AN ASSESSMENT OF ETHNIC DIFFERENCES IN DRUG USE DECISION MAKING AMONG AFRICAN AMERICAN AND WHITE AMERICAN HYPERTENSIVE PATIENTS: IMPLICATIONS FOR HYPERTENSION MANAGEMENT By CAROLYN MARIE BROWN A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 1994 This manuscript is dedicated to my parents, Herbert and Beverly Brown, who have provided me with unyielding support over the years. My mother served as an exemplar of strength under the toughest circumstances. My father has always backed me in my educational decisions even when he had no idea how they were to be financed. I thank my two brothers, Jerome and Dexter, for serving as my connections to reality outside of graduate school and always keeping me in check. I would like to thank my grandmothers, aunts, uncles and cousins for their support as well as their acceptance of my collect calls. Finally, thanks go out to all of my wonderful friends and to my colleagues at Xavier University of Louisiana for their unwavering support and confidence in me. ACKNOWLEDGEMENTS My sincere gratitude goes to Dr. Richard Segal, my advisor, for his unyielding support, guidance and stamina throughout my graduate studies. I would also like to than): the following committee members for their encouragement, support and interest in my research project: Dr. Donna Berardo, Dr. Carole Kimberlin, and Dr. John Lynch. I would like to express my appreciation to the staff cf Pharmacy Health Care Administration for their support and patience over the years. My thanks go to Dennis, Ned and Dan Nissen for their computer support; the postdoctoral fellows and graduate students for being great colleagues; the PHCA faculty for helping me grow; Drs. Ried, Gums, Rutledge and Ron Stewart for their support and service on rv expert panel; Drs. Coward and Duncan for their interest in my project; the pretest sites and Ms. Copeland for their invaluable assistance with patient recruitment; the American Foundations for Pharmaceutical Education (AFPE) the Center , on Rural Health and Aging, the Florida Rural Health Researc- Center, Bristol-Meyers Sguibb, and Marion Merrell-Dow for providing financial support. Finally, I would like to extend my genuine love and appreciation to my parents, family, and friends. TABLE OF CONTENTS Page ACKNOWLEDGEMENTS iii ABSTRACT vi CHAPTERS 1 INTRODUCTION 1 The Need for the Study 1 Problem Statement 1 Purpose and Significance 8 Research Questions 9 2 REVIEW OF LITERATURE 11 Drug Use Behavior Research 11 Temporal Orientation Research 31 Summary 37 3 RATIONALE AND THEORETICAL FRAMEWORK 39 4 METHODOLOGY 54 Sample Selection 54 Data Collection Procedures 56 Nonrespondent Bias 59 Study Variables 50 Instrument Development and Validation 67 Data Analysis 80 Limitations 87 5 RESULTS 89 Sample Description 89 Evaluation of Nonrespondent Bias 91 Evaluation of Final Instrument 91 Health Perceptions and Hypertension Temporal Orientation 98 Patient Self-Reported Drug Use Behavior 100 Ethnic Differences in Health Perceptions and Hypertension Temporal Orientation 102 page Hypertension Temporal Orientation and Health Perceptions 106 Health Perceptions and Drug Use Behavior 117 6 DISCUSSION, CONCLUSIONS, AND RECOMMENDATIONS 129 The Health Belief Model (HBM) =nd Drug Use Behavior 129 Ethnicity, Hypertension Temporal Orientation and Health Perceptions 130 Effects of Health Perceptions en Compliance with Rx and Use of HR 138 Study Limitations 142 Conclusions 144 Implications 144 APPENDICES A INTERITEM AND CORRECTED ITEM TO TOTAL CORRELATIONS OF PRETEST SCALES 151 B INTERITEM AND CORRECTED ITEM TO TOTAL CORRELATIONS OF FINAL SCALES 154 C PRETEST SURVEY INSTRUMENT 157 D TEXT OF SCREENER AND SURVEY INSTRUMENT OF FINAL STUDY 176 E DESCRIPTION OF HOME REMEDIES AND THEIR USES... 194 REFERENCES 195 BIOGRAPHICAL SKETCH 203 Abstract of Dissertatirn Presented to the Graduate School of the University of Fl:rida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy AN ASSESSMENT OF ETE.VIC DIFFERENCES IN DRUG USE DECISION MAKING AMONG AFRICAN AME?ICAN AND WHITE AMERICAN HYPERTENSIVE PATIENTS: IMPLICATIONS FOR HYPERTENSION MANAGEMENT By Carclyn Marie Brown December 1994 Chairman: Professor Richard Segal Major Department: Pharmacy Health Care Administration The purpose of this study was to explain and to predict drug use behavior among African American and White American hypertensive patients within the context cf health perceptions and their subsequent effect on drug use practices. Using the Health Belief Model (HBM) as the theoretical framework, this study examined both the associations of cultural variables (ethnicity and hypertension temporal orientation) with health perceptions and the effects of these culturally-related health perceptions on compliance with prescription medication (Rx) and use of home remedies (HR) Data were collected via . telephone interviews with 300 individuals who had been medically diagnosed as having hypertension and who had not experienced any major cc-plications of uncontrolled hypertension. The study's findings revealed that, after controlling for selected covariates, African Americans perceived that the costs of Rx were more burdensome compared to White Americans. Ethnic group differences, however, were more apparent when the health perceptions were evaluated within the cultural context of hypertension temporal orientation. Factor analysis results indicated that hypertension temporal orientation can be categorized into three groups: (1) nonexperiential domain which represented potential consequences of hypertension; (2) experiential disease domain which involved the day-to-day dealing with hypertension; and (3) experiential treatment domain which involved the daily management of hypertension. African Americans were core present oriented than White Americans concerning their daily management of hypertension. A more future orientation regarding hypertension management was associated with higher perceptions of severity, susceptibility, benefits of Rx, and costs of HR and with lower perceptions of costs of Rx and benefits of HR. Significant predictors of compliance with Rx were age, costs of Rx and benefits of HR. Severity, benefits and costs of HR, ethnicity, and a poverty by education interaction significantly explained use of HR. The results of this study supported a number of principal conclusions: (1) cultural variables influence individual perceptions of disease and evaluations of treat-ent alternatives; (2) compliance with Rx is affected by demographic characteristics and by beliefs about costs of Rx and benefits of HR; and (3) use of HR is a function of demographic characteristics, perceptions of disease severity, and evaluations of benefits and costs of HR. CHAPTER 1 INTRODUCTION The Need for the Study Problem of Hypertension An estimated 60 million persons in the United States have hypertension. Of these, only about 32 million are aware of having this disease (The American Heart Association, 1990) The findings of a study conducted by . the South Carolina Department of Health in 1987 revealed that 28% of persons with hypertension were unaware of their hypertension, 12% were aware but not treated, 28% were being treated but not controlled, and 32% were being treated and controlled (Gorlin, 1991) Clark (1991) also cited evidence . indicating that more than half of the hypertensives are either untreated or inadequately controlled. Similarly, findings from a national report indicated that of the estimated 60 million hypertensives, possibly one-third are receiving medical treatment, and only six million are appropriately managed (The American Heart Association, 1990) Thus, it is reasonable to conclude that somewhere . between 10% to 32% of all people with hypertension are adequately controlled. 2 Hypertension has been an enduring problem in the African American community. Blacks have both a higher prevalence of hypertension and a higher age-specific mean blood pressure than that of whites (Klag et al., 1991). Most studies indicate that statistically significant blood pressure differences between the races occur sometime after age 17 (Hildreth and Saunders, 1991) The frequency with . which hypertension occurs in the African American community ranks as one of the highest in the world. The prevalence of Stage I (mild) and Stage II (moderate) hypertension is more that twice as high in black adults as in white adults, and the incidence of Stage III (severe) hypertension is five to seven times higher in blacks than in whites (Hildreth and Saunders, 1991) Moreover, since blacks develop more severe . hypertension earlier and remain untreated or uncontrolled for longer periods of time, more severe consequences of longstanding hypertension result (Kannel, 1974). Millions of African-Americans die each year as a result of strokes, heart attacks, and other cardiovascular-related illnesses that are directly linked to uncontrolled hypertension. Among hypertensives in the United States, blacks are 10 to 18 times more likely to experience kidney failure, and three to five times more likely to develop chronic heart failure than whites (Fackelmann, 1991). Although the treatment of hypertension has generally improved over the last two decades, the rate of improvement