531794
research-article2014
TCNXXX10.1177/1043659614531794Journal of Transcultural NursingWelsh et al.
Research Department
Lifestyles of Jamaican Men With Hypertension
Journal of Transcultural Nursing 2015, Vol. 26(5) 507–513 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1043659614531794 tcn.sagepub.com
Faithlee Elizabeth Welsh, MScN, FNP1, Edith Marilyn Duff, PhD, RN2, Khadene Campbell-Taffe, MSN, RN2, and Jascinth L.M. Lindo, PhD, RN2
Abstract Purpose: Determine the extent to which the lifestyles of Jamaican men with hypertension met the guidelines of the Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7). Design and Methods: Following informed consent, a convenience sample of Jamaican men with hypertension (n = 48), of African ethnicity, attending a Type 5 Health Center was interviewed over a four week period, using a 31-item interview schedule. Results: Mean age of respondents was 65.2 (± 12.1) years (range = 35-89 years) with 33% having blood pressure (BP) controlled to 130/80 mmHg. Those meeting the guidelines were normal weight 23 (47.9%), DASH (dietary approaches to stop hypertension) diet zero, medication 7 (14.6%), exercise 14 (29.2%), alcohol restriction 38 (79.2%), and smoking cessation 40 (83.3%). Medication adherence was associated with BP control (r = −0.30, p < .04). More than half of the respondents believed that hypertension could be cured and that they could stop all treatment if their BP was normal. Discussion and Conclusions: Only a third of the sample had BP controlled to ≤130/80 mmHg. Adherence to the JNC 7 lifestyle guidelines was inadequate. Implications for Practice: A nurse led intervention, focusing on perceptions and lifestyle practices, is indicated. Keywords lifestyles, Jamaican men with hypertension, blood pressure, body mass index, medication adherence
Introduction The prevalence of hypertension rises with age and occurs more frequently in Black than in White people (Agyemang & Bhopal, 2003; Sutters, 2010). Hypertension is estimated to cause 4.5% of the worldwide disease burden and is as prevalent in developing countries as in the developed world (Whitworth, 2005). The second report of the Jamaica Health and Lifestyle Survey (JHLS II) revealed that there was a 4% increase in hypertension prevalence between 2000 and 2008. Males had higher mean systolic and diastolic blood pressures (SBP and DBP, respectively) than females. Significantly more males (69.4%) were unaware of their condition compared with 30.5% females, and their BPs were not controlled (Wilks, Younger, Tulloch-Reid, McFarlane, & Francis, 2008). The Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) recommends medication therapy with different classes of drugs. It also recommends lifestyle modifications: weight loss, dietary approaches to stop hypertension (DASH) eating plan, reduced sodium intake, aerobic exercise, smoking cessation, and moderate alcohol consumption (National Institutes of Health, 2004; Tables 1 and 2).
There are few data on the effect of lifestyle intervention studies in Jamaica and the wider Caribbean (Duff & Wilks, 2003). A 6-month nurse led lifestyle intervention, however, was effective in significantly lowering BP in men and women attending a hospital clinic in Jamaica (Duff, Simpson, Whittle, Bailey, Lopez, & Wilks, 2000). There is international evidence that in the treatment of hypertension, nurse led interventions can improve on physicianled or usual care of hypertension (Clarke, Smith, Taylor, & Campbell, 2010). Many studies have addressed factors related to medication adherence in persons with hypertension; however, there is little on lifestyle modifications. Chen, Tsai, and Lee (2009) have suggested that perception of illness is a significant predictor for adherence to treatment. Since hypertension can be
1
North East Region Health Authority, Port Antonio, Jamaica The University of the West Indies School of Nursing, Kingston, Jamaica
2
Corresponding Author: Edith Marilyn Duff, PhD, RN, Faculty of Medical Sciences, The University of the West Indies School of Nursing, Mary J. Seivwright Building, 9 Gibraltar Camp Way, Mona Campus, Kingston 7, Jamaica. Email: [email protected]
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Table 1. JNC 7 Lifestyle Modifications to Manage Hypertension. Modification Weight reduction Adopt DASH eating plan Dietary sodium reduction Physical activity Moderation of alcohol consumption
Stop smoking
Recommendation Maintain normal body weight (BMI, 18.5-24.9 kg/m2) Consume diet rich in fruits, vegetables, and low-fat dairy products with a reduced content of saturated and total fat Reduce daily dietary sodium intake to no more than 100 Eq/L (2.4 g sodium or 6 g sodium chloride) Engage in regular physical activity such as brisk walking (at least 30 minutes per day, most days of the week) Limit consumption to no more than 2 drinks per day (1 oz or 30 mL ethanol (e.g., 24 oz beer, 10 oz wine, or 3 oz 80-proof whiskey) in most men and no more than 1 drink per day in women and lighter weight persons For overall cardiovascular risk reduction
Note. JNC7 = Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; BMI = body mass index; DASH = dietary approaches to stop hypertension. National Institutes of Health (2004).
Table 2. The Dietary Approaches to Stop Hypertension (DASH) Diet. The DASH diet is •• low in saturated fat, cholesterol, and total fat •• focuses on fruits, vegetables, and fat-free or low-fat dairy products •• is rich in whole grains, fish, poultry, beans, seeds, and nuts •• ontains fewer sweets, added sugars, and sugary beverages, and red meats than the typical American diet •• recommends that the person with hypertension consume no more than 2,300 mg of sodium per day •• for example, a 1,800 calorie diet would daily include: •• whole grains 6 servings, vegetables 4-5 servings, fruits 4-5 servings, fat-free or low-fat dairy 2-3 servings, lean meats 6 or less servings, nuts, seeds, legumes 4 servings/week, fats and oils 2-3 servings/day, sweets or added sugars 5 or less/week, maximum sodium 2,300 mg/day Note. National Heart, Lung and Blood Institute (2013).
asymptomatic, a lay person may not view it as an illness and this may affect adherence. Using the health belief model, researchers in Chile identified gender, occupational activity, smoking, adjustment of health behaviors, difficulties taking medication, view of benefits of treatment, knowledge, and perception about hypertension as factors affecting BP control (Mendoza, Munoz, Merino & Barriga, 2006). In the United States, among older Chinese immigrants, men had lower adherence to medications (69%) compared with women (75%) (Li, Wallhagen, &
Froeclicher, 2008). These findings were supported by a cross-sectional study done in Guadeloupe, which reported 22% BP control in men and 44% in women (Altallah, KellyIrving, Zouini, Ruidavets, Inamo, & Lang, 2010). Adherence to treatment for hypertension is also influenced by age, education, and number of pills to be taken. Adherence was more common in clients who were younger than 60 years, living in the city, better educated, adequately counseled by a physician and followed up by a private doctor, taking one pill daily, and those who had never changed their antihypertensive regimen or their doctor (Yiannakopoulou, Papadopulos, Cokkinos & Mountokalakis, 2005). A cross-sectional study done in Nigeria in a tertiary clinic, however, reported that gender, age, number of drugs used, level of education, and presence of other illnesses did not affect adherence, but factors such as client’s attitudes and beliefs, clinician consultation, finances, and medicationrelated factors were important (Amira & Okubadejo, 2007). Braverman and Dedier (2009) reported that the relationship between education and medication adherence in African Americans had significant variations, where men with lower educational level had better adherence to antihypertensive medication, women with lower educational background had a lower adherence rate. An Afro-Caribbean study conducted in Antigua and Barbuda reported that persons who received medications at low or no cost to them had a 70% BP control, when compared with 38% in those who had to buy medications (Martin, Bhaskar, & Umesh, 2008). A study conducted in the United States, looking at BP control in African Americans attending a primary health care facility, identified race, duration of hypertension, high levels of stress, and being worried about hypertension as some of the factors affecting BP control. African Americans reported higher levels of stress and had lower BP control (34%) compared with White persons (49%) (Bosworth, Powers, Grubber, Thorpe, Olsen, Orr, & Oddone, 2008). There are several factors related to adherence to exercise. In the United States, adults older than 60 years identified health issues, availability of time, and fear of exercise. Men had greater weight control and physical activity levels than women. Men smoked and used alcohol more frequently than women (Wright & Hyner, 2009). These findings were supported in a multiracial study looking at exercise adherence in older adults from 42 focus groups (Mathews, Laditka, Laditka, Wilcox, Corwin, Liu, & Longsdon, 2010). Motivation and availability of exercise facilities were identified as important factors influencing adherence to exercise in a study done in Australia. Awareness of the link between hypertension and lifestyle practices was also important (Cerin, Leslie, Sugiyama, & Owen, 2010). A study in Jamaica in men and women with uncontrolled hypertension attending a hospital clinic revealed that the majority were obese, with only 12% of men and 7% of women linking diet, nutrition, and obesity to BP control (Simpson, Duff, Whittle, & Wilks, 2000).
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Welsh et al. Table 3. Study Questionnaire. Knowledge Questions
Answer true or false for Questions 13-17 13. High blood pressure is called “the silent killer”_______ 14. High blood pressure can be cured _______ 15. Once your doctor/nurse practitioner says your blood pressure is normal, you can stop all treatment _______ 16. Medication alone is enough to manage high blood pressure ______ 17. You should have your blood pressure checked between visits _____ 18. What do you think will happen to you if you do not control your blood pressure over a period of time? ___________________ Medication Adherence Questions (1) I am now going to ask you about your medications. 19. What are the names of the medications you are taking every day for your blood pressure? __________ 20. How many tablets do you take each day for your blood pressure? ___________________ 21. How often do you take them? __________________________________ 22. Are you taking any bush or other substances to treat your high blood pressure? Yes [ ] No [ ] If so, what are they? _____________________________________ 23. How many days in the week do you not take (miss) your medications? _________ Medication Adherence Questions (2) 24. Please answer “always,” “sometimes,” or “never” for the following questions Do you
Always (5)
take the blood pressure tablets at the times they are prescribed? feel sick after taking your blood pressure medication? stop taking your blood pressure medication because you feel sick when you take it? bring your blood pressure medication(s) with you when you go out? have any problems remembering to take all your blood pressure medications? have any difficulty getting any of your blood pressure medications? Medication adherence score ______
Strong gender differences exist in the control of hypertension; therefore, separate targeted interventions addressing hypertension are necessary in men and women (Altallah et al., 2010). A population survey in Jamaica indicated that Jamaican men had higher mean SBPs and DBPs than women, were unaware of their condition, and were not controlled (Wilks et al., 2008). Poor adherence to treatment is a major limitation in the control of hypertension and may lead to increased morbidity, mortality, and cost (Van Onzenoort, Verberk, Kroon, Kessels, Nelemans, van der Kuy, & de Leeuw, 2010). This study, therefore, sought to answer the following question: To what extent do Jamaican men with hypertension, attending a selected urban public health clinic, in Jamaica, adhere to the lifestyle recommendations of the JNC 7?
Method A cross-sectional, descriptive study using a 31-item interview schedule was used to determine the extent to which life style factors of Jamaican men with hypertension were in congruence with the JNC 7 recommendations for BP control (Tables 1 and 2). The instrument tested knowledge (Table 3) and included demographics and scale questions on adherence to medication
Sometimes (2)
Never (0)
(Table 3) and lifestyle modifications, in keeping with the JNC 7 recommendations. No patient clinic records were used. A convenience sample (n = 48) of men with hypertension, of mixed African descent, from a population (N = 60) attending a Type 5 Health Center in Jamaica over a 4-week period was selected. A Type 5 Health Center is a multidisciplinary, government-administered outpatient free clinic. The sample size (n = 48) was determined using the Raosoft (2004) sample size calculator (www.raosoft.com/samplesize.html), based on a 5% margin of error, 95% confidence level, population of 60 men with hypertension and a 50% response distribution. All males older than 18 years diagnosed with hypertension, attending the Type 5 Health Center within the period of the study, were included. Males newly diagnosed with hypertension within 1 week of the interview and those men who were unable or unwilling to answer the questions on the interview schedule were excluded. Following informed consent, each participant rested for 5 minutes before measurement of BP. A mean of two BP readings using a standard mercury sphygmomanometer on the right arm were done, using an appropriate size cuff with the participant sitting with feet on the floor and arm supported at
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Table 4. Characteristics of Jamaican Men With Hypertension.
Age (years) Duration of hypertension (years) BMI (kg/m2) Waist circumference (cm) Systolic BP (mmHg) Diastolic BP (mmHg)
M
SD
Min/Max
65.2 5.0 (Mdn) 25.2 90.5 (Mdn) 146.4 85.4
12.1
35-89 0.25-42 18.1-40.2 68.5-115 94-205 61-109
4.5 24.0 11.2
Note. BMI = body mass index; BP = blood pressure; SD = standard deviation; Mdn = median; Min = minimum; Max = maximum.
heart level. Waist circumference (WC), height, and weight were measured without shoes, using the same calibrated measurement tools and the same measurer/interviewer (F.E.W.) for each patient. Body mass index (BMI) was calculated. The SPSS® version 17.0 was used for analysis. Measures of central tendency were used to describe the data. Associations between the variables were explored using Spearman’s correlation coefficient. Responses to open-ended questions were categorized and summarized for reporting. Approval was granted by the University Ethics Committee overseeing this study, as well as the Ministry of Health.
Results General Characteristics of the Sample The response rate was 92%. The respondents had a mean age of 65.2 years, and a median of 5 years since diagnosis (Table 4). Seventeen (35.4%) of the respondents had hypertension only, 14 (29.2%) had diabetes mellitus, and 17 (35.4%) had other illnesses such as bronchial asthma, cardiovascular conditions, eye, or prostate problems. Thirty (62.5%) of the respondents were in a union (marital, common law, or visiting). Thirty-one (64.6%) completed primary education, eight (16.7%) secondary, six (12.5%) basic, and three no formal education. There was a negative association between age and education level, r = −0.35, p < .01. Twenty-four (50%) had skilled occupations, 14 (29.2%) had unskilled occupations, and 10 (20.8%) were retired. Thirty-nine (81.3%) were Christians, three (6.2%) were Rastafarians, and six (12.5%) reported no religion.
Physical Characteristics The mean BMI was 25.2 kg/m2 (Table 4). Twenty-five (52%) were overweight or obese. The median WC was 90.5 cm (Table 4). Five (10.4%) respondents had a WC >102 cm. There was a significant association between BMI and waist circumference r = 0.91, p < .0001. The mean SBP was 146.4 mmHg (Table 4). Sixteen (33.3%) had SBP ≤130 mmHg. Mean DBP was 85.9 mmHg (Table 4), and 16 (33.3%) had DBP ≤80 mmHg. Respondents rated their stress level on the day of interview from 0 to 5. Seventeen (37.5%) reported experiencing little or no stress, 9 (18.8%)
Table 5. Knowledge, Medication Adherence, and Diet Scores of Jamaican Men With Hypertension.
Knowledge (%) Medication (%) Diet (%)
Mdn
LQ, UQ
Min/Max
83.3 70 30
50, 95.8 60, 91.4 22.3, 40.0
50-100 34.3-100 12.7-65.4
Mdn = median; LQ = lower quartile; UQ = upper quartile; Min = minimum; Max = maximum.
rated stress as moderate, and 11 (22.9%) rated stress as high. The main sources of stress were financial difficulty (54.2%), conflicts with friends (16.6%) or family (12.5%), and illness. Fourteen (29.2%) lived alone while others lived with 1 to 30 family members. Thirteen (27.1%) reported no financial support or encouragement from family or friends. Level of stress was not related to BP but was negatively associated with age, r = −0.28, p < .05.
Knowledge The median score in knowledge of hypertension was 83.3% (Table 5). All the respondents answered “true” to the statement “High blood pressure is also called a silent killer.” Forty-five (93.7%) understood that uncontrolled BP could lead to stroke or death; however, 22 (45.8%) believed that hypertension could be cured. Twenty-five (52.1%) said they would stop taking all treatment if their doctor or practitioner told them their blood pressure was normal. Twenty-two (45.8%) believed that medication alone was enough to manage high BP.
Medication and Use of Alternative Remedies Twenty-one (43.7%) respondents reported always taking medications as prescribed, 8 (16.7%) felt ill after taking medications, 29 (60.4%) traveled with medications when leaving home, 10 (20.8%) had difficulty remembering to take medications, and 21 (43.7%) experienced difficulty obtaining medications at the pharmacy. Forty-five (93.8%) could not recall the name of any of their medications. The median number of missed medication days per week was 1 day (range = 0-6 days). Sixteen (33.3%) respondents ingested undetermined amounts of alternative remedies. Ten respondents used these with medications, while others used them as substitutes. These remedies included garlic (Allium sativum), guinea hen weed (Phytolaccaceae), lime juice (Citrus aurantifolia), hibiscus flowers (Hibiscus rosa-sinesis), sour sop (Annona muricata) leaf, devil’s horseweed (Conyza canadensis), noni (Morinda citrofolia) leaf, and cerassee (Momordica charantia) (Lowe, Payne-Jackson, Beckstrom-Sternberg & Duke, 2001). The median medication adherence score was 70% (Table 5). Seven (14.6%) scored full marks (Table 5). There was a negative association between SBP and medication adherence score,
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Welsh et al. r = −0.33, p < .02; DBP and medication adherence score, r = −0.35, p < .01; and DBP and number of days of missed medications, r = 0.40, p < .005.
Diet and Exercise The median diet score was 30% (Table 5). Six of the respondents (12.5%) reported being on a “special diet.” Thirty-five (72.9%) did not prepare their own meals, 39 (81.2%) reported that their meals were always prepared with salt, and 44 (91.6%) did not read the labels on packaged foods. Thirtyeight (79.2%) ate “fast food,” nine (18.7%) ate at least three vegetable servings per day, and only one respondent followed the DASH diet requirement of eating at least five servings of fruits per day. Thirteen (27.1%) consumed low-fat dairy products “sometimes” and five (10.4%) always avoided fried or greasy foods. Sixteen (33.3%) reported performing no exercise. Eighteen (37.5%) did brisk walking fewer than 4 days per week while 14 (29.2%) did brisk walking “most days.”
Alcohol and Smoking Thirty-eight (79.2%) respondents consumed none or
research-article2014
TCNXXX10.1177/1043659614531794Journal of Transcultural NursingWelsh et al.
Research Department
Lifestyles of Jamaican Men With Hypertension
Journal of Transcultural Nursing 2015, Vol. 26(5) 507–513 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1043659614531794 tcn.sagepub.com
Faithlee Elizabeth Welsh, MScN, FNP1, Edith Marilyn Duff, PhD, RN2, Khadene Campbell-Taffe, MSN, RN2, and Jascinth L.M. Lindo, PhD, RN2
Abstract Purpose: Determine the extent to which the lifestyles of Jamaican men with hypertension met the guidelines of the Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7). Design and Methods: Following informed consent, a convenience sample of Jamaican men with hypertension (n = 48), of African ethnicity, attending a Type 5 Health Center was interviewed over a four week period, using a 31-item interview schedule. Results: Mean age of respondents was 65.2 (± 12.1) years (range = 35-89 years) with 33% having blood pressure (BP) controlled to 130/80 mmHg. Those meeting the guidelines were normal weight 23 (47.9%), DASH (dietary approaches to stop hypertension) diet zero, medication 7 (14.6%), exercise 14 (29.2%), alcohol restriction 38 (79.2%), and smoking cessation 40 (83.3%). Medication adherence was associated with BP control (r = −0.30, p < .04). More than half of the respondents believed that hypertension could be cured and that they could stop all treatment if their BP was normal. Discussion and Conclusions: Only a third of the sample had BP controlled to ≤130/80 mmHg. Adherence to the JNC 7 lifestyle guidelines was inadequate. Implications for Practice: A nurse led intervention, focusing on perceptions and lifestyle practices, is indicated. Keywords lifestyles, Jamaican men with hypertension, blood pressure, body mass index, medication adherence
Introduction The prevalence of hypertension rises with age and occurs more frequently in Black than in White people (Agyemang & Bhopal, 2003; Sutters, 2010). Hypertension is estimated to cause 4.5% of the worldwide disease burden and is as prevalent in developing countries as in the developed world (Whitworth, 2005). The second report of the Jamaica Health and Lifestyle Survey (JHLS II) revealed that there was a 4% increase in hypertension prevalence between 2000 and 2008. Males had higher mean systolic and diastolic blood pressures (SBP and DBP, respectively) than females. Significantly more males (69.4%) were unaware of their condition compared with 30.5% females, and their BPs were not controlled (Wilks, Younger, Tulloch-Reid, McFarlane, & Francis, 2008). The Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) recommends medication therapy with different classes of drugs. It also recommends lifestyle modifications: weight loss, dietary approaches to stop hypertension (DASH) eating plan, reduced sodium intake, aerobic exercise, smoking cessation, and moderate alcohol consumption (National Institutes of Health, 2004; Tables 1 and 2).
There are few data on the effect of lifestyle intervention studies in Jamaica and the wider Caribbean (Duff & Wilks, 2003). A 6-month nurse led lifestyle intervention, however, was effective in significantly lowering BP in men and women attending a hospital clinic in Jamaica (Duff, Simpson, Whittle, Bailey, Lopez, & Wilks, 2000). There is international evidence that in the treatment of hypertension, nurse led interventions can improve on physicianled or usual care of hypertension (Clarke, Smith, Taylor, & Campbell, 2010). Many studies have addressed factors related to medication adherence in persons with hypertension; however, there is little on lifestyle modifications. Chen, Tsai, and Lee (2009) have suggested that perception of illness is a significant predictor for adherence to treatment. Since hypertension can be
1
North East Region Health Authority, Port Antonio, Jamaica The University of the West Indies School of Nursing, Kingston, Jamaica
2
Corresponding Author: Edith Marilyn Duff, PhD, RN, Faculty of Medical Sciences, The University of the West Indies School of Nursing, Mary J. Seivwright Building, 9 Gibraltar Camp Way, Mona Campus, Kingston 7, Jamaica. Email: [email protected]
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Journal of Transcultural Nursing 26(5)
Table 1. JNC 7 Lifestyle Modifications to Manage Hypertension. Modification Weight reduction Adopt DASH eating plan Dietary sodium reduction Physical activity Moderation of alcohol consumption
Stop smoking
Recommendation Maintain normal body weight (BMI, 18.5-24.9 kg/m2) Consume diet rich in fruits, vegetables, and low-fat dairy products with a reduced content of saturated and total fat Reduce daily dietary sodium intake to no more than 100 Eq/L (2.4 g sodium or 6 g sodium chloride) Engage in regular physical activity such as brisk walking (at least 30 minutes per day, most days of the week) Limit consumption to no more than 2 drinks per day (1 oz or 30 mL ethanol (e.g., 24 oz beer, 10 oz wine, or 3 oz 80-proof whiskey) in most men and no more than 1 drink per day in women and lighter weight persons For overall cardiovascular risk reduction
Note. JNC7 = Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; BMI = body mass index; DASH = dietary approaches to stop hypertension. National Institutes of Health (2004).
Table 2. The Dietary Approaches to Stop Hypertension (DASH) Diet. The DASH diet is •• low in saturated fat, cholesterol, and total fat •• focuses on fruits, vegetables, and fat-free or low-fat dairy products •• is rich in whole grains, fish, poultry, beans, seeds, and nuts •• ontains fewer sweets, added sugars, and sugary beverages, and red meats than the typical American diet •• recommends that the person with hypertension consume no more than 2,300 mg of sodium per day •• for example, a 1,800 calorie diet would daily include: •• whole grains 6 servings, vegetables 4-5 servings, fruits 4-5 servings, fat-free or low-fat dairy 2-3 servings, lean meats 6 or less servings, nuts, seeds, legumes 4 servings/week, fats and oils 2-3 servings/day, sweets or added sugars 5 or less/week, maximum sodium 2,300 mg/day Note. National Heart, Lung and Blood Institute (2013).
asymptomatic, a lay person may not view it as an illness and this may affect adherence. Using the health belief model, researchers in Chile identified gender, occupational activity, smoking, adjustment of health behaviors, difficulties taking medication, view of benefits of treatment, knowledge, and perception about hypertension as factors affecting BP control (Mendoza, Munoz, Merino & Barriga, 2006). In the United States, among older Chinese immigrants, men had lower adherence to medications (69%) compared with women (75%) (Li, Wallhagen, &
Froeclicher, 2008). These findings were supported by a cross-sectional study done in Guadeloupe, which reported 22% BP control in men and 44% in women (Altallah, KellyIrving, Zouini, Ruidavets, Inamo, & Lang, 2010). Adherence to treatment for hypertension is also influenced by age, education, and number of pills to be taken. Adherence was more common in clients who were younger than 60 years, living in the city, better educated, adequately counseled by a physician and followed up by a private doctor, taking one pill daily, and those who had never changed their antihypertensive regimen or their doctor (Yiannakopoulou, Papadopulos, Cokkinos & Mountokalakis, 2005). A cross-sectional study done in Nigeria in a tertiary clinic, however, reported that gender, age, number of drugs used, level of education, and presence of other illnesses did not affect adherence, but factors such as client’s attitudes and beliefs, clinician consultation, finances, and medicationrelated factors were important (Amira & Okubadejo, 2007). Braverman and Dedier (2009) reported that the relationship between education and medication adherence in African Americans had significant variations, where men with lower educational level had better adherence to antihypertensive medication, women with lower educational background had a lower adherence rate. An Afro-Caribbean study conducted in Antigua and Barbuda reported that persons who received medications at low or no cost to them had a 70% BP control, when compared with 38% in those who had to buy medications (Martin, Bhaskar, & Umesh, 2008). A study conducted in the United States, looking at BP control in African Americans attending a primary health care facility, identified race, duration of hypertension, high levels of stress, and being worried about hypertension as some of the factors affecting BP control. African Americans reported higher levels of stress and had lower BP control (34%) compared with White persons (49%) (Bosworth, Powers, Grubber, Thorpe, Olsen, Orr, & Oddone, 2008). There are several factors related to adherence to exercise. In the United States, adults older than 60 years identified health issues, availability of time, and fear of exercise. Men had greater weight control and physical activity levels than women. Men smoked and used alcohol more frequently than women (Wright & Hyner, 2009). These findings were supported in a multiracial study looking at exercise adherence in older adults from 42 focus groups (Mathews, Laditka, Laditka, Wilcox, Corwin, Liu, & Longsdon, 2010). Motivation and availability of exercise facilities were identified as important factors influencing adherence to exercise in a study done in Australia. Awareness of the link between hypertension and lifestyle practices was also important (Cerin, Leslie, Sugiyama, & Owen, 2010). A study in Jamaica in men and women with uncontrolled hypertension attending a hospital clinic revealed that the majority were obese, with only 12% of men and 7% of women linking diet, nutrition, and obesity to BP control (Simpson, Duff, Whittle, & Wilks, 2000).
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Welsh et al. Table 3. Study Questionnaire. Knowledge Questions
Answer true or false for Questions 13-17 13. High blood pressure is called “the silent killer”_______ 14. High blood pressure can be cured _______ 15. Once your doctor/nurse practitioner says your blood pressure is normal, you can stop all treatment _______ 16. Medication alone is enough to manage high blood pressure ______ 17. You should have your blood pressure checked between visits _____ 18. What do you think will happen to you if you do not control your blood pressure over a period of time? ___________________ Medication Adherence Questions (1) I am now going to ask you about your medications. 19. What are the names of the medications you are taking every day for your blood pressure? __________ 20. How many tablets do you take each day for your blood pressure? ___________________ 21. How often do you take them? __________________________________ 22. Are you taking any bush or other substances to treat your high blood pressure? Yes [ ] No [ ] If so, what are they? _____________________________________ 23. How many days in the week do you not take (miss) your medications? _________ Medication Adherence Questions (2) 24. Please answer “always,” “sometimes,” or “never” for the following questions Do you
Always (5)
take the blood pressure tablets at the times they are prescribed? feel sick after taking your blood pressure medication? stop taking your blood pressure medication because you feel sick when you take it? bring your blood pressure medication(s) with you when you go out? have any problems remembering to take all your blood pressure medications? have any difficulty getting any of your blood pressure medications? Medication adherence score ______
Strong gender differences exist in the control of hypertension; therefore, separate targeted interventions addressing hypertension are necessary in men and women (Altallah et al., 2010). A population survey in Jamaica indicated that Jamaican men had higher mean SBPs and DBPs than women, were unaware of their condition, and were not controlled (Wilks et al., 2008). Poor adherence to treatment is a major limitation in the control of hypertension and may lead to increased morbidity, mortality, and cost (Van Onzenoort, Verberk, Kroon, Kessels, Nelemans, van der Kuy, & de Leeuw, 2010). This study, therefore, sought to answer the following question: To what extent do Jamaican men with hypertension, attending a selected urban public health clinic, in Jamaica, adhere to the lifestyle recommendations of the JNC 7?
Method A cross-sectional, descriptive study using a 31-item interview schedule was used to determine the extent to which life style factors of Jamaican men with hypertension were in congruence with the JNC 7 recommendations for BP control (Tables 1 and 2). The instrument tested knowledge (Table 3) and included demographics and scale questions on adherence to medication
Sometimes (2)
Never (0)
(Table 3) and lifestyle modifications, in keeping with the JNC 7 recommendations. No patient clinic records were used. A convenience sample (n = 48) of men with hypertension, of mixed African descent, from a population (N = 60) attending a Type 5 Health Center in Jamaica over a 4-week period was selected. A Type 5 Health Center is a multidisciplinary, government-administered outpatient free clinic. The sample size (n = 48) was determined using the Raosoft (2004) sample size calculator (www.raosoft.com/samplesize.html), based on a 5% margin of error, 95% confidence level, population of 60 men with hypertension and a 50% response distribution. All males older than 18 years diagnosed with hypertension, attending the Type 5 Health Center within the period of the study, were included. Males newly diagnosed with hypertension within 1 week of the interview and those men who were unable or unwilling to answer the questions on the interview schedule were excluded. Following informed consent, each participant rested for 5 minutes before measurement of BP. A mean of two BP readings using a standard mercury sphygmomanometer on the right arm were done, using an appropriate size cuff with the participant sitting with feet on the floor and arm supported at
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Journal of Transcultural Nursing 26(5)
Table 4. Characteristics of Jamaican Men With Hypertension.
Age (years) Duration of hypertension (years) BMI (kg/m2) Waist circumference (cm) Systolic BP (mmHg) Diastolic BP (mmHg)
M
SD
Min/Max
65.2 5.0 (Mdn) 25.2 90.5 (Mdn) 146.4 85.4
12.1
35-89 0.25-42 18.1-40.2 68.5-115 94-205 61-109
4.5 24.0 11.2
Note. BMI = body mass index; BP = blood pressure; SD = standard deviation; Mdn = median; Min = minimum; Max = maximum.
heart level. Waist circumference (WC), height, and weight were measured without shoes, using the same calibrated measurement tools and the same measurer/interviewer (F.E.W.) for each patient. Body mass index (BMI) was calculated. The SPSS® version 17.0 was used for analysis. Measures of central tendency were used to describe the data. Associations between the variables were explored using Spearman’s correlation coefficient. Responses to open-ended questions were categorized and summarized for reporting. Approval was granted by the University Ethics Committee overseeing this study, as well as the Ministry of Health.
Results General Characteristics of the Sample The response rate was 92%. The respondents had a mean age of 65.2 years, and a median of 5 years since diagnosis (Table 4). Seventeen (35.4%) of the respondents had hypertension only, 14 (29.2%) had diabetes mellitus, and 17 (35.4%) had other illnesses such as bronchial asthma, cardiovascular conditions, eye, or prostate problems. Thirty (62.5%) of the respondents were in a union (marital, common law, or visiting). Thirty-one (64.6%) completed primary education, eight (16.7%) secondary, six (12.5%) basic, and three no formal education. There was a negative association between age and education level, r = −0.35, p < .01. Twenty-four (50%) had skilled occupations, 14 (29.2%) had unskilled occupations, and 10 (20.8%) were retired. Thirty-nine (81.3%) were Christians, three (6.2%) were Rastafarians, and six (12.5%) reported no religion.
Physical Characteristics The mean BMI was 25.2 kg/m2 (Table 4). Twenty-five (52%) were overweight or obese. The median WC was 90.5 cm (Table 4). Five (10.4%) respondents had a WC >102 cm. There was a significant association between BMI and waist circumference r = 0.91, p < .0001. The mean SBP was 146.4 mmHg (Table 4). Sixteen (33.3%) had SBP ≤130 mmHg. Mean DBP was 85.9 mmHg (Table 4), and 16 (33.3%) had DBP ≤80 mmHg. Respondents rated their stress level on the day of interview from 0 to 5. Seventeen (37.5%) reported experiencing little or no stress, 9 (18.8%)
Table 5. Knowledge, Medication Adherence, and Diet Scores of Jamaican Men With Hypertension.
Knowledge (%) Medication (%) Diet (%)
Mdn
LQ, UQ
Min/Max
83.3 70 30
50, 95.8 60, 91.4 22.3, 40.0
50-100 34.3-100 12.7-65.4
Mdn = median; LQ = lower quartile; UQ = upper quartile; Min = minimum; Max = maximum.
rated stress as moderate, and 11 (22.9%) rated stress as high. The main sources of stress were financial difficulty (54.2%), conflicts with friends (16.6%) or family (12.5%), and illness. Fourteen (29.2%) lived alone while others lived with 1 to 30 family members. Thirteen (27.1%) reported no financial support or encouragement from family or friends. Level of stress was not related to BP but was negatively associated with age, r = −0.28, p < .05.
Knowledge The median score in knowledge of hypertension was 83.3% (Table 5). All the respondents answered “true” to the statement “High blood pressure is also called a silent killer.” Forty-five (93.7%) understood that uncontrolled BP could lead to stroke or death; however, 22 (45.8%) believed that hypertension could be cured. Twenty-five (52.1%) said they would stop taking all treatment if their doctor or practitioner told them their blood pressure was normal. Twenty-two (45.8%) believed that medication alone was enough to manage high BP.
Medication and Use of Alternative Remedies Twenty-one (43.7%) respondents reported always taking medications as prescribed, 8 (16.7%) felt ill after taking medications, 29 (60.4%) traveled with medications when leaving home, 10 (20.8%) had difficulty remembering to take medications, and 21 (43.7%) experienced difficulty obtaining medications at the pharmacy. Forty-five (93.8%) could not recall the name of any of their medications. The median number of missed medication days per week was 1 day (range = 0-6 days). Sixteen (33.3%) respondents ingested undetermined amounts of alternative remedies. Ten respondents used these with medications, while others used them as substitutes. These remedies included garlic (Allium sativum), guinea hen weed (Phytolaccaceae), lime juice (Citrus aurantifolia), hibiscus flowers (Hibiscus rosa-sinesis), sour sop (Annona muricata) leaf, devil’s horseweed (Conyza canadensis), noni (Morinda citrofolia) leaf, and cerassee (Momordica charantia) (Lowe, Payne-Jackson, Beckstrom-Sternberg & Duke, 2001). The median medication adherence score was 70% (Table 5). Seven (14.6%) scored full marks (Table 5). There was a negative association between SBP and medication adherence score,
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Welsh et al. r = −0.33, p < .02; DBP and medication adherence score, r = −0.35, p < .01; and DBP and number of days of missed medications, r = 0.40, p < .005.
Diet and Exercise The median diet score was 30% (Table 5). Six of the respondents (12.5%) reported being on a “special diet.” Thirty-five (72.9%) did not prepare their own meals, 39 (81.2%) reported that their meals were always prepared with salt, and 44 (91.6%) did not read the labels on packaged foods. Thirtyeight (79.2%) ate “fast food,” nine (18.7%) ate at least three vegetable servings per day, and only one respondent followed the DASH diet requirement of eating at least five servings of fruits per day. Thirteen (27.1%) consumed low-fat dairy products “sometimes” and five (10.4%) always avoided fried or greasy foods. Sixteen (33.3%) reported performing no exercise. Eighteen (37.5%) did brisk walking fewer than 4 days per week while 14 (29.2%) did brisk walking “most days.”
Alcohol and Smoking Thirty-eight (79.2%) respondents consumed none or
