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Illness Perceptions and Health Behaviors of Black Women

Stallings, Devita T. PhD, RN

The Journal of Cardiovascular Nursing: November/December 2016 - Volume 31 - Issue 6 - p 492–499
doi: 10.1097/JCN.0000000000000276
ARTICLES: Prevention

The Common Sense Model of Illness Representations proposes that representations or perceptions of illness drive health behaviors. The purpose of this study was to explore the relationships between hypertension representations, exercise, and dietary behaviors in hypertensive black women (N = 204, aged 18–65 years). Regression results revealed that perceiving hypertension as chronic and perceiving it a result of environmental causes were inversely related to moderate-intensity physical activity (β = −.15 [P = .05] and β = −.25 [P = .05], respectively). Having more emotional responses to hypertension (β = .23, P = .05) was related to moderate-intensity physical activity and more fruit and vegetable consumption (β = .28, P = .05). These findings suggest that hypertension representations can interfere with recommended lifestyle changes among black women. Assessing hypertension representations and implementing measures to clarify misperceptions of hypertension among black women may lead to better blood pressure control and health outcomes.

Devita T. Stallings, PhD, RN Assistant Professor, School of Nursing, Saint Louis University, Missouri.

Results of this research study were presented as a poster presentation at the Midwest Nursing Research Society’s annual research conference in April 2012.

The author has no funding or conflicts of interest to disclose.

Correspondence Devita T. Stallings, PhD, RN, School of Nursing, Saint Louis University, 3525 Caroline Mall, St Louis, MO 63104 (

Hypertension is a leading risk factors for cardiovascular disease, which is the primary cause of death worldwide.1 Black women have the highest prevalence of hypertension in the world. In addition, blacks develop hypertension at an earlier age and generally have higher blood pressure averages as compared with whites. Compared with whites, blacks are 1.5 times more likely to die of heart disease and have 1.8 times higher rate of fatal stroke and 4.2 times higher rate of end-stage renal disease. In addition, 46% of black women have hypertension as compared with 30% of white women.1 The initial recommended strategy for lowering blood pressure—according to the Seventh and Eighth Reports of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure guidelines—is the implementation of lifestyle modifications, including physical activity and diet.2,3 Despite the many benefits of physical activity to health, among adults 18 years or older, 39% of blacks are more likely to be inactive compared with 27% of whites.1 In regard to diet, it is known that diets rich in fruits and vegetables may lower chronic disease risks. Yet in 2009, only 33.7% of blacks reported consuming 2 or more fruits per day, and 21.9% reported consuming 3 or more vegetables per day.4 Despite efforts to improve diet and physical activity, the health of black women continues to be compromised by inactive lifestyles and poor dietary choices.1,5 Prior researchers found that lifestyle behaviors are influenced by individuals’ perceptions of disease.6,7 Exploring black women’s perceptions using the Common Sense Model may help to understand part of what underlies the hypertension disparity in black women. Therefore, the purpose of this study was to examine the relationships between hypertension representations and health behaviors, specifically moderate and high physical activity and fruit and vegetable consumption, in hypertensive black women.

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Common Sense Model of Illness Representations and Lifestyle Behaviors

According to the Common Sense Model of Illness Representations, people develop their views of illness by processing key factors related to their disease.8 These views, or meanings of illness, are referred to as cognitive and emotional representations, which are the perceptions, interpretations, or subjective appraisals of the sensations, thoughts, and feelings associated with illness. The cognitive representations include the development and duration (timeline); the label and symptoms of the disease or health threat (identity); whether the threat is preventable, controllable, or curable (control); impact on functional capacity or quality of life (consequences); causes of their health threat (causes)9; and understanding of illness (coherence).10 Emotional representations are the emotional responses to the illness or health threat. Individuals manage representations through actions or coping strategies. Representations of illness are modified as coping strategies are appraised.9 The Figure shows a graphical representation of Leventhal’s Common Sense Model.



Hypertension representations can hinder engagement in treatment and self-care strategies. Wilson and colleagues11 noted that black women regarded hypertension as symptomatic and caused by emotional stress for which the women used home remedies such as garlic and vinegar as well as stress-reduction techniques. Similarly, Fongwa and colleagues12 found that black women reported symptoms of hypertension and a lack of understanding the disease. Webb and Gonzalez13 found that black women perceived that they were vulnerable to hypertension and that it was inevitable given their psychological burdens such as perceptions of striving to be overachievers; multiple roles involving family, work, and the community; and the burden of kinship due to a strong commitment to family. In addition, the women regarded hypertension as serious and were aware of risk factors such as unhealthy eating and inactive lifestyles, but the women in the study were concerned that many black men and women have limited knowledge of how to manage hypertension. They reported stress to be the cause of psychological symptoms (eg, fatigue, lethargy, anger) that decreased motivation for physical activity.13 Likewise, research findings suggest that blacks commonly reported stress as a major cause of hypertension and were less likely to have heart-healthy diets that included low-sodium and low-fat foods.14 Hypertension self-management among minority patients may be improved if clinicians were more aware of their patients’ beliefs.15

Black women’s beliefs that hypertension is symptomatic,11,12 caused by stress,11,12,16 and inevitable12 are barriers to effective hypertension treatment, which includes physical activity and a heart-healthy diet. Few researchers have explored hypertension representations using a multidimensional theoretical model in a large sample of black women. The Common Sense Model is a useful multidimensional framework for examining the hypertension representations and lifestyle behaviors among black women. Therefore, the specific aims of this study were 2-fold. First, the relationship between hypertension representations and moderate and high physical activity was explored. Second, we explored the relationship between hypertension representations and fruit and vegetable intake.

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Design, Setting, and Sample

Using a descriptive cross-sectional design, black women were recruited from 5 churches. They were 18 to 65 years old, reported physician-diagnosed hypertension, and were able to read, write, and speak English. Two churches were in Tennessee (1 was a satellite location of larger church), and 3 were in Mississippi (2 were satellite locations). To obtain a large-enough sample, women also were recruited from a hair salon in Tennessee.

For this study, power analysis was calculated using G-Power 3.1. Under ideal conditions for an observed effect of 0.15, α of .05, desired power of 0.95, and 12 predictors, an approximate sample size of 184 was needed.17 A total of 204 black women were recruited in this study.

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Participants completed the Illness Perception Questionnaire to measure representations, 7-Day Physical Activity Recall, the Fruit and Vegetable Quick Food Scan (All-Day Screener version), and demographic form and had measures of blood pressure and body mass index taken by the research team.

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Hypertension Perception Questionnaire

A revised version of the Illness Perception Questionnaire developed by Moss-Morris and colleagues10 was used to measure hypertension representations by replacing the word illness with the term high blood pressure. This questionnaire was used to obtain a quantitative assessment of the cognitive and emotional representations of hypertension. It included subscales that reflected the representational attributes including timeline (cyclical/chronic), identity, control (personal and treatment), consequences, coherence, cause, and emotional representations. Coherence, which was later described by Moss-Morris and colleagues10 to evaluate the ability of an individual to make sense of illness, refers to the individual’s understanding of illness. The Appendix includes a list of the attributes, attribute meanings, and sample items included in the Hypertension Representations Questionnaire.

Items on the Revised Illness Perception Questionnaire (all except for the identity items) mainly consisted of a 26-item, 5-point, Likert-type scale that ranged from 1 (strongly disagree) to 5 (strongly agree) and were scored by computing a mean across all items. Higher mean scores represent stronger hypertension representations of the concept’s subscale. Mean scores on timeline subscales indicate the perceived degree of chronicity of hypertension and whether hypertension was thought to be unpredictable or cyclical. On the identity subscale, participants responded “yes” or “no” when asked whether they had experienced a symptom recently and, if so, whether the symptom was related to their hypertension. The items on the identity subscale are scored by summing the “yes”-rated items. Higher scores on the identity subscale represent the belief that more symptoms are linked to hypertension. The identity subscale was scored differently because it included symptoms believed to be related to hypertension.

The control subscales’ mean score represents beliefs about the personal or treatment control of hypertension. Mean scores on the consequences subscale represent the perceived negative consequences of hypertension. The coherence mean subscale score represents the individual’s perceived personal understanding of hypertension. Mean scores on the emotional subscale represent stronger emotional responses to hypertension. Emotional responses about hypertension can either positively motivate health behaviors or negatively affect behavior when emotions are overwhelmingly experienced.8

The causal subscale was analyzed separately, because causal beliefs vary according to the illness or population being studied. Causes can be biological, emotional, environmental, or psychological.10 For this study, the 18 items of the cause subscale were subjected to principal components analysis with the emergence of 4 factors. These 4 factors are consistent with previous research as well as with the Common Sense Model. Each of the 4 factors was analyzed as separate subscales. Higher mean scores indicate a stronger perception of the subscale as being a cause of hypertension.

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Seven-Day Physical Activity Recall

The 7-Day Physical Activity Recall was used to measure exercise.18 An estimation of kilocalories was computed from the hours that the study participants spent performing physical activity of light, moderate, and hard intensities. Each category of activity is classified by its average energy expenditure and expressed in metabolic equivalents of task (METs). For this study, hours spent performing light, moderate, and hard activities during the prior 7 days were computed from women’s reported time spent at these levels of physical activity. Light activity hours equal the number of hours not spent performing moderate or hard activities. Moderate-intensity physical activity was defined as walking at a normal pace or as if going somewhere. Hard-intensity physical activity was defined as harder than walking but not as strenuous as running. For physical activity of moderate or hard intensity, the participants had to engage in the activity for at least 10 minutes during each portion of the day (morning, afternoon, and evening) for it to be recorded.18 Activities for each level of intensity over a 7-day period was multiplied by their respective MET values to yield mean weekly MET-hours (in kilocalories per kilogram). For example, 1 hour of each of the following activities was given the listed value: sleep = 1 MET, light activity = 1.5 METs, moderate activity = 4 METs, hard activity = 6 METs, and very hard activity = 10 METs. The 7-Day Physical Activity Recall is a well-validated scale that is administered by an interviewer in standard English.19 Sirard and colleagues20 showed evidence of validity for the Physical Activity Recall through a correlation (r) of 0.51 with the ActiGraph accelerometer, which directly measures physical activity.

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The Fruit and Vegetable Quick Food Scan

The Fruit and Vegetable Quick Food Scan (All-Day Screener), a 19-item questionnaire, measures frequency of usual intake of 10 categories of fruit and vegetables during the past day, week, or month. Computations of the All-Day Screener reflect the average daily fruit and vegetable servings for each food group based on the Food Guide Pyramid. Fruit and vegetable servings are scored by multiplying the participants’ frequency of intake by the participants’ assessed portion size. The total daily numbers of fruit and vegetable servings are estimated by summing the food group totals.21 The All-Day Screener was shown to be correlated with true intake (r = 0.66).22

Data on age, gender, marital status, education, ethnicity/race, current employment status, and pretax annual household income were collected. Blood pressure was measured with the use of the standard mercury sphygmomanometer and in accordance with the American Heart Association’s guidelines.23 All participants rested for at least 5 minutes before their blood pressure was measured. The average of 2 systolic and diastolic blood pressure readings taken 1 minute apart was recorded. The measurements were taken with the women in a seated position with their feet resting flat on the floor. Height and weight were measured without shoes or other heavy clothing with the use of a portable stadiometer and a portable digital scale. To ensure accuracy, the researcher checked the scale’s accuracy each time it was relocated by test weighing a 50-lb dumbbell. Measures of height and weight were used to calculate body mass index (in kilograms per meter squared).

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This study was approved by the university’s institutional review board. On designated Sundays, private locations in the churches were used to collect data. During church services, an announcement about the study was made as part of each church’s visually broadcast PowerPoint announcements, and the pastors encouraged participation in the study. Willing volunteers proceeded to designated locations after church services and were screened for eligibility. Those who were not able to complete data collection after church services arranged to meet for data collection at a time and place of their choice. After they were screened for eligibility, participants completed a Health Information Portability and Accountability Act form and the questionnaires and had their measurements taken.

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Data Analysis

Measures of central tendency, dispersion, frequency, and distribution were calculated using SPSS (Version 22 for Windows; Chicago, Illinois) to describe the sample and to check for violations of univariate and multivariate normality. Violations of normalcy were corrected as needed.

Relationships among timeline, identity, control, consequences, coherence, causes, and emotional representations were examined with Pearson correlations. Hierarchical multiple regression was used to assess the relationship between hypertension representations for subscale scores (ie, timeline acute/chronic, timeline cyclical, identity, control personal, control treatment, consequences, coherence, cause risks, cause environmental, cause lifestyle, cause psychological, and emotional) and outcome measures. Separate regressions were run for outcomes, physical activity scores, and fruit and vegetable intake. Age, income, and body mass index were used as covariates in the models. The order of entry of variables included in the regression was assigned on the basis of theoretical and logical reasoning.24

Before interpretation of regression results, residual scatterplots were inspected to further assess the assumptions of multivariate analyses. No deviations from normality, linearity, and homoscedasticity were identified, except on the 7-Day Physical Activity Recall, which showed evidence of skewness and kurtosis. Transformations were not conducted with the 7-Day Physical Activity Recall because low weekly energy expenditure scores were anticipated.

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Participant Characteristics

All of the women in this study (N = 204) were black and had self-reported hypertension. The women were 48.12 ± 10.3 years old. Most were married and employed, and 50% had college education. In this study, 43.6% of the women had systolic blood pressures of 140 mm Hg or greater, and 69.6% had diastolic blood pressures of 80 mm Hg or greater. The mean body mass index was 34.14 ± 8.00 kg/m2; 70.1% of the participants were classified as obese. Table 1 presents the demographic and physiological characteristics of the sample.



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Hypertension Representations

Table 2 shows Pearson correlations between hypertension representations and outcomes (physical activity and fruit/vegetable intake). Pearson correlations ranged from −0.17 to 0.16.



Table 3 provides the hypertension representations subscales and causal attributions, the number of items included for each subscale, Cronbach’s α, the score range, and the mean scores and SDs. Previous Cronbach’s α’s for chronic illnesses ranged from .79 to .89.9 For this study, Cronbach’s α’s (internal consistency) ranged from .54 to .92. The subscales with lower performance included personal control (.54) and treatment control (.62).



According to the participants’ mean subscale scores (range, 1–5) on the hypertension representation questionnaire, they perceived that hypertension was controllable with medical treatment (3.7 ± 0.7) and personal control (3.9 ± 0.9) and understood their illness quite well (coherence; 3.8 ± 0.9). The women overall had more neutral perceptions of the duration of hypertension, chronic versus acute timeline (2.6 ± 0.9), predictability (3.0 ± 0.8), consequences (2.7 ± 0.7) of hypertension, and emotional responses to hypertension (2.4 ± 0.7).

From principal components analysis of the causal subscale, 4 factors emerged and explained a total of 58.3% of the variance. These causal factors included the following: (1) risk factor, (2) psychological behavior, (3) environmental behavior, and (4) lifestyle behavior, which accounted for 30.2%, 13.5%, 8.6%, and 6% of the variance, respectively. The participants perceived that there were psychological causes (eg, stress, worry, family problems) of hypertension (3.4 ± 0.8). In addition, lifestyle factors (eg, personal behaviors, diet, or eating habits; [3.3 ± 0.9]), environmental factors (eg, pollution in the environment, chance or bad luck [2.4 ± 0.8]), and risk factors (eg, personality, alcohol, smoking [2.2 ± 0.8]) were also perceived causes of hypertension.

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Physical Activity and Fruit and Vegetable Intake

A measure of the participants’ total weekly hours spent performing moderate and hard physical activity was calculated. The weekly MET-hours were then calculated by multiplying the weekly hours spent at each physical activity level by that level’s respective MET-hours (moderate = 4, hard = 6). The mean hours per week and the total MET-hours per week spent performing moderate-intensity physical activity were 3.59 ± 7.1 and 14.4 ± 28.3 kcal/kg, respectively. The mean hours per week and the total MET-hours per week for high-intensity physical activity were 0.16 ± 0.8 and 0.98 ± 4.6 kcal/kg, respectively. The mean number of daily fruit and vegetable servings for the participants was 3.90 ± 3.22.

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Hypertension Representations Related to Physical activity and Fruit and Vegetable Intake

Regression results (Table 4) showed that perceiving hypertension as chronic (β = −.149; P = .05) and perceiving as having environmental causes (β = −.25, P = .05) were inversely related to moderate-intensity physical activity. Emotional representations (β = .23, P = .05) were significantly associated with moderate-intensity physical activity. There were no significant relationships between the hypertension representations and physical activity of high intensity.



Emotional representations and the presence of an emotional response to hypertension were the only significant measures associated with fruit and vegetable consumption (β = .28, P = .01).

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The goals of this study were 2-fold. First, the relationship between hypertension representations and moderate and high physical activity was explored. Second, we explored the relationship between hypertension representations and fruit and vegetable consumption. Hypertension representations found to be significantly associated with moderate-intensity physical activity included perceiving hypertension as chronic, caused by environmental factors and emotional responses to hypertension. Perceiving hypertension as chronic and caused by environmental factors negatively influenced moderate-intensity physical activity. Emotional representations or responses positively influenced moderate-intensity physical activity. The only hypertension representation found to be significantly associated with fruit and vegetable consumption was emotional representations.

To the researcher’s knowledge, this is the only study to explore relationships between hypertension representations and exercise by intensity as well as fruit and vegetable consumption among hypertensive black women. This substantiates the importance of understanding factors that influence lifestyle behaviors among them. Webb and Gonzalez13 found that black women perceived hypertension as an inevitable disease caused by their many psychological burdens and perceived hypertension to be serious, yet reported inactive lifestyles and diets that primarily consisted of unhealthy foods. Likewise, the women in this study were primarily inactive and overall did not consume the recommended 5 or more servings of fruit and vegetables each day. In addition, similar to the findings of Webb and Gonzalez,13 the women in this study perceived hypertension was caused by psychological factors but held more neutral hypertension representations of the seriousness of hypertension. Other researchers report that life stressors are associated with less self-management of hypertension.6,16 In this study, there was not a significant relationship between perceived psychological causes of hypertension and lifestyle behaviors; however, the women did perceive that there were psychological causes of their hypertension.

The results of this study add to our understanding of hypertension representations and self-management behaviors among black women. The least perceived cause of hypertension was lifestyle behaviors such as diet or eating habits in this study. Also, the women in this study engaged in less moderate intensity physical activity when they perceived that hypertension was chronic and caused by environmental factors. This may imply the women in this study were not motivated to change behaviors known to be beneficial to hypertension self-management. In addition, women with emotional responses to hypertension engaged in more moderate-intensity physical activity and consumed more fruit and vegetables. This may imply that some level of fear and anxiety about hypertension may lead to beneficial health behaviors. Emotional responses to illness can positively motivate behavior when emotions are not overwhelmingly experienced.8 It may also be implied that women who experience some level of emotions about their hypertension may be more aware of its seriousness or consequences and are more likely to engage in health behaviors.

Researchers report that blacks are less aware of the beneficial effects of lifestyle modifications and may consider their healthcare providers to be less concerned with controlling their blood pressures when lifestyle modifications are stressed.25 However, the women in this study were well educated overall and therefore may have some degree of understanding the beneficial effects of lifestyle modifications. In addition, women in this study perceived hypertension as controllable through medical and personal treatment, yet their physical activity and fruit/vegetable consumptions overall were low. This further implies that the women may be less motivated to change lifestyle behaviors. Other factors such as high stress levels or psychological factors, ineffective coping, not understanding the seriousness of hypertension, and lack of motivation to engage in physical activity and eat more fruit and vegetables may be more associated with the women in this study.

None of the hypertension representations were found to be statistically related to high-intensity physical activity. These findings were not surprising, because few participants engaged in high-intensity physical activity. This supports national findings of blacks being more sedentary and not meeting recommendations for physical activity.1

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This study is limited by its cross-sectional design, so causal relationships among variables cannot be implied. However, a cross-sectional design is adequate for exploring relationships before time-intensive and expensive intervention studies are performed. The convenience sample recruited from churches and a hair salon is potentially biased as a result of self-selection because the women who participated likely had similar traits; future research with a larger sample that includes participants from multiple sites and communities will increase the generalizability of results.26 Another limitation was the self-reporting of physician-diagnosed hypertension. A confirmed diagnosis of hypertension in future studies may be needed to ensure that the participants do indeed have hypertension. In this study, the mean systolic and diastolic blood pressures were 138.4 (SD, 14.9) mm Hg and 83.5 (SD, 9.9 mm Hg), respectively, which revealed that many of the women had high blood pressures despite having been prescribed antihypertensive medications. This supports their self-reported diagnosis of hypertension. More importantly, the women perceived that they had hypertension. Most women in this study were well educated, married, and employed, which further limits the generalizability of findings. National data reveal that lower educational attainment and socioeconomic status are associated with low levels of physical activity, less fruit and vegetable consumption, and obesity.1

In addition, it is important to note that the control subscale had low internal consistency, personal control (.54), and treatment control (.62). Low performance with personal and treatment control (.63 and .59, respectively) was also noted in a study by Pickett and colleagues.14 It has been suggested by the authors of the Illness Perception Questionnaire that more work is needed with the control items.10

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In this study, hypertension representations were associated with physical activity and fruit and vegetable consumption. These findings suggest that interventions to improve hypertension self-management may be more successful when they include strategies that seek to understand individual perceptions of hypertension, clarify misunderstandings of hypertension, improve stress coping skills, and motivate self-management of hypertension. The inclusion of each patient’s unique perceptions of hypertension in his/her treatment plans may lead to better control and health outcomes among patients.27 Clinicians can use the information presented here to support the incorporation of more individually tailored hypertension and behavioral counseling and education. More effort is needed to provide patient-centered care to address hypertension representations that may hinder self-management. Future research and interventions with larger sample sizes are needed to explore whether changing representations or perceptions of hypertension can lead to long-term self-management of disease and reduce the public health burden of hypertension in blacks.

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Implications for Practice

Findings of this study do have clinical implications. Clinicians should include an assessment of hypertension representations in treatment plans, especially for patients with uncontrolled hypertension. Then, efforts to clarify misunderstandings of hypertension or reframe negative perceptions should be initiated. Clinicians should also assess patients’ perceived emotional responses to hypertension and offer ways to cope with more negative emotions such as overwhelming fear or anxiety. For example, cognitive and behavioral interventions may be used to empower patients to modify health behaviors such as physical activity and diet that are known to be beneficial to health. Interventions that offer ways to cope with environmental or stressful life situations may be more accepting to blacks. Motivational interviewing, a form of health coaching,28 may be an attractive behavioral counseling approach to motivate black women to engage in health behaviors known to be beneficial to self-management of hypertension.

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What’s New and Important

  • Perceiving that hypertension is chronic and caused by environmental factors was associated with less moderate-intensity physical activity in hypertensive Black women.
  • Emotional representations or responses to hypertension such as fear or anxiety were positively associated with moderate-intensity physical activity and consuming more fruit and vegetables.
  • Efforts to assess hypertension perceptions and clarify misunderstandings of hypertension are needed, especially among patients with uncontrolled hypertension.
  • Black women with hypertension strongly perceived psychological causes of hypertension. Hypertension treatment recommendations and interventions to improve blood pressure control may be more effective if they included strategies to improve coping with stressors of life.
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black women; diet; hypertension; perceptions; physical activity

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