A N NA L S O F FA M I LY M E D I C I N E ✦ W W W. A N N FA.docx

A N NA L S O F FA M I LY M E D I C I N E ✦ W W W. A
N N FA M M E D . O R G ✦ VO L . 6 , N O. 6 ✦ N OV E M
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Racial Disparity in Hypertension Control:
Tallying the Death Toll
ABSTRACT
PURPOSE Black Americans with hypertension have poorer
blood pressure control
than their white counterparts, but the impact of this disparity on
mortality among
black adults is not known. We assessed differences in systolic
blood pressure (SBP)
control among white and black adults with a diagnosis of
hypertension, and mea-
sured the impact of that difference on cardiovascular and
cerebrovascular mortality
among blacks.
METHODS Using SBP measurements from white and black
adults participating in
the National Health and Nutrition Examination Survey, 1999-
2002, we modeled
changes in mortality rates resulting from a reduction of mean
SBP among blacks
to that of whites. Our data source for mortality estimates of
blacks with hyper-
tension was a meta-analysis of observational studies of SBP;

our data source for
reduction in mortality rates was a meta-analysis of SBP
treatment trials.
RESULTS The fi nal sample of participants for whom SBP
measurements were
available included 1,545 black adults and 1,335 white adults.
The mean SBP
among blacks with hypertension was approximately 6 mm Hg
higher than that
for the total adult black population and 7 mm Hg higher than
that for whites
with hypertension. Within the hypertensive population, a
reduction in mean
SBP among blacks to that of whites would reduce the annual
number of deaths
among blacks from heart disease by 5,480 and from stroke by
2,190.
CONCLUSIONS Eliminating racial disparity in blood pressure
control among
adults with hypertension would substantially reduce the number
of deaths
among blacks from both heart disease and stroke. Primary care
clinicians should
be particularly diligent when managing hypertension in black
patients.
Ann Fam Med 2008;6:497-502. DOI: 10.1370/afm.873.
INTRODUCTION
C
ardiovascular disease, the leading cause of death in the United
States, occurs at the highest rate among black Americans.1 As a

precursor to cardiovascular disease, hypertension is one of the
most important contributors to racial disparities in mortality
rate.2 The
age-adjusted prevalence of hypertension is signifi cantly higher
among
blacks (39%) than among whites (29%).3 Uncontrolled
hypertension has
an enormous impact on the health of minorities,1,4 accounting
for up to
one-quarter of all deaths among black adults, primarily from
cardiovascu-
lar and cerebrovascular causes.5
Recent data suggest that among persons under treatment for
hyperten-
sion, blacks have poorer blood pressure control.3 Only a few
studies have
quantifi ed the effects of racial disparities in health care
interventions on
the number of deaths among.6,7 To our knowledge, none have
quantifi ed
the impact of disparity in hypertension control on black
mortality.
To model the impact of this disparity in hypertension control,

we
used national data on systolic blood pressure (SBP), mortality
data, and
published estimates of the relative risk associated with
decreases in SBP.
Specifi cally, we calculated the annual numbers of heart and
stroke deaths
Kevin Fiscella, MD, MPH1,2
Kathleen Holt, PhD1
1Department of Family Medicine, Univer-
sity of Rochester School of Medicine and
Dentistry, Rochester, New York
2Department of Community and Preven-
tive Medicine, University of Rochester
School of Medicine and Dentistry, Roch-
ester, New York
Confl icts of interest: none reported
CORRESPONDING AUTHOR
Kevin Fiscella, MD, MPH
Departments of Family Medicine,

and Community and Preventive Medicine
University of Rochester School
of Medicine and Dentistry
1381 South Ave
Rochester, NY 14620
[email protected]
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R A C I A L D I S PA R I T Y I N H Y P E R T E N S I O N
C O N T R O L
that would be avoided or postponed assuming blacks
with hypertension had their blood pressure controlled
to the same level as whites.
METHODS
Data Sources
We used SBP data from the National Health and
Nutrition Examination Survey (NHANES) for the

years 1999-2002. NHANES is a periodic national
survey of the health status of the United States and is
designed to yield nationally representative estimates.
It includes data from questionnaires, physical examina-
tions, and medical tests. Eligibility criteria for our sam-
ple included (1) self-identifi cation as white or black, (2)
age of 25 years or older, and (3) diagnosis of hyperten-
sion (regardless if treated or not). We also used 2002
US black mortality data for heart disease and stroke,
stratifi ed by sex and age.8
We estimated the additional risk associated with
an elevated SBP based on a meta-analysis of epidemio-
logic studies of SBP and mortality. This meta-analysis,
based on approximately 1 million individuals, estimated
the risks, stratifi ed by age and sex, of heart disease
and stroke associated with elevated blood pressure.9
We estimated the effect of reductions in SBP based
on relative risks for heart disease and stroke mortality

from a meta-analysis of randomized treatment trials of
hypertension.10
Estimating Black Mortality Risk
From Hypertension
National mortality rates are known for all black adults
(ie, those with and without hypertension), but not for
black adults with hypertension. To estimate sex- and
age- specifi c mortality rates for this group, we used
NHANES data to derive the mean difference in SBP
between blacks with hypertension and all blacks by sex
and age. Next, we calculated the relative risk associ-
ated with a given difference in SBP between blacks
with hypertension and all blacks using the following
sex- and age-specifi c exponential function, derived
from a meta-analysis of observational studies of blood
pressure and mortality9:
RR = RRs
(ΔSBP/20)
where ΔSBP equals the difference in mean SBP
between blacks with a hypertension diagnosis and

all blacks aged 25 years or older, and RRs equals the
relative risk for heart disease or stroke by age and sex
for a standardized ΔSBP of 20 mm Hg. The relative
risk was then applied to each sex and age category for
heart disease and stroke mortality to produce mortality
rates adjusted for hypertension. For example, the dif-
ference in mean SBP among black men aged 55 to 64
years with hypertension relative to all black men in this
age category was 5 mm Hg (142 vs 137 mm Hg). This
difference represents a relative risk for heart disease
mortality of 1.17 (1/0.53 (5/20)). The overall mortality
rate for black men in this age-group is 605 deaths per
100,000. Among black men of this age with hyperten-
sion, the overall mortality is thus estimated at 708 per
100,000 (605 × 1.17). This estimate is conservative
because it does not adjust for comorbidity (such as
diabetes, hyperlipidemia, or obesity) associated with
hypertension.11

Estimating Relative Risk From Disparity in SBP
We estimated the relative risk associated with racial dis-
parity in SBP based on a reduction in the mean SBP for
blacks to that of whites in the same sex and age group.
We calculated the mean difference in SBP between
blacks and whites for each group using NHANES
data and used a relative risk for reduction in SBP from
a meta-analysis of randomized trials of hypertension
treatment.10 In that meta-analysis, an 8.3-mm Hg reduc-
tion in SBP was associated with a relative risk of 0.80
(95% confi dence interval [CI], 0.77-0.84) for heart
disease mortality and a relative risk of 0.67 (95% CI,
0.61-0.74) for stroke mortality. We then estimated the
relative risk in heart disease mortality for various reduc-
tions in SBP using the following formula:
RR = RRs
Δ SBP/8.3
where ΔSBP equals the difference in SBP between
blacks and whites matched for sex and age based on

NHANES data, and RRs is the relative risk for heart
disease or stroke standardized to an 8.3-mm Hg
decrease in SBP. We then converted relative risks to
relative risk reductions (RRR = 1 – RR).
Estimating Deaths From Disparity in SBP
To estimate the number of deaths among blacks that
would be postponed or avoided if parity in SBP control
were achieved, we multiplied the relative risk reduc-
tion by the sex- and age-specifi c mortality rates (AMR)
for blacks adjusted for SBP to obtain the absolute risk
reduction. We then multiplied this by the estimated
number of blacks (N) in each sex and age group,
derived from NHANES data. Our estimate for deaths
was thus equal to RRR × AMR × N.
Statistical Analyses
The number of persons in each sex and age group and
mean SBPs for blacks and whites were derived from
NHANES data, weighted to yield national estimates

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C O N T R O L
using SAS (SAS Institute Inc, Cary, North Carolina).
All other calculations were performed using Microsoft
Excel (Microsoft Corp, Redmond, Washington).
Sensitivity Analyses
We conducted a series of sensitivity analyses around
key estimates in the model. First, we assessed the effect
of assuming a ±30% black-white difference in SBP.
We also assumed a constant difference in SBP across
all age-groups using the mean SBP by sex to assess
the effect of age distributions on our fi ndings. Next,
we used the 95% CIs surrounding the estimated rela-
tives risks associated with decreases in SBP.10 Last, we
assumed comparable risk per change in SBP regardless
of the source of the estimate, for example, observa-

tional data vs treatment data.10
RESULTS
There were 661 black adults and 1,335 white adults
with hypertension in the sample and an additional
884 blacks without hypertension. Table 1 shows the
number of black men and women in the sample with
hypertension in each age-group along with their mean
SBP and corresponding 95% CIs. For men, the mean
SBP was 22 mm Hg higher in the oldest as compared
with the youngest cohort. For women, that difference
was 26 mm Hg.
The differences in mean SBP by age and sex among
blacks with hypertension, the entire black adult popu-
lation, and non-Hispanic whites with hypertension are
shown in Table 2. The mean SBP among black men
with hypertension was 6 mm Hg higher than that for
all black men and 6.5 mm Hg higher than that for
white men with hypertension. For women, the differ-
ences were 6.5 and 8.2 mm Hg, respectively.

Table 3 shows the annual mortality rates by age
and sex for heart disease and stroke for the entire black
population, estimates of annual mortality rates for
those with hypertension, and estimates for blacks with
hypertension assuming racial parity in blood pressure
control. Parity in SBP control would reduce annual
mortality rates from heart disease and stroke among
men by 17% and 16%, respectively. For women, the
reductions would be smaller, 9% and 14%, respectively.
Racial parity in hypertension control would reduce
the annual number of deaths from heart disease and
stroke by an estimated 5,480 and 2,190 (Table 4). Sen-
sitivity analyses are shown in the Supplemental Appen-
dix (available online at http://www.annfammed.
org/cgi/content/full/6/6/497/DC1). Use of 30%
lower or higher estimates for racial differences in
SBP yielded a 23% to 28% variation in death estimates.
Use of a constant (mean SBP difference by race) across

age-groups yielded slightly lower estimates for men,
but substantially higher estimates for women relative to
the base case. In general, use of a constant difference
Table 1. Mean Systolic Blood Pressures of Blacks
With Hypertension by Age and Sex, United
States, NHANES 1999-2002
Age-Group,
Years
US Population
2002
Mean Systolic Blood
Pressure (95% CI),
mm Hg
Men
25-34 2,537,000 128 (121-135)
35-44 2,681,000 135 (130-141)
45-54 2,116,000 138 (133-143)
55-64 1,116,000 142 (136-148)
65-74 693,000 139 (138-144)
≥75 436,000 150 (141-159)
Women
25-34 2,792,000 126 (121-130)
35-44 3,024,000 135 (130-141)
45-54 2,460,000 142 (136-147)
55-64 1,438,000 141 (136-146)

65-74 977,000 148 (142-153)
≥75 849,000 152 (145-159)
NHANES = National Health and Nutrition Examination Survey;
CI = confi dence
interval.
Table 2. Differences in Mean Systolic Blood
Pressures by Age and Sex Between Blacks With
Hypertension vs the Black Population and vs
Non-Hispanic Whites With Hypertension
Group
Difference in Systolic
Blood Pressure, mm Hg
Blacks With
Hypertension
vs Entire Black
Population
Blacks With
Hypertension
vs Whites With
Hypertension
Men
Age-group, years
25-34 8 1
35-44 9 7
45-54 7 9
55-64 5 10

65-74 1 3
≥75 6 9
Unweighted mean Δ 6.0 6.5
Women
Age-group, years
25-34 12 14
35-44 13 13
45-54 12 10
55-64 3 4
65-74 1 4
≥75 2 1
Unweighted mean Δ 6.5 8.2
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in SBP increased the number of deaths
from heart disease by 43% and that
from stroke by 49%. Use of the 95%
upper and lower CIs yielded roughly

8% to 15% variations in estimates for
heart disease deaths and 18% to 22%
variations in those for stroke deaths.
Last, substitution of age- and sex-spe-
cifi c relative risk values from observa-
tional studies for those from treatment
studies yielded a 9% higher estimate
of deaths from heart disease and a 21%
lower estimate of deaths from stroke
relative to the base case, but very simi-
lar estimates of death from heart disease
and stroke combined (7,670 vs 7,720).
DISCUSSION
Our fi ndings show that racial disparity
in SBP control contributes to nearly
8,000 excess deaths annually from
heart disease and stroke among blacks.
These fi ndings are fairly robust to
changes in key model assumptions. Pre-

vious analyses have shown that hyper-
tension is the single largest contributor,
of any medical condition, to racial disparity in adult
mortality.2 This excess mortality results from a com-
bination of a higher age-adjusted prevalence of hyper-
tension and poorer control of blood pressure among
those under treatment.3 Our analysis estimated the
contribution of just the latter factor to deaths among
blacks, but nonetheless, found a substantial impact on
the number of deaths in this racial group.
To our knowledge, this study represents the fi rst
effort to quantify the toll of racial disparities in blood
pressure control. Given the high prevalence of hyper-
tension in blacks, appreciable benefi ts of blood pres-
sure reduction, and signifi cant disparity in control, it is
not surprising that disparity in blood pressure control
results in appreciably more deaths than those estimated
from other health care disparities, including infl uenza

vaccination, mammography screening, use of β-block-
ers after myocardial infarction, treatment of childhood
asthma, and diabetes.6,7
The causes of racial disparity in blood pressure
control are not known.12 There are several potential
explanations—differences in access to care, clini-
cian management, hypertension severity, and patient
adherence. Surprisingly, NHANES data show no
racial difference in treatment among all patients with
hypertension, suggesting that rates of diagnosis and
treatment among blacks in this sample are the same
Table 3. Black Mortality Rates by Age, Sex, and Blood Pressure
Group
Entire Black
Populationa
Black
Adults With
Hypertensionb
With Racial
Parity in Blood

Pressure Controlb
Heart
Disease Stroke
Heart
Disease Stroke
Heart
Disease Stroke
Men
Age-group, years
25-34 65 12 85 19 83 19
35-44 107 20 146 33 121 24
45-54 246 47 314 69 246 44
55-64 605 110 709 141 542 87
65-74 1,192 262 1,225 273 1,130 236
≥75 3,556 864 4,047 1,017 3,177 659
Age adjusted 419 90 733 167 603 140
Women
Age-group, years
25-34 24 7 39 11 7 6
35-44 58 17 98 28 89 15

45-54 125 36 186 54 142 33
55-64 312 70 334 75 277 54
65-74 734 181 758 187 680 154
≥75 3,438 975 3,527 1,000 3,433 953
Age adjusted 400 109 589 159 538 136
Note: mortality rates are expressed as number of deaths per
100,000.
a Data from Kochanek and Smith.8
b Derived estimates. See Methods for calculation details.
Table 4. Annual Deaths From Heart Disease
and Stroke Avoided or Postponed Among
Blacks Through Parity in Blood Pressure
Control Between Black and White Adults With
Hypertension, by Age and Sex
Group
Annual No. of Deathsa
Heart Disease Stroke
Men
Age-group, years
25-34 10 0
35-44 120 50
45-54 480 170
55-64 940 300

65-74 420 160
≥75 1,450 600
Overall 3,420 1,280
Women
Age-group, years
25-34 50 20
35-44 230 110
45-54 420 200
55-64 560 210
65-74 440 190
≥75 360 180
Overall 2,060 910
Men and women 5,480 2,190
a Derived estimates. See Methods for calculation details.
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as among whites.3 Although there is considerable
evidence for racial disparity in management of car-

diovascular disease,13 there is little evidence of racial
disparity in treatment of hypertension. Specifi cally,
among those with hypertension, there is no signifi cant
difference in rates of drug treatment of hypertension
by race.12 In addition, some data suggest no difference
in clinician adherence to national hypertension treat-
ment guidelines or intensifi cation of antihypertensive
treatment by race.14
It is possible that blacks have more severe hyper-
tension or respond less favorably to antihypertensive
drugs. There is no clear evidence, however, for racial
differences in severity, and meta-analyses of treatment
trials show a similar response to antihypertensive medi-
cation by race, with whites having a slightly greater
response to β-blockers and blacks having a slightly
greater response to diuretics.15
There is evidence for racial disparity in patient
adherence to antihypertensive medication, including
studies conducted within the Veterans Administra-

tion Health System, where fewer differences in access
appear to exist.16-18 Differences in adherence by race
may be due to affordability of medicines, personal
beliefs, anticipated adverse effects, and health literacy
that disproportionately affect blacks.18-20
Although multiple causes may contribute to racial
disparity in blood pressure control, this disparity is
not inevitable. Disparity in hypertension control is
signifi cantly smaller in the Veterans Administration
Health System, where access barriers are fewer.21 Little
or no disparity in blood pressure control was noted in
the treatment arms of 2 large community-based hyper-
tension treatment trials, the Hypertension Detection
and Follow-up Program and the Multiple Risk Factor
Intervention Trial.22,23 It is thus probable that elimina-
tion of racial disparity in SBP is an attainable goal, pro-
vided suffi cient resources are available to discover and
address adherence barriers.

The strengths of this study include use of a nation-
ally representative sample to estimate blood pressures
among persons with hypertension; use of race-, sex-,
and age-specifi c national mortality rates for heart
disease and stroke; and estimates of relative risk associ-
ated with SBP derived from meta-analyses.
The limitations of our study merit comment. The
sample of hypertensive blacks, although derived from
a nationally representative sample, was relatively small.
CIs surrounding estimates of blood pressure for spe-
cifi c groups were therefore relatively wide. Because
the number of deaths rises exponentially with age,
even small variation in estimates of racial disparity
in blood pressure among the elderly blacks can yield
appreciable changes in estimates. This phenomenon
is best illustrated by the results for women. Despite
a higher black-white disparity in SBP, our fi ndings
showed that elimination of this disparity would reduce

deaths more among black men than among black
women because the disparity for women is skewed
toward younger ages. It is for this reason that use
of a constant SBP yielded much higher estimates
for women than men. In addition, because of small
subgroup sizes, we used an upper age category of 75
years or older. Mean life expectancy at birth in 2004
was 69.5 years for black men and 75.3 years for black
women.1 Use of this cutoff underestimates the impact
of these disparities on deaths among elderly black
women. For these reasons, fi ndings that racial dispar-
ity in SBP disproportionately affects male mortality
should be viewed with caution pending more precise
estimates of racial disparity in blood pressure control
among men and women of advanced age.
These caveats notwithstanding, our fi ndings sug-
gest that racial disparity in hypertension control con-
tributes appreciably to deaths among blacks from heart

disease and stroke. Our analyses highlight the need
to more fully understand the causes of these dispari-
ties and develop viable strategies to eliminate them,
particularly clinician attention to adherence barriers
among patients.
To read or post commentaries in response to this article, see it
online at http://www.annfammed.org/cgi/content/full/6/6/497.
Key words: Race/ethnicity; blacks; mortality; heart disease;
stroke;
hypertension; blood pressure; control
Submitted October 28, 2007; submitted, revised, January 29,
2008;
accepted March 3, 2008.
Funding support: Funding was provided by the Robert Wood
Johnson
Foundation and by a grant from the National Heart, Lung, and
Blood
Institute (R01 HL081066-01A2).
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Prevalence and predictors of poor antihypertensive medication
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Title
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© Meharry Medical College Journal of Health Care for the Poor
and Underserved 26 (2015): 260–265.
BRIEF COMMUNICATION
Attitudes and Perceptions about Hypertension
among Churchgoing Blacks
Kendall M. Campbell, MD
José E. Rodríguez, MD
Alexandra C. H. Nowakowski, PhD, MPH
Paulin Gotrace, MS
Abstract: Purpose.This study evaluates beliefs churchgoing
Blacks hold about causes of
hypertension and impact on adherence to non- pharmacologic
treatment. Methods. We
created a 17-question survey about participants’ family history,
medication use, behavioral
modification, causes of hypertension, intake of fruit and
vegetables, salt intake and physical
activity. Data came from three predominantly Black churches in
Florida. We conducted
statistical analyses using Microsoft Excel 2010 and Stata
Version 12. Results. Over 67%
responded that physical activity was effective in lowering blood
pressure, while greater than
53% responded that a diet high in fruits and vegetables was
effective in lowering blood

pressure. Over 78% responded that a low- salt diet is effective
in lowering blood pressure.
Respondents also felt that exercise (71%) and low- salt diet
(72%) were as effective as medica-
tions in lowering blood pressure. Conclusions. Our sample
believes non- pharmacological
treatments are effective in lowering blood pressure, regardless
of perceived cause.
Key words: Hypertension, Blacks, attitudes, pharmacological
hypertension management,
lifestyle modification.
Hypertension is the leading cause of cardiovascular disease. The
ravages of this disease are well known and include
cerebrovascular accident, peripheral vascu-
lar disease and myocardial infarction. Approximately 78 million
adults in the United
States age 20 or older have hypertension; the presence of
hypertension is notably higher
amongst Blacks than others worldwide.1 The prevalence of
hypertension is related to
behavioral factors and family history,2 and we sought to find
out the attitudes and beliefs
of Blacks about the causes of hypertension and how those
attitudes and beliefs shape their
thoughts on non- pharmacologic treatment of hypertension. This
raises the question if
KENDALL M. CAMPBELL is Co- Director, Center for
Underrepresented Minorities in Academic
Medicine, and Associate Professor of Family Medicine and
Rural Health, Florida State University College
of Medicine. JOSÉ E. RODRÍGUEZ is Co- Director, Center for
Underrepresented Minorities in Academic
Medicine, and Associate Professor of Family Medicine and

Rural Health, Florida State University College
of Medicine. ALEXANDRA C. H. NOWAKOWSKI is Research
Faculty 1, Florida State University
College of Medicine. PAULIN GOTRACE is a Year 2 medical
student, Florida State University College
of Medicine. Please address any correspondence to Kendall M.
Campbell at 1115 West Call Street, Talla-
hassee, FL 32306, (850) 645-9828 office, (850) 645-2859 fax,
Kendall [email protected] .edu
261Campbell, Rodríguez, Nowakowski, and Gotrace
we, as health care providers, should place even more emphasis
on non- pharmacologic
treatment modalities for hypertension and do a better job of
empowering our patients.
The impact of non- pharmacologic treatment for hypertension
cannot be overstated.
We know that reducing dietary sodium can reduce systolic
blood pressure by approxi-
mately 2-8mmHg and adopting the Dietary Approaches to Stop
Hypertension (DASH)
eating plan, a diet with more fruits and vegetables can reduce
systolic blood pressure
by 8– 14mmHg.3 Educating patients regarding behavioral
change is a standard of care
for treating hypertension starting from pre- hypertensive to
stage two hypertensive
patients.3 Managing underserved patients brings additional
challenges to care,4– 6 and
these challenges emphasize the need to spend more time
addressing behavioral changes
that can be made to help lower blood pressure. Empowering

patients to take better care
of themselves has promise in the fight against hypertension.7
Measures such as home
self- measurement of blood pressure reduce the need for
antihypertensive therapy8 and
provide cardiovascular risk data.9 Increasing access to healthy
foods shows promise in
lowering blood pressure.
We chose to focus on churchgoing Blacks because we were
familiar with that popu-
lation, and had access to them through personal contacts. We
also chose them because
many of our churches have health ministries, and we hoped that
we would be focusing
on an informed, health literate, Black community. We
hypothesized that Black churchgo-
ers believe that hypertension was due to family history, and
therefore un- preventable,
and because of this belief they would see lifestyle interventions
as ineffective. Our study
posed several questions assessing perceptions of the causes of
high blood pressure. We
began with an overarching conceptual inquiry: What attitudes
and beliefs do Black
churchgoing Florida residents hold about hypertension?
Methods
We developed a series of questions to capture different aspects
of thinking about high
blood pressure and related issues. Sample survey questions are
displayed in Table 1.
Each of these questions captured unique information about
respondents’ understanding
of where hypertension comes from, and/or how to manage the

condition. The research
assistant (PG) developed the questions with faculty guidance
from Drs. Campbell
(KMC) and (ACHN) Nowakowski. They were then tested on a
group of parishioners
at a Tallahassee church.
Respondents provided a series of quantitative responses
reflecting their history,
beliefs, and attitudes concerning hypertension. No follow-up
was conducted with any
of the participants. Our team manually entered these data into
spreadsheets showing
responses for each question by respondent. Churches with large
Black populations
were targeted for sampling. All adult congregation members
from each sampled church
were considered eligible to participate. Study participants were
recruited from churches
in Tallahassee, Havana, or Orlando. Tallahassee is a mid- sized
city in north Florida;
Havana is a rural town due northwest of Tallahassee; and
Orlando is a large city in
central Florida. One church from each city participated in the
survey. Most congrega-
tions visited had about 50 in attendance on the day the survey
was administered.
Tallahassee constituted the pilot site for the survey; subsequent
surveys were
262 Hypertension in churchgoing Blacks
administered in Havana and Orlando. The survey was

administered at the close of
Sunday worship services. The congregation leader gave time to
the research assistant to
announce the survey from the pulpit, and it was then
distributed. The research assistant
then collected the completed surveys and tabulated the results.
Each respondent read
the survey and responded individually. No compensation or
incentives were offered
to the participants. All analyses were conducted using Microsoft
Excel 2010 and Stata
Version 12.10 This study was approved by the Florida State
University Human Subjects
Committee
We aggregated and coded data for the pilot (Tallahassee) and
non- pilot (Havana
and Orlando) groups into a single dataset. We created a numeric
version of the dataset
that translated responses for each question into numbered
values.
Results
A total of 112 individuals participated in the blood pressure
survey, 19 from the Talla-
hassee location, and 93 from the Havana/ Orlando location.
Participant’s demographic
Table 1.
SAMPLE OF QUESTIONS FROM THE SURVEY WITH YES,
NO
AND I DON’T KNOW (IDK) RESPONSES
Question Yes No IDK

If high blood pressure runs in the family, is a diet high
in fruits and vegetables effective in lowering high blood
pressure? 53% 14% 29%
If high blood pressure runs in the family, is physical activity
effective in lowering high blood pressure? 67% 11% 18%
If high blood pressure runs in the family, is a low- salt diet
effective in lowering high blood pressure? 83% 8.9% 13%
If high blood pressure is caused by the environment/
behavioral factors, is a diet high in fruits and vegetable
effective in lowering high blood pressure? 70.5% 9.8% 18%
behavioral factors, is physical activity effective in lowering
high blood pressure? 73% 8% 16%
behavioral, is a low- salt diet effective in lowering high
blood pressure? 78% 7% 14%
Is a diet high in fruits and vegetables as effective medication
in reducing high blood pressure? 60% 17% 21%
Is exercise as effective as medication in reducing high blood
pressure? 71% 15% 22%
Is a low- salt diet as effective as medication in reducing high
blood pressure? 72% 13% 22%
characteristics are listed in Table 2. Of note, a majority of
respondents had high blood
pressure (54%) and were taking medication for it (79%). Even
more of them had a family
history of high blood pressure (83%). The participants also

answered other questions
as listed in Table 1. The questions in Table 1 are not dependent
on the answers to the
question “What do you think causes high blood pressure?”
Discussion
This survey targeted middle age Black individuals and was a
means to assess attitudes
towards causes of high blood pressure and effective ways to
lower high blood pressure.
In looking at the age demographic, the majority of participants
were between the ages
of 32 and 65, making up 68% of the total participants. The
entire participant group
(100%) was Black, as were the parishioners on the Sundays that
the survey was offered.
This can be attributed to the location of these churches in
predominantly Black com-
munities. Conducting this survey in primarily Black
communities can help identify ways
towards improving the health of Black populations in Florida.
Most of the participants
either have family members with high blood pressure and/or
have high blood pressure
themselves. Although more than half of the participants
responded that a diet high in
fruits and vegetables, exercise, and a low- salt diet are effective
in lowering high blood
pressure, there were at least 20% or more of participants
responding “No” or “I don’t
know.” Also noted in this study were the percentages
concerning salt intake. Across
both groups lowering salt intake was seen to be more important
than other selected
behavioral changes; 83% in the “if high blood pressure runs in

the family” group, and
78% in the “if high blood pressure is caused by behavioral
factors” group. Recent studies
Table 2.
DEMOGRAPHIC CHARACTERISTICS OF STUDY
PARTICIPANTS
Demographic Characteristics of Study Participants
Total Participants
Tallahassee
Orlando/ Havana
112
19 (17%)
93 (83%)
Age
18– 31
32– 50
51– 65
66 and older
Did not disclose
9 (8%)
35 (31%)
41 (37%)
17 (15%)
10 (9%)
Race/ Ethnicity
Black 112 (100%)
High Blood Pressure History

Personal (has disease)
With hypertension on medication
Family History (one member)
62 (54%)
49/ 62 (79%)
93 (83%)
264 Hypertension in churchgoing Blacks
suggest that Black patients are less likely than Whites to adhere
to the DASH (Dietary
Approaches to Stop Hypertension—which is low- salt) diet,11
but are more likely to
report reducing salt and alcohol intake, changing eating habits
and taking medication,
and exercising.12 Percentages for other behavioral changes for
both groups were less.
This is consistent with the findings of a recent meta- analysis
showing that a low- salt
diet results in a significant reduction in blood pressure, in all
ethnic/ racial groups.13
Our data can be used by the food industry to justify providing
an even larger selection
of low sodium containing foods that are accessible to Black
patients. Data from this
study show that the Black individuals we surveyed have some
understanding of the
association between salt and high blood pressure.
The most telling finding from our study is that there is no
substantial difference
between those who thought that family history was the cause of

hypertension and
those who thought it was environmental or behavioral. We
hypothesized that those
who thought that hypertension was due to family history would
not believe that non-
pharmacological interventions could make a difference in
lowering their blood pressure.
However, this was not the case, as in our sample those who
believed that hypertension
was caused by family history were as likely to state that non-
pharmacological inter-
ventions could work as those who stated hypertension was
caused by environmental/
behavioral factors. Our hypothesis was proven wrong. The
results give hope for those
interventions that are not pharmacologic, and motivates us as
health care providers
to promote those interventions among our Black patients, who
unfortunately share a
disproportionate burden from hypertension. This finding should
be seen in the context
of multi- faceted hypertension treatment. Diet, exercise and
medication all have a role
in hypertension therapy, and the best outcomes are associated
with the use of all three.
This paper provides evidence that regardless of perceived cause
of hypertension, these
participants believe dietary changes and exercise can help. This
belief could be used in
conjunction with pharmacological therapy to improve patient’s
health outcomes, and
as motivation to prescribe exercise.
While this finding makes us hopeful, we are also aware that we
sampled a hopeful
group. One hundred percent of our participants were Black

churchgoers. The attitudes
of this population might not be representative of the attitudes of
the Black population
in general, although we recognize that there is a very high
prevalence (87%) of religious
affiliation among Blacks in America.14 Attendance at religious
services has an inverse
relationship with systolic blood pressure; this effect is larger in
Black and White popu-
lations when compared with Mexican Americans.15 Black
patients prefer treatments
that reduce stress when compared to pill treatment for
hypertension.16 It is difficult to
separate the spirituality from health care beliefs among Blacks
in the United States,17
and our sample is arguably a spiritual one. It is likely that this
sample gives us insight
into their attitudes, but a larger study should be performed to
determine if the results
are generalizable to the Black population in general.
Our sample is not large enough to analyze how socioeconomic
factors could be
relevant to the survey responses. With more participants the
quality of the data would
be more substantial and more accurate. Future surveys should
include demographic
questions about participants’ socioeconomic status.
From this study it is clear that there are varying beliefs as to
what effect behaviors

and environmental factors have on high blood pressure. Health
care providers should
look closely at clarifying what patients with high blood pressure
can do in their everyday
lives to help lower blood pressure.
References
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heart disease and stroke
statistics—2013 update: a report from the American Heart
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Pressure. Atlanta, GA:
Centers for Disease Control and Prevention, 2014. Available at:
http:// www .cdc .gov
/ bloodpressure/ index .htm.
3. Chobanian AV, Bakris GL, Black HR, et al. Seventh report
of the Joint National Com-
mittee on Prevention, Detection, Evaluation, and Treatment of
High Blood Pressure.
Hypertension. 2003;42(6):1206– 52.
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J Natl Med Assoc. 2010 Jan;102(1):10– 7.
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measurement of blood pressure at
home reduces the need for antihypertensive drugs: a
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consequences of adher-
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13. He FJ, Li J, Macgregor GA. Effect of longer- term modest
salt reduction on blood
pressure. Cochrane Database Syst Rev. 2013 Apr
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14. DeShay A. The Black Church. 2013. Accessed November
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Reproduced with permission of the copyright owner. Further
reproduction prohibited without
permission.

O R I G I N A L P A P E R
The Association Between Self-Efficacy and Hypertension
Self-Care Activities Among African American Adults
Jan Warren-Findlow • Rachel B. Seymour •
Larissa R. Brunner Huber
Published online: 6 May 2011
� Springer Science+Business Media, LLC 2011
Abstract Chronic disease management requires the
individual to perform varying forms of self-care behaviors.
Self-efficacy, a widely used psychosocial concept, is
associated with the ability to manage chronic disease. In
this study, we examine the association between self-effi-
cacy to manage hypertension and six clinically prescribed
hypertension self-care behaviors. We interviewed 190
African Americans with hypertension who resided in the
greater metropolitan Charlotte area about their self-efficacy
and their hypertension self-care activities. Logistic
regression for correlated observations was used to model
the relationship between self-efficacy and adherence to

hypertension self-care behaviors. Since the hypertension
self-care behavior outcomes were not rare occurrences, an
odds ratio correction method was used to provide a more
reliable measure of the prevalence ratio (PR). Over half
(59%) of participants reported having good self-efficacy to
manage their hypertension. Good self-efficacy was statis-
tically significantly associated with increased prevalence of
adherence to medication (PR = 1.23, 95% CI: 1.08, 1.32),
eating a low-salt diet (PR = 1.64, 95% CI: 1.07–2.20),
engaging in physical activity (PR = 1.27, 95% CI:
1.08–1.39), not smoking (PR = 1.10, 95% CI: 1.01–1.15),
and practicing weight management techniques (PR = 1.63,
95% CI: 1.30–1.87). Hypertension self-efficacy is strongly
associated with adherence to five of six prescribed self-care
activities among African Americans with hypertension.
Ensuring that African Americans feel confident that
hypertension is a manageable condition and that they are
knowledgeable about appropriate self-care behaviors are

important factors in improving hypertension self-care and
blood pressure control. Health practitioners should assess
individuals’ self-care activities and direct them toward
practical techniques to help boost their confidence in
managing their blood pressure.
Keywords Adherence � Hypertension � Minorities �
Self-efficacy � Self-management
Introduction
Over 40% of adults aged 45–64 and over 70% of adults
over age 65 have hypertension [1]. Current clinical policy,
based on the Joint National Committee on Prevention,
Detection, Evaluation, and Treatment of High Blood
Pressure (JNC7), recommends that people with hyperten-
sion engage in six self-care activities: adhering to antihy-
pertensive medication regimens, maintaining or losing
weight, following a low-salt diet, limiting alcohol, engag-
ing in regular physical activity, and eliminating tobacco
use [2]. The positive effects of these self-care behaviors on

the treatment and management of high blood pressure have
been demonstrated in randomized control trials [3]. How-
ever, rates of self-care engagement among hypertensive
adults are relatively low [4–7].
Among African Americans, the prevalence of hyper-
tension is significantly higher than among White Ameri-
cans (45.2% versus 29.1%) [8]. African Americans are also
less likely to have their blood pressure controlled than
Whites [9]. Studies that examine factors that predict
J. Warren-Findlow (&) � L. R. Brunner Huber
Department of Public Health Sciences, The University of North
Carolina Charlotte, 9201 University City Boulevard, Charlotte,
NC 28223, USA
e-mail: [email protected]
R. B. Seymour
Center for Research on Health and Aging, The University
of Illinois Chicago, Chicago, IL, USA
123
J Community Health (2012) 37:15–24

DOI 10.1007/s10900-011-9410-6
control of blood pressure frequently adjust for participants’
clinical risk factors such as obesity, other chronic condi-
tions and treatment with medication, but less frequently
assess the self-care activities that individuals engage in to
help manage their blood pressure. Poor adherence to self-
care behaviors may explain in part the health disparities
experienced by African Americans with respect to hyper-
tension and its consequences.
Adherence to antihypertensive medications is lower
among African Americans than among Whites [6, 10].
African Americans are frequently prescribed a more com-
plex drug regimen than Whites, that requires them to take
multiple medications [4]. They are more likely to complain
of uncomfortable side effects from drugs such as diuretics,
which may contribute to their low adherence [11]. African
Americans are more likely than Whites to eat a high fat diet

[12] and African American women have lower rates of
engaging in physical activity than Whites [13], thus
increasing the risk of obesity. Obesity is a risk factor for
prehypertension and hypertension [14, 15]. Maintaining or
losing weight can have a positive effect on blood pressure
management however African Americans are less likely to
achieve significant or lasting weight loss [16, 17]. Non-
Hispanic Blacks with hypertension are 39% less likely than
non-Hispanic Whites with hypertension to be following a
low-salt diet, such as DASH (Dietary Approaches to Stop
Hypertension) [5]. African Americans smoke cigarettes at
approximately the same rate as Whites, but are signifi-
cantly more likely to be exposed to secondhand smoke
[18, 19]. Alcohol usage among African Americans can be
described as encompassing opposite ends of the spectrum
with a higher prevalence of total abstinence but among
those who do drink alcohol, more reported occasions of
binge drinking [20]. This constellation of health risk factors

can make managing high blood pressure particularly
challenging, both for African Americans with hypertension
and for the health providers and practitioners working with
them. Cumulatively, these multiple risk factors create the
potential for even greater health disparities in relation to
stroke, kidney disease, end stage renal disease, disability
and death [21].
Helping individuals understand that hypertension is a
manageable condition can increase their confidence about
living with a chronic disease. Self-efficacy [22], or confi-
dence in one’s ability to participate in a given behavior, is a
common element in programs designed to improve chronic
illness self-management [23–25]. Self-efficacy has been
associated with better chronic disease self-care among
individuals managing asthma, diabetes, and arthritis [26, 27].
Within the context of chronic disease self-management,
measures of self-efficacy have focused on illness-related
domains such as managing pain and other symptoms, com-

municating with one’s physician, obtaining health-related
information, dealing with depression, and taking medication
[28]. Additional studies have examined self-efficacy in
relation to other self-care behaviors, such as diet and exer-
cise, but not necessarily within the chronic illness self-
management context [25].
Among African Americans with hypertension, self-
efficacy has been associated with self-report and objective
measures of adherence to medication regimens [4, 29, 30]
as well as participation in physical activity [31]. Further
studies have found that self-efficacy has been demonstrated
to be a predictor of African Americans’ participation in
other healthy behaviors such as following a recommended
diet [32] and weight loss [33]. To date, however, no study
has examined self-efficacy and its association with the
cluster of self-care behaviors that are recommended for
hypertension management. The purpose of this study is to
examine the association between self-efficacy to manage

hypertension and adherence to the current JNC7-recom-
mended self-care behaviors among African Americans with
hypertension. Findings from this study can be used to
inform patient self-care interventions for African Ameri-
cans with hypertension.
Methods
Study Design
The Caring for Hypertension in African American Families
(CHAAF) study was a cross-sectional study conducted at
the University of North Carolina at Charlotte (UNC
Charlotte) from September 2008 to August 2010. The
purpose of CHAAF was twofold: one, to assess chronic
illness self-care behaviors among African American adults
with hypertension [34]; and two, to examine psychosocial
factors that influence self-care adherence among this pop-
ulation, in particular family influences [35].
Study Recruitment
Study staff recruited older parent-adult child pairs from the

larger Charlotte, NC metropolitan community. We recrui-
ted through diverse outlets such as partnership with the
local chapter of the American Heart Association/American
Stroke Association, community-based organizations, low-
income health care clinics, Black churches, and barber
shops and hair salons. Several recruitment strategies were
utilized including mass emails to African Americans
employed at the university, letters to previous research
participants, newspaper and radio interviews describing the
study, and word-of-mouth from study participants.
Recruitment occurred from October 2008 through April
2010. All participants completed an informed consent
16 J Community Health (2012) 37:15–24
123
process approved by the UNC Charlotte Institutional
Review Board. A total of 190 participants were recruited
into the study (95 older parent-adult child pairs).

Study Inclusion and Exclusion Criteria
Eligible participants were African American, at least
21 years old, self-reported having been diagnosed with
high blood pressure for at least 6 months, and were pre-
scribed hypertensive medications. An individual was not
enrolled until his or her partner, either parent or child who
met the same eligibility criteria, was enrolled. During
prescreening for enrollment, we confirmed participants’
hypertension diagnosis by conducting a medication
inventory and then verifying that they were prescribed one
or more antihypertensive medications. For purposes of this
analysis, individuals missing data on the variables of
interest were excluded (n = 2); thus 188 individuals
remained for analysis.
Measures
All data for this study were collected using an original
survey. The six JNC7 prescribed hypertension self-care
activities were assessed using the H-SCALE (Hypertension

Self-Care Activity Level Effects), which was specifically
designed for this purpose. The H-SCALE, its items and
properties, have been previously described in detail [34].
Trained African American research assistants (undergrad-
uate students majoring in Public Health) conducted face-to-
face interviews at the participant’s preferred location (92%
were in his or her home or the home of a relative also
participating in the study). Interviews lasted an average of
58 min.
Exposure Variable
The exposure of self-efficacy to manage hypertension was
derived from a five item scale (see Table 1). This scale was
modified from an existing validated measure to assess self-
efficacy to manage disease in general by substituting the
words ‘‘high blood pressure’’ for ‘‘illness’’ [28]. Each item
begins with the phrase ‘‘How confident are you that you
can…?’’. Response options ranged from 1 (not confident at
all) to 10 (totally confident). Internal consistency for the
measure was good (a = .81). A mean score was calculated

and respondents who scored a 9 or above were classified as
having good self-efficacy.
Outcome Variables
To assess medication adherence, three items related to the
number of days in the past week that an individual (1) takes
blood pressure medication, (2) takes it at the same time
every day, and (3) takes the recommended dosage were
used. Responses were summed and participants reporting
that they followed these 3 recommendations on 7 out of
7 days were considered adherent. Internal consistency for
this scale was good (a = .84).
Twelve items assessed practices related to eating a low-
salt diet, such as avoiding salt while cooking and eating,
and avoiding foods high in salt content. Nine of the items
were negatively phrased; these items were reverse coded. A
mean score was calculated and participants who followed
low-salt diet practices on 6 out of 7 days were considered
adherent. Internal consistency for this scale was adequate
(a = .74).

Physical activity was assessed with two items. ‘‘How
many of the past 7 days did you do at least 30 min total of
physical activity?’’ and ‘‘How many of the past 7 days did
you do a specific exercise activity (such as swimming,
walking or biking) other than what you do around the
house or as part of your work?’’ Responses were summed
(range 0–14). Participants who scored an 8 or better were
coded as adhering to physical activity recommendations.
We established this criterion to ensure that participants had
to engage in a combination of frequency and duration of
activity and intensity of activity, in order to meet or exceed
the minimum requirements of 150 min per week of mod-
erate physical activity [36].
Smoking status was assessed with one item, ‘‘How many
of the past 7 days did you smoke a cigarette or cigar, even
Table 1 Self-efficacy to manage hypertension
1. Having high blood pressure often means doing different tasks
and activities to manage your condition. How confident are you
that you can
do all the things necessary to manage your high blood pressure

on a regular basis?
2. How confident are you that you can judge when changes in
your high blood pressure mean you should visit a doctor?
3. How confident are you that you can do the different tasks and
activities needed to manage your high blood pressure so as to
reduce your
need to see a doctor?
4. How confident are you that you can reduce the emotional
distress caused by your high blood pressure so that it does not
affect your
everyday life?
5. How confident are you that you can do things other than just
taking medication to reduce how much your high blood pressure
affects your
everyday life?
J Community Health (2012) 37:15–24 17
123
just one puff?’’ Respondents who reported zero days were
considered a nonsmoker.
Alcohol intake was assessed using an existing measure,
the 3-item, National Institute on Alcohol Abuse and
Alcoholism (NIAAA) Quantity and Frequency Question-

naire [37]. For these analyses, adherence was deemed to be
alcohol abstinent. Participants who reported not drinking
any alcohol in the last 7 days, or who indicated that they
usually did not drink alcohol were considered abstainers.
Internal consistency of the scale was good (a = .88).
Adherence to weight management was assessed with ten
items to determine dietary practices such as cutting portion
size and making food substitutions as well as exercising to
lose weight. Items were assessed based on recall of activ-
ities over the last 30 days. Using a 5-point Likert scale,
participants who reported that they agreed or strongly
agreed with all 10 items were considered adherent to
weight management practices. Internal consistency of the
scale was good (a = .87).
Covariates
The study collected information on a number of potential
confounders, including: age, gender, marital status, income
and education, as well as health-related variables. Self-
rating of health was assessed with responses ranging from

excellent (5) to poor (1). Participants who reported good to
excellent health were considered to have good self-rated
health. Participants were asked if they had any additional
chronic health problems from a prepared list of chronic
conditions [38]. Participants reporting no additional
chronic conditions in addition to hypertension were coded
as ‘‘hypertension only’’. Body mass index was calculated
from self-reported weight in pounds and height in inches.
Following conventional guidelines [39], BMI was catego-
rized as normal weight (BMI B 25.0), overweight
(BMI [ 25.0 and B30.0), obese (BMI [ 30.0 and B40.0),
and extremely obese (BMI [ 40.0). We also assessed how
many participants lacked health insurance.
Statistical Analyses
Frequencies and percentages were calculated for demo-
graphic and health characteristics as well as participants’
adherence to the self-care activities. Unadjusted odds ratios
(ORs) and 95% confidence intervals (CIs) were obtained to
examine the association between self-efficacy and hyper-

tension self-care outcomes, and to identify other factors
associated with the self-care outcomes. Since the data
included parent–child dyads, a generalized estimating
equations (GEE) approach was used to carry out logistic
regression for correlated responses. Multivariate logistic
regression for correlated responses was used to further
explore the relationship between self-efficacy and hyper-
tension self-care outcomes. A variable was considered to
be a confounder of the association between good self-
efficacy and a self-care outcome if it changed the OR by at
least 10%. Ultimately, there were no confounders associ-
ated with good self-efficacy and the outcomes for low-salt
diet adherence, physical activity, non-smoking, or weight
management. For the good self-efficacy and medication
adherence association, good self-rated health was identified
as a confounder. For the self-efficacy and alcohol absti-
nence association, gender was confirmed as a confounder.
Because the self-care outcomes were not rare occurrences,

we used the odds ratio correction method proposed by
Zhang and Yu [40] to provide a more reliable measure of
the prevalence ratio for all unadjusted and adjusted asso-
ciations. All analyses were conducted using SPSS v. 17 and
statistical significance was set at P B .05.
Results
An overall statistical description of the sample (n = 188)
by levels of self-efficacy is shown in Table 2. Participants
ranged in age from 22 to 88 years, with a mean age of
53 years. Over half were age 50 or above and nearly 70%
of the sample was female. Slightly more than a third of the
sample was married. Over three-fourths rated their health
as good to excellent. Eighty percent of the sample was
overweight or obese based on body mass index. Approxi-
mately 11% of participants did not have health insurance.
Adherence to hypertension self-care ranged from 22% for
low-salt diet adherence to 75% for not smoking, with
adherence to medication at 58%.

Bivariate and Multivariate Results
Demographic and Health Characteristics Associated
with Hypertension Self-Care
In unadjusted analyses (see Table 3), participants aged 50
and older had increased prevalence of being adherent to
medication (PR = 1.43, 95% CI: 1.13–1.69) as did women
(PR = 1.51, 95% CI: 1.10–1.85), and these results were
statistically significant. Overweight individuals had 39%
lower prevalence for medication adherence (95% CI:
0.33–0.97). Being a woman was statistically significantly
associated with higher prevalence of adherence to low salt
diet techniques. For physical activity, being uninsured
increased the prevalence of adherence by 1.54 times (95%
CI: 1.09–1.81). For adherence to smoking, women and those
participants with a 4 year college or graduate degree had
increased prevalence of not smoking (PR = 1.23, 95% CI:
1.04–1.36; PR = 1.25, 95% CI: 1.06–1.35; respectively).

123
Table 2 Characteristics for African Americans by self-efficacy
to manage hypertension
Characteristic Good SE to manage HTN (n = 111) Poor SE to
manage HTN (n = 77) Total (n = 188)
N % N % N %
Age
50 or older 65 58.6 45 58.4 110 58.5
Less than 50 46 41.4 32 41.6 78 41.5
Gender
Female 75 67.6 59 76.6 134 71.3
Male 36 32.4 18 23.4 54 28.7
Marital status
Married 38 34.2 29 37.7 67 35.6
Not currently married 73 65.8 48 62.3 121 64.4
Household income
Over $50,000 33 29.7 31 40.3 64 34.0
$10,000–$50,000 56 50.5 33 42.9 89 47.3

0 to $10,000 22 19.8 13 16.9 35 18.6
Education
4 year college degree or better 23 20.7 25 32.5 48 25.5
Some college or 2 year degree 42 37.8 33 42.9 75 39.9
High school degree or less 46 41.4 19 24.7 65 34.6
Self-rated health
Good to excellent 81 73.0 66 85.7 147 78.2
Fair or poor 30 27.0 11 14.3 41 21.8
Chronic conditions
HTN only 19 17.1 18 23.4 37 19.7
Chronic condition ? HTN 92 82.9 59 76.6 151 80.3
Body mass index
Extremely obese (BMI C 40.0) 13 11.7 10 13.0 23 12.2
Obese (BMI C 30.0 but 40.0) 38 34.2 29 37.7 67 35.6
Overweight (BMI C 25.0 but 30.0) 38 34.2 23 29.9 61 32.4
Normal weight (BMI 25.0) 22 19.8 15 19.5 37 19.7
Uninsured
Yes 14 12.6 7 9.1 21 11.2

No 97 87.4 70 90.9 167 88.8
Medication adherence
Yes 56 50.5 53 68.8 109 58.0
No 55 49.5 24 31.2 79 42.0
Low-salt diet adherence
Yes 18 16.2 24 31.2 42 22.3
No 93 83.8 53 68.8 146 77.7
Physical activity adherence
Yes 48 43.2 50 64.9 98 52.1
No 63 56.8 27 35.1 90 47.9
Non-smoking adherence
Yes 77 69.4 64 83.1 141 75.0
No 34 30.6 13 16.9 47 25.0
Alcohol abstinence
Yes 70 63.1 53 68.8 123 65.4
No 41 36.9 24 31.2 65 34.6
Weight management adherence
Yes 22 19.8 35 45.5 57 30.3

No 89 80.2 42 54.5 131 69.7
123
Lacking health insurance reduced the prevalence of not
smoking by 36% (95% CI: 0.36–0.92). Older age and gender
were associated with increased prevalence of alcohol absti-
nence (PR = 1.53, 95% CI: 1.27–1.72; PR = 1.75, 95% CI:
1.43–1.99; respectively). Participants who had no other
chronic conditions had reduced prevalence of being absti-
nent (PR = 0.79, 95% CI: 0.57–0.98), as did those who were
uninsured (PR = 0.41, 95% CI: 0.18–0.74). Those who were
extremely obese had 1.42 times the prevalence of being
abstinent from alcohol (95% CI: 1.08–1.55). Having a 4 year
college or graduate degree was associated with prevalence of
weight management adherence in unadjusted analyses
(PR = 1.71, 95% CI: 1.01–2.46.
Self-efficacy and Hypertension Self-Care

In models examining self-efficacy and hypertension self-
care (see Table 4), good self-efficacy to manage hyperten-
sion was statistically significantly associated with a higher
prevalence of adherence for five of the six JNC7 recom-
mended self-care behaviors. In unadjusted results the prev-
alence of adherence with medication was 1.20 times higher
among those with good self-efficacy as compared to those
with poor self-efficacy. After adjusting for self-rated health,
this prevalence was increased in magnitude and remained
statistically significant (PR = 1.23, 95% CI: 1.08–1.32). In
bivariate models, individuals with good self-efficacy had
Table 3 Corrected unadjusted associations between demographic
and health characteristics and hypertension self-care activities
Medication
adherence PR
(95% CI)
Low-salt diet
adherence PR

(95% CI)
Physical activity
adherence PR
(95% CI)
Nonsmoking
PR (95% CI)
Alcohol
abstinence
PR (95% CI)
Weight
management
adherence
PR (95% CI)
Age
50 or older 1.43 (1.13–1.69) 1.02 (0.62–1.57) 0.84 (0.59–1.11)
1.10 (0.94–1.23) 1.53 (1.27–1.72) 1.18 (0.74–1.71)
Less than 50 Referent Referent Referent Referent Referent
Referent
Gender

Female 1.51 (1.10–1.85) 2.04 (1.01–3.58) 1.08 (0.78–1.37) 1.23
(1.04–1.36) 1.75 (1.43–1.99) 1.15 (0.68–1.76)
Male Referent Referent Referent Referent Referent Referent
Marital status
Married 1.05 (0.78–1.30) 0.75 (0.40–1.30) 0.95 (0.67–1.20)
1.05 (0.86–1.18) 1.08 (0.83–1.27) 1.13 (0.69–1.68)
Not currently married Referent Referent Referent Referent
Referent Referent
Household income
$50,000 or more 1.07 (0.69–1.40) 0.90 (0.36–1.88) 0.97 (0.59–
1.33) 1.10 (0.90–1.23) 0.74 (0.43–1.07) 1.68 (0.93–2.47)
$10,000–$49,999 0.98 (0.66–1.27) 0.79 (0.34–1.58) 1.19 (0.79–
1.57) 1.11 (0.93–1.23) 0.76 (0.47–1.05) 1.43 (0.80–2.13)
Less than $10,000 Referent Referent Referent Referent Referent
Referent
Education
4 year college degree or better 1.15 (0.80–1.44) 1.32 (0.64–
2.35) 1.08 (0.68–1.43) 1.25 (1.06–1.35) 0.81 (0.53–1.08) 1.71
(1.01–2.46)
Some college or 2 year degree 0.89 (0.63–1.13) 0.80 (0.39–
1.46) 1.06 (0.72–1.37) 1.06 (0.90–1.17) 0.84 (0.58–1.09) 1.14
(0.69–1.68)
High school degree or less Referent Referent Referent Referent
Referent Referent

Self-rated health
Good to excellent 0.81 (0.55–1.05) 1.35 (0.64–2.46) 1.23 (0.82–
1.62) 1.20 (0.98–1.34) 0.86 (0.59–1.08) 1.37 (0.82–2.06)
Fair or poor Referent Referent Referent Referent Referent
Referent
Chronic conditions
Hypertension only 0.84 (0.57–1.08) 1.11 (0.59–1.82) 1.78
(0.91–1.54) 0.93 (0.72–1.08) 0.79 (0.57–0.98) 1.30 (0.75–2.07)
Additional chronic conditions Referent Referent Referent
Referent Referent Referent
Body mass index
Extremely obese 0.69 (0.30–1.16) 0.73 (0.21–1.95) 0.91 (0.45–
1.38) 1.13 (0.80–1.28) 1.42 (1.08–1.55) 0.46 (0.15–1.20)
Obese 0.70 (0.38–1.06) 0.99 (0.45–1.89) 1.23 (0.78–1.63) 1.07
(0.81–1.23) 1.11 (0.82–1.32) 0.90 (0.47–1.53)
Overweight 0.61 (0.33–0.97) 1.06 (0.47–2.04) 0.93 (0.53–1.32)
0.99 (0.73–1.15) 0.99 (0.72–1.20) 0.83 (0.42–1.45)
Normal weight Referent Referent Referent Referent Referent
Referent
Uninsured
Yes 0.55 (0.28–0.91) 0.39 (0.09–1.43) 1.54 (1.09–1.81) 0.64
(0.36–0.92) 0.41 (0.18–0.74) 0.62 (0.22–1.39)

No Referent Referent Referent Referent Referent Referent
123
64% higher prevalence of adhering to low salt diet strategies
and 27% increased prevalence of engaging in physical
activity (low salt diet: PR = 1.64, 95% CI: 1.07–2.20;
physical activity: PR = 1.27, 95% CI: 1.08–1.39). Those
with good self-efficacy had 10% higher prevalence of not
smoking (PR = 1.10; 95% CI: 1.01–1.15). All of these asso-
ciations were statistically significant. Participants with good
self-efficacy had 63% higher prevalence of following good
weight management strategies (PR = 1.63; 95% CI:
1.30–1.87). Self-efficacy was not statistically significantly
associated with alcohol abstinence in unadjusted or adjusted
models.
Discussion and Conclusion
Discussion

This study found that the majority of African American
participants with hypertension had good self-efficacy to
manage their chronic illness. Individuals with good self-
efficacy had statistically significantly increased odds of
being adherent to medication regimens, using low-salt diet
techniques, engaging in physical activity, not smoking, and
utilizing common weight management strategies. Consistent
with other studies, self-efficacy is important to hypertension
self-care [41] and is associated with weight management
[33], and diet adherence [42]. Self-efficacy is also associated
with antihypertensive medication adherence [4, 29, 30].
Better self-efficacy was not associated with abstaining
from alcohol. It is possible that participants do not asso-
ciate reducing alcohol consumption as a hypertension self-
care behavior. This reasoning would suggest that health
providers should intervene to increase awareness of alcohol
consumption and its effects on hypertension management.
Alternatively our measure of self-efficacy may not be

specific enough to be associated with alcohol, perhaps
because of its addictive quality [43, 44]. Alcohol intake has
been associated with increased stress among African
Americans, suggesting that it may be used as a form of
stress coping [45].
In this sample of African Americans with hypertension,
less than one-third of participants were practicing common
strategies to maintain or lose weight even though most
were clinically overweight or obese. African Americans
may not realize how their weight status influences their
blood pressure, and that losing or maintaining their weight
as part of a comprehensive chronic disease management
strategy can have a positive effect on high blood pressure
[46]. Findings from this study point to the need to develop
and disseminate interventions which increase self-efficacy
related to hypertension management and that include
strategies for weight management or weight loss.
Importantly in this study we found that a disease-

specific measure of self-efficacy was associated with multiple
self-care behaviors. Typically self-efficacy is considered to
be behavior-specific [25], as for example in the case of
self-efficacy to take medication [29]. With this approach
Table 4 Corrected unadjusted
and corrected adjusted
prevalence ratios and 95%
confidence intervals for the
associations between self-
efficacy and adherence to
recommended hypertension
self-care behaviors (n = 188)
a
Adjusted for good self-rated
health
b
Adjusted for gender
Good SE to
manage HTN
Poor SE to

manage HTN
Medication adherence
Unadjusted PR (95% CI) 1.20 (1.05–1.31) 1.00 (Referent)
Adjusted PR (95% CI)
a
1.23 (1.08–1.32) 1.00 (Referent)
Low-salt diet adherence
Adjusted PR (95% CI) N/A N/A
Physical activity adherence
Non-smoking
Adjusted PR (95% CI) N/A 1.00 (Referent)
Alcohol abstinence
Adjusted PR (95% CI)
b

1.05 (0.81–1.21) 1.00 (Referent)
Weight management adherence
123
the investigator is required to measure participants’ confi-
dence level for each self-care activity and situation,
potentially increasing participant burden. From a theoreti-
cal perspective, when assessing self-efficacy related to
chronic illness self-management, our findings suggest that
the disease context is important to measure; less emphasis
may be placed on any one individual behavior. This finding
suggests that encouraging patients to have more confidence
in their ability to care for their high blood pressure may
yield multiple benefits in terms of their self-care adherence.
Importantly, self-efficacy is not a trait; it is a mutable

characteristic and, therefore, amenable to intervention
[25, 28].
Strengths and Limitations
The study findings should be interpreted with caution.
Hypertension self-care activities were self-reported. Mis-
classification could have occurred if participants reported
their behaviors incorrectly or inconsistently. It is also pos-
sible that there was recall bias, as participants were asked to
report their adherence over either the past 7 day or 30 day
(for weight management practices) time frame. Any mis-
classification would likely bias the results toward the null.
A second form of misclassification could have occurred
because of the lack of established adherence criteria.
Medication adherence has been measured with single
items, multiple items, over varying time periods, and with
different levels of adherence being deemed acceptable
[47]. In this study we used a restrictive criterion and
established medication adherence at 100%, which con-

tributes to the strength of our findings. Minimum physical
activity levels have been established for older adults
(including those with chronic illness) at 150 min per week
of moderate intensity [36]. We established our criteria for
physical activity adherence to be higher than that because
we also had younger participants in our study, and we
wanted a measure that combined frequency and duration of
activity with some assessment of intensity. Smoking is
classified as an all or nothing activity, however, even with
patients who do not smoke, it is important to assess how
many live with smokers. Recent data suggest that non-
smoking, African Americans continue to have passive
smoking exposure; thus maintaining their disease risk [19].
While alcohol is firmly established as a risk factor for
hypertension, recommended consumption levels remain
contradictory given potential heart healthy benefits [48].
However, these benefits have not been established for
African Americans [20]. The other two self-care activities

measure practical techniques that people use to aid in
eating a low-salt diet and/or losing or maintaining weight;
thus no previous criteria for adherence have been
determined.
Selection bias may have occurred. The African Ameri-
can adults who agreed to participate in this study could be
different from those who did not participate. Notably this
study recruited participants in parent–child pairs; adults
with hypertension who did not have a parent with hyper-
tension (or a living parent with hypertension) or an adult
child diagnosed with hypertension may be different than
those individuals enrolled in the study. If selection bias did
occur, it could result in an over or underestimate of the true
association.
We collected data on several potential confounders. One
of these, years living with hypertension, could not be
analyzed due to missing and inconsistent data. It is con-
ceivable that increased years of living with hypertension

could affect an individual’s self-efficacy to manage the
disease and/or a person’s adherence to self-care. Inability
to control for this variable could result in an over or
underestimate of the true association.
This study used a cross-sectional design which pre-
cludes the ability to determine causality or direction. The
study did not collect self-reported or actual measures of
blood pressure; thus we cannot examine the association
between self-efficacy and blood pressure control, or any of
the self-care behaviors and blood pressure control.
Strengths of this study include the assessment of all six
JNC7 recommended self-care behaviors using a validated
measure specifically designed for this purpose. We also
include the examination of a wide spectrum of demographic
and health factors in relation to hypertension self-care
activities among African Americans with hypertension. To
limit potential biases, we used race congruent interviewers
who conducted sessions in the participants’ homes to reduce

barriers to participation. Our sample included many
younger adults with hypertension and the sample was
middle class based on education and income. These two
groups of African Americans are often missing from the
hypertension research literature. Our measure of self-effi-
cacy was short, valid and reliable and could easily be used
in a primary care setting. The sample is diverse with respect
to the demographic and health factors studied, although it
should be noted that participants are from a Southern, urban
area that may limit the generalizability of the results to all
African Americans in the US. However, the results may be
generalizable to other African Americans residing in cities
in the Southeast US.
Conclusion
Self-efficacy to manage hypertension is associated with five
of six JNC7 prescribed self-care activities for managing high
blood pressure. Health care providers and public health
practitioners should work within the context of hypertension

123
self-care to increase patient knowledge and improve self-
efficacy for hypertension management. African Americans
may then have the prerequisite tools to more readily adopt
and adhere to self-care behaviors with the potential to reduce
significant health disparities. Future studies should be con-
ducted to determine if a dose–response relationship exists at
varying levels of adherence between these recommended
self-care activities and blood pressure control.
Providers need to consider the role of self-care adherence
among African Americans with uncontrolled hypertension.
Assessment of individuals’ self-care activities in addition to
medication adherence is an important first step. Given the
prevalence of hypertension within African American fami-
lies and communities, and the poor health outcomes expe-
rienced by this segment of the population, African

Americans may have low self-efficacy with respect to
hypertension. They may require specific counseling and
encouragement that hypertension is a manageable condition.
Acknowledgments Funding for this study was provided by a
grant
(R03AG030523) from the National Institute on Aging.
Conflict of interest The authors have no financial or other
relationship.
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123
http://dx.doi.org/10.249/MSS.0b013e3181a0c95c
http://dx.doi.org/10.249/MSS.0b013e3181a0c95c
Reproduced with permission of the copyright owner. Further
reproduction prohibited without permission.
c.10900_2011_Article_9410.pdfThe Association Between Self-
Efficacy and Hypertension Self-Care Activities Among African
American AdultsAbstractIntroductionMethodsStudy
DesignStudy RecruitmentStudy Inclusion and Exclusion
CriteriaMeasuresExposure VariableOutcome
VariablesCovariatesStatistical AnalysesResultsBivariate and
Multivariate ResultsDemographic and Health Characteristics
Associated with Hypertension Self-CareSelf-efficacy and
Hypertension Self-CareDiscussion and
ConclusionDiscussionStrengths and
LimitationsConclusionAcknowledgmentsReferences

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