, 999 9,999 Oil., 999 ;19,999 more 9. How many y e ars have you had high blood p re ssu re?

84 7k 10. I s th ere a h is to r y of high blood p ressu re in your fam ily? 1. Yes 2. No 3. Don' t Know Knowle dge Now I have some q u estio n s about h y p e rte n sio n. Many of them can be answered by tru e or f a l s e. Choose the b e st answer. In t h i s s e c tio n th e re is a c o rre c t answer to each q u estio n. 11. What is h y p erten sio n? I s i t 1. High blood p re ssu re 2. P ressu re on the tem ples w ith headache 3. Being o v erly anxious or e x c ite d ij.. Don11 know 12. People who are o ld e r are more l i k e l y to develop high blood p re ssu re than younger p eo p le. 1. True 2. F alse 3. Don t Know 13. High blood p ressu re cannot be cured bu t i t can be c o n tro lle d. 1. True 2. F alse 3. Don t Know II4.. Which one of the fo llo w in g kinds of people would be most l i k e l y to g e t high blood p ressu re? 1. People who are underw eight 2. People who are a th le te s 3. People who are overw eight 1;.. People who are young 5. Don t know

85 15. Which one of the fo llo w in g may not ra is e your blood p re ssu re? 1. E atin g s a lty foods 2. W orrying too much 3. Losing w eight Ij.. Don t know 16. A d ie t which could h elp to lower your blood p re s sure might b e : 1. Low in s a lt 2. High in c a lo r ie s 3. High in s a l t if.. Don t know 17. D octors may p re sc rib e low s a l t d ie ts fo r people w ith high blood p re ssu re b ecau se: 1. Low s a l t d ie ts are easy to fo llo w 2. Low s a l t d ie ts are low in c a lo r ie s 3. S a lt can cause your body to r e t a i n w ater and in c re a se your blood p ressu re 4. Don t know 18. I t won t h u rt a p erson w ith high blood p re ssu re to keep busy and a c tiv e. 1. True 2. F alse 3. Don t know 19. Smoking may have a bad e f f e c t on people who have high blood p re ssu re. 1. True 2. F alse 3. Don t Know 20. A person w ith w e ll- tr e a te d high blood p re ssu re : 1. Should avoid e x e rc ise 2. Should e x e rc ise on a re g u la r b a s is 3. I s r e a l l y an in v a lid I}.. Don t know 75

86 High blood p ressu re th a t is not tr e a te d may cause a s tr o k e. 1. True 2. F alse 3. Don t Know 22. Kidney tro u b le may be caused by high blood p ressu re i f i t is n o t tre a te d. 1. True 2. F alse 3. Don11 Know 23. High blood p ressu re t h a t is not tre a te d may cause can cer. 1. True 2. F alse 3. Don t Know 2l±. I t is not n ecessary to take your blood p re ssu re m edicine when you are fe e lin g w e ll. 1. True 2. F alse 3. Don t Know 25. M edicine taken fo r the tre a tm e n t of high blood p ressu re can prevent many co m p licatio n s True F alse 3. Don t Know 26. Once a p erso n has high blood p ressu re he w i l l a l ways have i t even though h is high blood p re ssu re may be c o n tro lle d w ith m edicine. 1. True 2. F alse 3 Don t Know Compliance Now I have some q u e stio n s about how you are g e ttin g along.

87 Have you been to ld by the d o cto r to take any p i l l s f o r your high blood p ressu re? 1. Yes 2. No 28. May I see the p i l l s you have been to ld to take? 1. Yes 2. No 29. I f Yes, re c o rd the fo llo w in g in fo rm atio n : Name S tren g th Dosage How many p i l l s did you take y este rd ay and at what tim es did you take them? Name Frequency/Day # P i l l s Each Time How o fte n to you take your p i l l s as you did y este rd ay? That is tim es a day and p i l l s each time? Name of P i l l A ll o f the time Most of the time m3. 3. About h a lf of the time

88 ?8 L. k-* Some of the time R arely, i f ever 32. I f tak es p i l l s d i f f e r e n t l y than ask. How do you take your p i l l s d i f f e r e n t l y than you d id y esterday? Name of P i l l How Takes D if f e r e n tly k What are the reasons why you sometimes take your p i l l s in a d if f e r e n t way than the way you took them yesterd ay? 3 b C onfirm ation of fin d in g w ith m edical re c o rd : 1. P a tie n t not tak in g any p i l l s 2. P a tie n t tak in g p i l l s c o r re c tly 3. P a tie n t not talcing p i l l s c o r r e c tly. 35. Are you tak in g any o th e r m edications on a re g u la r b a s is th a t has been p re s c rib e d fo r you by a doctor? 1. Yes 2. No 3. Don*t Know 36. I f Yes, th en ask, How many o th e r m edications do you take re g u la rly? (Number) 37. How much d id you weigh at the time you were to ld you had high blood p ressu re? pounds

89 How many pounds do you weigh now? pounds 39. How t a l l are you? inches 1 0. Has i t been suggested th a t you should lose any weight sin ce you have had high blood p ressu re? 1. Yes 2. No 3. D on't Know IjJ.. Have you been able to lo se any weight since you have had high blood p ressu re? 1. Yes 2. No 3. Don t Know lj.2. I f Yes, how many pounds have you lo s t? pounds l o s t I4.3. Before you were to ld you had high blood p re ssu re, how o fte n d id you add s a l t to your food from a s a lt shaker? 1. At most every meal 2. Two meals a day 3. One meal a day Jp. Never 5. Other ijlj-. How o fte n do you now add s a l t to your food from a s a l t shaker? As compared to b efore you were to ld had high blood p ressu re? 1. More o fte n th an b efo re 2. About th e same as befo re 3. Less than befo re 4. Never use s a l t from shaker since 5. Other I4.5. Do you e a t foods th a t c o n tain s a lt such as bacon, pota to ch ip s, p ic k le s, canned f is h and/or canned v e g etab les? 1. Yes

90 80 2. No 3. DonTt Know i.6. Is any s a l t added to your food when i t is being p re p ared and before i t is pu t on the ta b le? 1. Yes 2. No 3. Don t Know 4?. Were you to ld not to add any s a lt to your food by the doctor or nurse? 1. Yes 2. No 3. Don t Know 48. How o fte n have you been able to keep your m edical appointm ents fo r the day and time when th ey have been given to you? 1. Always 2. Most of the time 3. About h a lf of the time 4. Some of the time. 5. None of the time 49. Can you t e l l me what the reaso n s are when you have not been able to keep your m edical appointm ents? 1. Lack of tr a n s p o r ta tio n 2. Lack of money _3. I ll n e s s - s e lf 4* I ll n e s s - fam ily Working Not r e a l l y im portant i f I go or not 7. O ther reaso n - p e rso n a l 8. O ther reaso n - fam ily 9. Other 50. Are you re c e iv in g any tre a tm e n ts in your home, such as h e a t a p p lic a tio n s, s p e c ia l e x e rc ise s, oxygen, or p o s itiv e b re a th in g tre atm e n ts? 1. Yes 2. No 3. Don t Know

91 51. Are you on a s p e c ia l d i e t fo r a c o n d itio n o th e r than f o r your high blood p re ssu re? 1. Yes 2. No 3. Don t Know 81

92 LIST OF REFERENCES Bergman, Abraham, and R ichard W erner. "F a ilu re of C hildren to Receive P e n c illin by Mouth," New England Jo u rn a l of M edicine, 268: , June 13, B erkow itz, Norman, Mary Malone, Malcolm K lein, and Ann Eaton. " P a tie n t Follow-Through in the O u t-p a tien t D ep artm en t," N ursing R esearch, 12: 16-22, Winter 1963 Bloom, Benjamin. Taxonomy of E d ucational O b je c tiv e s, The C la s s if ic a tio n of E d u catio n al Goals Handbook I: C ognitive Domain. New York: David McKay Company, Bruner, Jerome. Beyond the In fo rm atio n Given: S tudies in the Psychology of Knowing. New York: W. W. Norto n, C aldw ell, John, Sidney Cobb, Monroe Dowling, and D asja DeLongh. "The Dropout Problem in A nti-h ypertensive T reatm en t: A P i l o t Study of S o cial and Em otional F a cto rs In flu e n c in g a P a t i e n t s A b ility to Follow A nti-h ypertensive T reatm ent," Jo u rn al of Chronic D ise a se s, 22: , February Charney, Evan, Rufus Bynum, Donald E ldredge, Donald Frank, James MacWhinney, Neal McNobb, A lbert S cheiner, Edwin Sympter, and Howard I k e r. "How Well Do P a tie n ts Take O ral P e n ic illin? A C o llab o rativ e Study in P riv a te P r a c tic e," P e d i a t r i c s, 4-0: , August Cole, P h i l l i p, and S is te r Emmanuel. "Drug C o n su ltatio n : I t s S ig n ific a n c e to the D ischarged H o s p ita l Pat i e n t and i t s Relevance as a Role f o r the Pharmac i s t, " American Jo u rn a l of H o sp ita l Pharmacy, 28: , December Davis, M ilton. "V ariatio n s in P a t i e n t s Compliance With D o c to rs O rders: A nalysis of Congruence Between Survey Responses and R e s u lts of E m pirical I n v e s t i g a tio n s," Jo u rn al of M edical E ducation, 4-1: ,

93 F in n e rty, F rank, Edward M a ttie, and F rancis F in n e rty. H ypertension in the In n e r C ity: A nalysis of C lin ic D ropouts, C ir c u la tio n, If.?: 73-78, F r e is, Edward. The Modern Management o f H y p e rten sio n. W ashington, D. C.: V eteran s A d m in istr a tio n, H o llingshead, A. Two-Factor Index of S o cial P o s itio n. New Haven, Conn., 195>7. Judd, C harles, E rnest B re s lic k, J. M. M cc allister, and Ralph T y ler. E ducation as C u ltiv a tio n of the H igher M ental P ro c e ss e s. New York; MacMillan Company, K ingsley, Howard. The N ature and C onditions of L earn in g. R evised by Ralph Garry. Englewood C lif f s, N. J. : P re n tic e -H a ll, 19i 6, Krathwohl, David, Benjamin Bloom, and Bertram M asis. Taxonomy of E d u cation al O b je c tiv e s: The C la s s i f i c a t i o n o f E d u ca tio n a l G oals. Handbook I I: A f f e c t iv e Domain. New York: David McKay Company 19W - Leary, Jean, D olores V e sse lla, and Evelyn Ye aw. S e lf- A dm inistered M e d ic a tio n s, American Jo u rn a l of N u rsin g, 71: , Lew in, K urt. Behavior and Development as a F u n ctio n of the T o ta l S i t u a t i o n, Manual of C hild D evelopment. E d ited by L. C arm ichael. New York! W iley Malahy, B ern ad in e. The E f f e c t of I n s tr u c tio n and Labeling on the Number of M edication E rro rs Made by P a tie n ts a t Home, American Jo u rn al of H o sp ita l Pharmacy, 23: ", June M artin, J a n e. E x p lain in g, U nderstanding, and T eaching. New York; McGraw-Hill, M clnnis, Jane. Do P a tie n ts Take T heir A n ti-t u b e r c u lo sis Drugs?, American Jou rn al o f N u rsin g, 70: , O ctober 1970.

94 McKenney, James, Ju d ith S lin in g, H. Henderson, Douglas D evins, and M artin B arr. "The E ffe c t of C lin ic a l Pharmacy S erv ic es on P a t i e n t s w ith E s s e n tia l H y p erten sio n," C irc u la tio n, I4.8 : l].-llll, November M etro p o litan L ife Insurance Company. "Overweight: I t s P rev en tio n and S ig n ific a n c e," S t a t i s t i c a l B u l l e t i n, May I960. Mohler, D aniel, David W allin, and Edward D rey fu s. "Studies in the Home Treatm ent o f S tre p to c o c c a l D isease. I. F a ilu re of P a tie n ts to Take P e n i c i l l i n by Mouth as P r e s c r ib e d," New England Jo u rn al of M edicine, 252: , June 23, 19 p. Moulding, Thomas, David O nstad, and Jong S b arb aro. "Superv is io n of O u tp atien ts Drug Therapy w ith the Medic a tio n M onitor," Annals of I n te r n a l M edicine, 73: , P e rg rin, J e s s ie. "Autonomy and Job S a tis f a c tio n of Family Nurse P r a c titio n e r s and D iab etic and H ypertensive P a tie n t Outcomes." Ph.D. d i s s e r ta ti o n, U n iv e rsity of North C aro lin a, Department of Epidem iology, Redman, B arbara. The P rocess of P a tie n t Teaching in N ursing. S t. LouisJ Mo.: C. V. Mosby, Rezac, B arbara. "S elected F a c to rs In flu e n c in g a P a t i e n t Ts D ecisio n to Continue in or Drop Out of an A n tih y p erte n siv e Treatm ent Program." M a ste r's th e s is. U n iv e rsity of Arizona, C ollege of N ursing, R yle, G ilb e r t. The Concept of Mind. London: H utchinson, Tab a, H ild a. C urriculum Development: Theory and. P r a c tic e. New York: H arco u rt, Brace and World, Tagliocozzo, D aisy, and K enji Ima. "Knowledge of I lln e s s as a P re d ic to r of P a tie n t B ehavior," Jo u rn al of Chronic D ise a se s, 22: , November V eterans A d m in istratio n C ooperative Study Group on A n tih y p erten siv e Agents. "E ffe ct of Treatm ent on M orbidity in H ypertension: Part I, " Journal of the American M edical A s s o c ia t io n, 202: , December 11, %

95 V eterans A d m in istrativ e C ooperative Study Group on A n tih y p erte n siv e Agents. "E ffe c ts of Treatm ent on M orbidity in H ypertension: P a rt I I, " Jo u rn a l of the American M edical A s s o c ia tio n, : l l i ].3 " l l 5 2, August 17, W atkins, J u li a, F ra n k lin W illiam s, Don M artin, M ichael Hogan, and E velyn A nderson. "A Study o f D ia b e tic P a tie n ts at Home, American Jou rn al o f P u b lic H e a lth. 5?: ij , March 196?. W illiam s, T., Dan M artin, M ichael Hogan, J u l i a W atkins, and E. E l l i s. "The C lin ic a l P ic tu re of D iab etic C o n tro l, S tu d ied in Four S e ttin g s," American Jo u rn a l of P ublic H ealth, 57: l if-l-l}.5l/ March 19&7.

96