S c h o l a r l y A r t i c l e h y p e r t e n s i o n : P a t ie n t A d h e r e n c e , H e a l t h B e l ie f s , H e a l t h B e h a v io u r a n d M o d if ic a t io n . ABSTRACT: This paper presents the difficulties inherent in the m anage­ m ent o f hypertension. As patients are required to manage their hyper­ tension by means o f changing their health behaviour their own personal health beliefs come into play. Patients ’ health beliefs are dependent on their particular culture, their understanding o f health and their reactions to the health care system. An argument is made that fo r health behaviour to change patients have to be seen within a system which includes themselves, their fa m ilies and the health care providers. Health advice has to be appropriate f o r individual patients and they have to be supported by their fam ilies and the health care system KEY WORDS: HYPERTENSION, ADHERENCE, HEALTH BELIEFS, HEALTH BEHAVIOUR, MODIFICATION. STEWART A , MSc (MED) EALES CJ, PhD (Wits)' 1 D e p a rtm e n t o f P h y sio th erap y , Faculty H e a lth Sciences U n iversity o f th e W itw a te rs r a n d . HYPERTENSION-INCIDENCE AND MANAGEMENT There is a high incidence o f hyperten­ sion in South Africa. Out o f a population o f approxim ately 42 million, five and a half million South Africans have blood pressures above 140/90. O f these three million are black South Africans (Steyn et al 1992). Stroke is one o f the most disrupting and alarming com plications o f hyperten­ sion. Rates o f between 32% -53% are reported in Southern Africa. In addition data suggest that stroke is the second m ost com m on cause o f death in Southern Africa (Lisk 1993; M atenga et al 1986). It therefore becom es essential that hypertension is controlled to prevent com plications like stroke. In 1992 guidelines were developed in South Africa for the m anagem ent o f hypertension (Heart Foundation Consen­ sus Statem ent 1992). Persistently high blood pressure o f more than 160/90 or 100 is usually the level at w hich C O RRESPO ND ENCE TO: A Stewart D epartm ent o f Physiotherapy University o f the W itwatersrand 7 York Road, Parktown 2193 Tel: (011)488-3450 F a x :(0 1 1 )4 8 8 -3 2 1 0 Email: 159aimee@ chiron.wits.ac.za pharm acological intervention begins. For blood pressures o f more than 140/90 non-pharm acological m anagem ent or life-style m odification should be im ple­ mented (Heart Foundation Consensus Statem ent 1992; JNC V 1993). Effective control o f blood pressure should be achieved by the least intrusive methods possible. Non-pharmacological manage­ ment or life-style modification should be “vigorously encouraged’ (JNC V 1993). N on-pharm acological intervention when properly used offers many benefits at minimal risk to the patient and at little cost. Patients should be em pow ered to participate in their own management. The guidelines have clearly stated edu­ cational principles which include know­ ledge o f the disease and risk factor modi­ fication (Heart Foundation Consensus Statem ent 1992). Patients have to adhere to a m anagem ent programme. ADHERENCE TO RISK FACTOR MODIFICATION BY HYPERTENSIVE PATIENTS Adherence to any kind o f medical inter­ vention in the long term, requires some form o f behaviour modification. This behaviour modification may range from a simple change to one that requires com plex changes. The modification is com plex when considerable life-style changes are involved (A grasl989). Poor adherence occurs in all chronic disease regardless o f the particular socio -economic level o f the patient. It does tend to be much more o f a problem in lower socio-econom ic groups (Haynes 1987). Hypertension tends to be more prevalent and also devastating in lower socio-econom ic groups (JNC V 1993). Poor adherence is associated with m any factors. T hese factors include general poor health, being unmarried, unem ployed, a lower incom e, being a sm oker, being younger, having an increased mass, com plex drug regimens, side effects, cigarette sm oking, high salt use, long term treatment, excessive alcohol use, perceived barriers to treat­ ment, beliefs about the disease and social norm ative values (Flack et al 1996; Norm an et al 1985). Two problem s exist when examining non-adherence. Firstly, current theories only partly explain non-adherence, and secondly, health-care providers seldom act according to recom m endations derived from research findings (Sluijs and Knibbe 1991). H ealth -care pro fessio n als tend to underestim ate the frequency o f adher­ ence problem s and what is involved in trying to adhere to health-care advice. They also do not understand the diffi­ culties involved in trying to adhere to a com plicated m edical regim en (Sotile 1996). There are five main com ponents o f ad h eren ce behaviour. T hese are: 12 SA J o u r n a l o f P h y s io t h e r a p y 2002 V o l 58 No 1 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) mailto:159aimee@chiron.wits.ac.za starting treatment; keeping appointments with medical personnel; taking m edica­ tion correctly; making life-style changes and avoiding heath-risk behaviours (Agras 1989). If life-style m odification is to be considered an im portant part o f the managem ent o f hypertensives, health­ care practitioners should understand how patients perceive their own health and its managem ent (M orisky et al 1986; JNC V 1993). Adherence needs to be seen in the light o f total health promotion rather than ju st a narrow adherence to a parti­ cular medical regimen (Spilker 1996). Blam ing patients for treatm ent diffi­ culties ignores the shared responsibilities o f others, like the family and medical personnel (Sotile, 1996 ). Patients who only receive routine care are more than twice as likely to drop out o f treatm ent than those who receive routine care and periodic visits from health-care practi­ tioners. The addition o f some sort o f fam ily support whether it is structured or informal also increases adherence (Sotile 1996; Jensen and Lorish 1994). Time may well be an important factor in understanding adherence behaviour. “T he discounting effects o f future events” may affect a patient’s w illing­ ness to adhere (Brown and Segal 1996). By this is meant that the benefits o f adherence which are only felt far in the future do not necessarily motivate patients. So the effect o f time needs to be considered when developing adhe­ rence models. HEALTH Prior to considering health behaviour some consideration needs to be given to what patients understand by health. In a study done in the U K patients described good health as being able to function, not having any symptoms, the absence o f illness, feelings o f well-being and of being fit (De La Paz 1992). H yper­ tensive patients in Alexandra described feeling well when they felt strong and could get up in the morning and do their work. W hen they were not feeling well they felt weak and did not want to get up (Stewart et al 1999). In both studies patients interpreted health in a functional way, as being able to cope, feeling fit and being symptom free. Although there are varied meanings o f health it is generally recognised as being one end o f a continuum , the other end being disease. Thus health can be a com parative term. So at the one end o f the continuum patients experience w ell­ ness and the other end o f the continuum patients perceive illness. Feinstein used the term illness to describe what the patient showed or felt as a result o f an underlying disease (in Fabrega 1979). Illness can then be seen in certain types o f behaviour. Certain sym ptom s will result in the patient not being able to continue his usual activities, he may elicit sym pathy from family or it may result in the person seeking medical help. So illness can be seen as the out­ ward manifestation o f a disease in its broadest behavioural sense. Although patients may have a chronic disease they may still be able to feel healthy or well (Lorig, 1996). People can also be thought o f as more or less healthy and can be judged against a standard or ideal o f health. So health can also be a relative term. People will experience th eir health as w ellness (Jensen et al 1997). Health was defined by the W HO in 1947, as “a state o f com plete physical, mental and social well-being and not merely the absence o f disease and infirm ity” . The standards or ideals o f health have been encapsulated in four models o f health. T hese are the eudaim onistic, adaptive, role perform ance and clinical models. The eudaim onistic model was o rig in ally proposed by the ancient Greeks and has its modern counterpart in M aslow ’s idea o f personality (1966). Here health means the highest aspira­ tions o f an individual, that is self actual- isation or in this context “exuberant w ell-b ein g ” . In the adaptive model disease is seen as the person’s inability to interact with his social or physical environment. Role perform ance is seen as the com m on sense model o f health. People measure how healthy they are relative to how well they can perform their daily activities or their different roles. The clinical model sees health as being the absence o f disease (Smith 1981). This model is very limited in that it im plies that patients with chronic disease cannot be healthy and cannot have a good quality o f life. The clinical model sees individuals as physiological systems; the role perfor­ mance model sees individuals as parts o f a social fabric. The adaptive model con­ siders individuals as flexible effective participants in the environm ent and the eudaim onistic model as the ideal o f the civilized cultured person with the capa­ city for continuous growth (Smith 1981). HEALTH BELIEFS AND HEALTH BEHAVIOUR As described above adherence issues can be problem atic as there are many variables which have been identified which relate to adherence. This is parti­ cularly so when considering situations in which patients have to adhere to life-style changes such as non pharm a­ cological intervention in hypertension. Health behaviour is the crucial depen­ dent variable in any health educational programme. In order to address these issues various models o f health behaviour have been developed and refined over the years. These models help to explain why patients behave in certain ways and provide a basis for health education and prom o­ tion interventions (Glanz et al 1997). Three models will be discussed here. The health belief model as described by Glanz et al (1997) is one o f the oldest and most resilient o f the models. This model hypothesises that behaviour is dependent on two variables, namely - the value that a patient places on a particu­ lar goal and the likelihood that a given action will achieve a given goal. Patients will consider their susceptibility to a particular disease and will evaluate the severity. Having done that they will then make the judgem ent as to whether the benefit to be gained from a particular behaviour is worth the cost. In basing an intervention on the Health B elief M odel the concepts o f the model can be used in the follow ing way. P atients’ susceptibility to the risk o f serious health consequences has to be personalised. Patients have to under­ stand very clearly what their own risk o f serious consequences o f their disease is. The benefits o f im proved health beha­ viour again need to be personalized. The difficulties or barriers associated with changed health behaviour need to SA J o u r n a l o f P h y s io t h e r a p y 2002 V o l 58 No 1 13 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) be identified and strategies put in place to m inimise the barriers. Patients also have to have confidence in their ability to change their behaviour (Glantz et al 1997). This model does not take into account the influences o f the patient’s family and social system (Dracup and M eleis 1982). The stages o f change model describes how p atients undergo a process o f change in order to bring about more beneficial health behaviour (Prochaska et al 1992). This model helps the health care practitioner to match his interven­ tion to the p atient’s fram e o f reference as the patient attempts to modify his behaviour. In the precontem plation stage patients are mired in inactivity and do not intend m aking any behavioural change. Typical reasons are, lack o f know ledge, know ledge gaps and dem o­ ralization. Patients will only advance to the contem plation stage if they realise that the pros o f changing outweigh the cons. H ow ever patients in this stage will not advance to the preparation stage unless reasons not to change decrease. Patients in the preparation stage are ready to take im m ediate action to change their health behaviour. They believe the benefits o f behavioural change will outweigh the costs but need to understand that they may need more than one attem pt at behaviour change. D uring the action stage patients need to place most o f their physical and emotional energies into achieving the desired behaviour change. Once they m ove into the m aintenance stage patients’ confidence increases and tem p­ tation to return to unhealthy habits decreases. Few patients progress to the term ination stage where they have total confidence that they will not revert back to their old habits. M ost patients have to continue with maintenance efforts. H ealth promotion needs to accom m o­ date these stages. As patients progress through the six stages o f the above model they go th ro u g h a p ro cess o f change. This process o f change involves a num ber of both o v ert and co v ert activ ities as patients move from stage to stage of health behaviour modification (Glanz et al 1997). Both the health b elief model and the stages o f change model include self-effi- cacy as part o f the model. Self-efficacy is the ability o f an individual to perform a particular behaviour. (Banduras 1977). Self-efficacy is an im portant prerequi­ site for behavioural change. The stages o f change model and the health belief model describe a patient’s reactions to situations in which he finds him self as well as the analytical processes he goes through when attem pting to c hange behaviour. N eith er o f these models puts the patient into a social and family context nor do they show how the patient can be affected by his interac­ tions within a social and family context. A systemic approach has been sug­ gested to overcom e criticism s o f the previous models. The system ic approach suggests patients, their fam ilies and health-care practitioners have a shared responsibility to respond to medical intervention. The focus is on the rela­ tionships betw een the patien t and health-care practitioner, betw een the patient and his or her fam ily and the family and the health-care practitioner (Doherty and Baird 1983 ). Harkaway and M adsen (1989) pre­ sent a model that considers the health­ care practitioner as an active participant in the family and treatm ent systems. They suggest that treatm ent problems occur in the context o f the above triad and not as a result o f one o f the indivi­ duals involved. They emphasise patients’ beliefs about the problem; beliefs about the treatm ent o f the problem; beliefs about the role o f the health-care practi­ tioner and beliefs about the role o f the family. Beliefs about the problem will influ­ ence how patients view the problem. If for exam ple patients and their families consider “hypertension” as a disease involving the nerves it is unlikely that they will consider dietary restrictions or increasing exercise output as relevant (H eurtin- R oberts and Reisin 1992). O ther culturally held beliefs will also influence patients’ and their fam ilies’ willingness to adhere to health advice (Heggenhougen and Shore 1986; Atuado 1985; H ugo 1992 ). In addition to the beliefs held by the patien t and the fam ily unit the health-care practitioner may have beliefs about the problem. The attitude o f health-care practiti­ oners will be influenced by previous experiences and ex pectations. There may be conflicting attitudes o f respect and m istrust. C ultural differences between patient and health-care practi­ tioners lead to m isunderstandings o f the role o f the health-care practitioner (de Villiers 1991; Hugo 1992; Atuado 1985). In addition there may be an authoritarian health -care p ro v id er and a passive patient and family. There may not be equal participation from all individuals within the system. The beliefs o f the family also need to be considered. If a fam ily’s belief about a disease and its role as a support system is not convergent with that o f the patient and health-care practitioner difficulties in modifying health behaviour will result. The fam ily may resent the perceived intrusion o f the health-care practitioner as it tries to cope with a family m em ber’s illness or it may abdicate all responsi­ bility to the health-care practitioner. For health behaviour modification to occur patients’ health beliefs need to be considered and close relationships between the triad o f patient, family and health-care practitioner need to be developed. BARRIERS TO HEALTH BEHAVIOUR A simple model which describes the barriers to health behaviour modification has been suggested by Bartlett (1982). He divides factors which can influence patients' behaviour into four categories o f barriers which will interfere with the patient’s ability to adhere to advice. They are individual factors, social fac­ tors, en v ironm ental factors and the medical regimen. Individual factors include patients’ know ledge, m otivation, fears, attitudes, denial and self-control. Social factors include the influences o f family, peers, em ployers, teachers and h ealth-care providers. Poor finances, transport, inac­ cessible clinics and long w aiting tim e at clinics constitute the environmental barriers. The com plexity and side effects o f the medical regimen can also act as barriers to adherence. A com plex rela­ tionship exists between the barriers with one being able to influence the other. In planning adherence program m es the health professional should take note o f 14 SA J o u r n a l o f P h y s io t h e r a p y 2002 V o l 58 No 1 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) these barriers (Bartlett 1982; Richardson et al J 993). One o f the most crucial individual barriers to changing health behaviour is patients’ lack o f knowledge about their disease, what its consequences are and how to look after themselves. Prochaska et al (1992) have gone so far as to con­ clude that health behaviour change in hypertensive patients cannot take place without patients understanding hyper­ tension, its risk factors, its m anagem ent and the consequences if left untreated. Hypertensive patients in the public health-care system in South Africa do not understand the causes o f the disease, particularly the lack o f exercise as a risk factor. They have som e idea o f a healthy diet and restricting salt ingestion (Stewart et al 1999; Stewart et al 2000). Those with higher educational levels, those who spoke English or Afrikaans and had a better quality o f life and sex life were more knowledgeable about their disease (Stew art et al 2000). W illiams et al (1998) showed a sim ilar level o f under­ standing in hypertensive and diabetic patients w ith low literacy levels. Between 35%-90% o f patients do not understand the information that is given to them (Prochaska et al 1992). The consequences o f uncontrolled hypertension were not well understood in the group o f patients studied by Stew art et al (2000). Kattapong et al (1998) d em onstrated that H ispanic women were significantly less likely to consider hypertension as a risk factor for stroke than non-Hispanic women. Both groups were found to have poor under­ standing o f the risk factors for stroke. Influences of society can be a pro­ found social barrier. Influences o f culture, societal norms and family can affect patients’ health behaviour. When exam ­ ining the adherence to medical advice of patients with chronic disease the effects of culture cannot be underestimated. (Heggenhougen and Shore 1986). Health and illness need to be seen according to the standards o f adaptation which are employed by different cultural groups. Traditional societies regard health as a state o f balance or equilibrium and traditional medicine achieves this balance. Health is seen in traditional societies as encom passing the physical, mental, social, moral and spiritual w ell­ being o f individuals (Ataudo 1985). C om parative studies o f blood pres­ sure levels have shown that in societies with a coherent value system which rem ains relatively unchallenged over generations blood pressure values are low but that m igration to societies w here the value systems are different, high levels o f blood pressure occur (H eggenhougen and Shore 1986). A lthough m any p ractices w hich are linked to ill-health are a matter o f per­ sonal choice they are often condoned within a particular culture. Examples are, alcohol consum ption, w hich is socially accepted in most cultures (with M uslims being notable exceptions) and dietary practices. Effective use o f orthodox medicine depends in part on the congruence o f patients and health-care practitioner’s beliefs about illness and treatm ent. Variations in underlying knowledge sys­ tems impede even w illing adherence on the part o f culturally divergent groups. T his is because inform ation is not understood when it is first communicated or it is not accurately recalled. W hat one understands is a function o f how well the information fits one’s existing know ­ ledge (Stefferson and C olker 1982). The relationship between the health­ care provider and the patient can be a social barrier to adherence. This is often between people o f different pow er and different cultures resulting in a huge cul­ tural gap between patients and medical practitioners. Traditional medicine pays attention to attitudes and feelings w here­ as there is a lack o f com m unication in allopathic medicine (Heggenhougen and Shore 1986). In South Africa medical encounters often occur in a transcultural context. When the understanding o f the patient and the health-care practitioner differs, problem s tend to occur in the clinical setting and this reduces the effectiveness o f the encounter. This has negative implications for the m anagem ent o f the patient (De Villiers 1991). Many people in South A frica find it difficult to expe­ rience healing within a Western health­ care system. This is because in such a system they experience more about dis­ ease and curing than about illness and healing. A traditional healer connects a patient’s sym bolic reasoning to his body and what he experiences in his body (Hugo 1992). Environmental barriers becom e enor­ m ously im portant for patients from lower socio-econom ic classes who have to use the public health system. The cost o f transport to the hospital; cost of treatment; loss of w ork time with the resultant loss o f earnings and the cost of a pru d en t d iet m ake ad h eren ce for hypertensive patients difficult (Stewart et al 1999). In addition the long waiting times which can be anything up to a five hour wait to see the doctor for 10 minutes and then a further five hour wait at the pharm acist for their medication prove to be significant environm ental barriers for patients (Stewart et al 1999). Patients use a variety o f criteria to determ ine the value o f m edication and this may becom e a barrier to adherence to medical regim ens. They may place an equal or greater value on com peting non-clinical outcomes. Physical, eco­ nomic, psychological and social factors influence the use of medication. Patients often take less drugs than required, due to their experiences with side effects and their symptoms (W allenius et al 1995). HEALTH BEHAVIOUR MODIFICATION Sotile (1996) has suggested that health beh av io u r m o dification program m es should be structured such that patients’ participation is facilitated. He suggests that such program m es should only last for three to six months. It is easier for patients to com m it for this length o f time and they are then less likely to drop out. Patients need to leave these programmes w ith enh an ced se lf esteem . T his is crucial in prom oting self-efficacy, which is the key to lasting changes in health behaviour. The key elem ent in prom oting a wide range of risk factor changes is educating the patient and the fam ily (Sotile 1996). Inclusion o f the family in an education program m e supports the patients’ efforts to modify health behaviour. There are only a few studies in the health education literature which show alterations in health behaviour rather than ju st a change in knowledge or attitudes as a result o f an educational SA J o u r n a l o f P h y s io t h e r a p y 2002 V o l 58 No 1, 15 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) intervention. Education alone does not change health behaviour although know ­ ledge is a prerequisite for a behaviour m odification program m e (Cohen and Cohen 1987). So health prom otion or patient education is a planned learning ex p erien ce using a com bination o f m ethods such as teaching, counseling and behaviour m odification which will influence p a tie n ts’ k n ow ledge and health b eh av io u r (S o tile 1996; H ill 1989). Patient education and patient counseling involve an interactive pro­ cess which assists patients to participate actively in their health care (Bartlett 1985). Education should be individu­ alised, the patient should have rapid feedback, there should be a clear under­ standing o f w hat is required, the patient should be m otivated and there should be congruence between the patient’s and health-care practitioner’s goals. D ifferent types o f people need and respond favourably to different kinds of interventions. Age, education literacy levels and socio-econom ic variables are the m ost im portant factors in predicting receptivity to health education. Patients with lower educational levels have been show n to respond to indiv id u alised clarification o f instructions and the sup­ port o f a fam ily member, whereas those with a higher level o f education respond to sm all group interactiv e m eetings (Morisky et al 1986; Morisky et al 1985). T he educatio n al program m e should include com m on sense strategies for better managing the life-style changes required for non-pharm acological inter­ vention o f hypertension (M orisky et al 1985; Hill 1989; Sotile 1996). As with physical diagnosis and m edi­ cal care, patient education should be based on careful assessm ent, a correct diagnosis and an individualised plan o f health behaviour m odification. H ealth­ care practitioners must be able to identify the specific needs o f patients for infor­ mation, skills, support and reinforce­ ment. They m ust m eet these needs with a com bination o f educational strategies adapting approaches as necessary over time. Health-care practitioners need to determ ine the quantity and quality of inform ation, interactions and procedures that reinforce appropriate behaviour. It becom es increasingly evident that in order for health behaviour m odifica­ tion program m es to be effective they have to be patient centered and have as their foundation an unam biguous educa­ tional com ponent to im prove patients’ know ledge about their disease and its m anagem ent. This needs to be enhanced by creating close relationships between patients, their fam ilies and health-care providers within a supportive environ­ ment. Health education influences patients’ behaviour through changes in know l­ edge, attitudes, beliefs, perceptions and social support, through self-reinforce- m ent and skill developm ent and through changes in professional behaviour towards patients (Hill 1989). The strategies for patient education include - identifying their existing knowledge, attitudes and beliefs and experiences; educating about the condition and treatment; tailoring the regim en to the patient; providing reinforcem ent; prom oting social and fam ily support and collaborating with other professionals as required (Hill 1989; Sotile 1996; B artlett 1982). CONCLUSION If the non-pharm acological m anagem ent o f hypertensive patients is to be taken seriously patients need to be evaluated and given the necessary support in order to make it possible for them to modify their health behaviour. Patients need to be appropriately supported by both their families and their health care providers in order to modify their health. 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