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The Relationship Among Health Beliefs, Depressive Symptoms, Medication Adherence, and Social Support in African Americans With Hypertension

Spikes, Telisa, MSN, RN; Higgins, Melinda, PhD; Quyyumi, Arshed, MD, FACC, FRCP; Reilly, Carolyn, PhD, RN, CHFN, FAHA; Pemu, Pricilla, MD, MSCR, FACP; Dunbar, Sandra, PhD, RN, FAAN, FAHA, FPCNA

doi: 10.1097/JCN.0000000000000519
ARTICLES: Depression

Background: African Americans are disproportionately affected by hypertension and have lower medication adherence when compared to other racial groups. Antecedent factors such as beliefs surrounding hypertension, the presence or absence of social support, and depressive symptoms have not been extensively studied collectively in relation to hypertension medication adherence in African Americans.

Objective: To determine the associations among demographic and clinical factors, depressive symptoms, hypertension beliefs, and social support with blood pressure medication adherence in middle-aged African American adults with a diagnosis of hypertension.

Methods: A cross-sectional study of (N = 120) African Americans (mean age, 49 years; 22.5% men) with a current diagnosis of metabolic syndrome, including hypertension, who reported having and taking a prescribed blood pressure–lowering medication were included. Descriptive statistics, bivariate correlation analysis, and logistic regression using odds ratio were used to examine the effects of high blood pressure beliefs, social support, and depression on medication adherence.

Results: A small but significant relationship was found between medication adherence and number of comorbidities (r = 0.19, P = .04). In a multivariate regression model, after controlling for gender, comorbidities remained associated with medication adherence (β = 0. 77, P = .04). Depressive symptoms, high blood pressure beliefs, and social support did not have a significant relationship with medication adherence.

Conclusions: Multiple comorbidities may have a positive impact upon medication adherence. Further study is needed in a larger sample of African Americans who have a diagnosis of hypertension in addition to other comorbidities requiring medication management.

Telisa Spikes, MSN, RN Predoctoral Fellow, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia.

Melinda Higgins, PhD Associate Research Professor, Biostatistics, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia.

Arshed Quyyumi, MD, FACC, FRCP Professor of Medicine, Division of Cardiology, Emory Clinical Cardiovascular Research Institute, Emory University, Atlanta, Georgia.

Carolyn Reilly, PhD, RN, CHFN, FAHA Associate Clinical Professor, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia.

Pricilla Pemu, MD, MSCR, FACP Professor, Morehouse School of Medicine, Atlanta, Georgia.

Sandra Dunbar, PhD, RN, FAAN, FAHA, FPCNA Professor and Associate Dean for Academic Advancement, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia.

This study was supported by the National Heart, Lung, and Blood Institute (NIH; 1 U01 HL079156-01; Dr Quyyumi, PI); PHS Grant UL1 RR025008 from the Clinical and Translational Science Award program, NIH, NCRR; and grant 5P20RR11104 from the NIH, National Center for Research Resources for the Morehouse Clinical Research Center. Effort for T. Spikes was funded in part by the National Institutes of Health National Institute of Nursing Research grant number T32NR012715 (PI, S. Dunbar). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

The authors have no conflicts of interest to disclose.

Correspondence Telisa Spikes, MSN, RN, Nell Hodgson Woodruff School of Nursing, Emory University, 1520 Clifton Rd, NE Atlanta, GA 30322-4027 (

Hypertension, a leading and modifiable risk factor for the development of cardiovascular disease, continues to remain a public health priority.1,2 In the United States, hypertension is estimated to affect approximately 85.7 million Americans or roughly 46% of the population.3,4 Hypertension continues to affect both African American men and women disproportionately when compared with whites or other ethnic minority groups in the United States.4,5 African American women have the highest prevalence of hypertension (46.3%), followed by African American men (45%), when compared with white men (34.5%) and women (32.3%); however,3,4 with the new hypertension guideline change (systolic blood pressure ≥ 130/80), the prevalence rates are expected to increase. This change estimates the prevalence of hypertension between African American men and women to increase to 59% and 56% and between white men and women to increase to 47% and 41%, respectively.6

Evidence suggests that African Americans tend to hold a differing set of beliefs surrounding the cause and control dimensions of hypertension when compared with other ethnic groups.7,8 Common themes surrounding hypertension beliefs expressed by African Americans include hypertension as a symptomatic illness manifested by headaches, an illness derived by adverse social stressors of discrimination and racism, and the belief that all blacks are diagnosed with high blood pressure.9–11 These beliefs tend to be in conflict with those of health providers, which further creates obstacles in achieving optimal medication adherence and blood pressure control.

Low to inconsistent adherence practices to prescribed blood pressure medications, discordant health beliefs, depressive symptoms, and lack of social support have each been identified as a contributing factor associated with poor hypertension control in both the general population and African Americans7,12–16; however, the underlying contributors of stressors that are experienced by African Americans, such as being of a minority status and social inequities, are what differentiates their high risk for poor hypertension control when compared with whites.16,17 These stressors have been associated with greater depressive symptoms in African Americans; albeit, the link from psychosocial factors to blood pressure medication adherence is not distinctively clear.12,17 Similar to depressive symptoms, the relationship of social support with medication adherence has yielded inconsistent findings and has been considered a weak influence of medication adherence in African Americans.8,18,19

Hypertension is also one of the most important components of metabolic syndrome, a cluster of three of the following five health problems: hypertension, fasting blood glucose over 100 mg/dL, hyperlipidemia, elevated waist circumference, and reduced high-density lipoprotein of less than 40 mg/dL in men and less than 50 mg/dL in women.20 The mechanism linking hypertension and insulin resistance is not clearly understood,21 yet it has been suggested that masked hypertension (having hypertension based on out-of-clinic blood pressure measurements without hypertension based on clinic blood pressure measurements) is associated with increased end-organ damage and risk for cardiovascular disease.22 Compared with other racial groups, African Americans tend to develop hypertension at earlier ages, further increasing the potential for the development of cardiovascular disease, stroke, kidney disease, heart failure, and early mortality.2,5,23–25

The research question proposed for this study was “What effect do social support, hypertension health beliefs, and depressive symptoms have on hypertension medication adherence in a sample of African Americans with metabolic syndrome and hypertension as one of the components?” The purpose of this secondary data analysis is to determine the associations among depressive symptoms, hypertension beliefs, social support, and blood pressure medication adherence in middle-aged African American adults with a diagnosis of hypertension.

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Conceptual Model

Components of the Health Belief Model and social network/social support model were used to guide this secondary data analysis. Elements from both models were incorporated into the original study design. These models provide the framework to conceptualize key constructs associated with medication adherence. Unlike the Health Belief Model, the social network/social support model is not considered a single theory but instead a model used to explain and identify the linkages that may or may not provide social support, thus influencing health behaviors.26 The Health Belief Model is an individual behavioral theory that seeks to explain why people will take action to prevent, screen, or control illness conditions.27 The individual antecedent factors proposed to be related to medication adherence included age, gender, social support, and socioeconomic status. Individual belief factors of the Health Belief Model that were examined include perceived severity and susceptibility to high blood pressure. Cues to action include actions or behaviors to reduce high blood pressure susceptibility.

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Poor Medication Adherence

Poor adherence to prescribed antihypertensive treatment is a significant patient-related barrier that contributes to worse cardiovascular disease outcomes in African Americans.28 Medication nonadherence is defined as the patient's passive failure to follow a prescribed regimen.29,30 Addressing poor medication adherence is a challenging and daunting task for clinician providers managing hypertension among other various chronic conditions.31 Rates of medication nonadherence in the general population are estimated to range anywhere from 9% to 37%, with an estimated 27% to 66% of patients discontinuing their antihypertensive medications after 1 year.32,33 It is important to note that numerous studies have shown that, when blood pressure-lowering medications are taken, they are effective.34–36 The implications from nonadherence to blood pressure-lowering medications are not only fatal to an individual's health but also costly. The combined direct ($68 billion) and indirect ($42 billion) cost of hypertension in the United States is an estimated $110 billion dollars.37 This figure includes cost associated with healthcare services, medications, and missed days from work. Improving medication adherence is argued to yield greater health benefits than any other improvements in medical interventions; however, due to various research studies relating to the causes of medication nonadherence, studies have often yielded contradictory and inconclusive results, thus adding another layer of complexity into addressing this problem.38

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Hypertension Illness Beliefs

Discordant health beliefs regarding high blood pressure is a common finding across various ethnic groups.7 Across various studies, evidence indicates that African Americans belief's regarding high blood pressure tend to differ quite significantly from those of healthcare providers, which may give credence to the growing hypertension disparity.7,39 Older African Americans frequently conceptualize hypertension as a condition that “causes blood to rush to the head due to an intense emotional state” and a disease that thickens the blood because of genetics.7 Many African Americans attribute their hypertension diagnosis as a stress-related model of illness stemming from the social hardships in which they are exposed including poverty, pollution, and racism.39 Unfortunately, in the absence of symptoms and the presence of cultural lay models of illness interpretation, management of hypertension presents many challenges.40

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Depressive Symptoms and Social Support

Adverse psychosocial factors serve as another important, yet often unrecognized patient-related barrier in achieving blood pressure control and optimal medication adherence practices. Depressive symptoms are more common in African Americans, other ethnic minority groups, and women.35 Depression is associated with many chronic diseases and has been referred as the unrecognized risk factor of both poor medication adherence and cardiovascular disease.13,41 Repeated stressors in African Americans related to racial and ethnic discrimination and social inequity have been associated with increased depressive symptoms, earlier onset of chronic illness, increased risk of cardiovascular disease, and poor self-ratings of health.13,42–44 The coping responses employed by African Americans to manage these adverse stressors have also been shown to have a deleterious effect on health. For instance, African American men who exhibited depressive symptoms were found to consume higher amounts of alcohol and demonstrate poorer antihypertensive medication adherence practices.45 Likewise, African American women who did not manage their response to adverse stressors had greater depressive symptoms compared to women who demonstrated increased active coping efforts.13

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In this cross-sectional study, N = 120 African American participants with a current diagnosis of metabolic syndrome, including hypertension as one of the components, who reported having a prescribed high blood pressure–lowering medication for blood pressure control were analyzed for this study. Secondary data analysis for this study was performed using baseline data from an existing database derived from the META-Health study. META-Health was a collaborative intervention study consisting of an intervention and control arm with multiple aims designed to examine the racial disparities in African Americans with metabolic syndrome at risk for cardiovascular events. Institutional review board approval was obtained for the original study prior to any data collection. All participants signed written informed consent forms. Inclusion criteria for the original study included (a) African American participants with a diagnosis of metabolic syndrome, (b) 18 years and older who met at least 2 clinical indicators of cardiovascular risk criteria (elevated triglycerides ≥ 150 mg/dL, waist circumference > 102 cm for men or > 88 cm for women, high-density lipoprotein cholesterol ≤ 40 mg/dL for men or < 50 mg/dL for women), (c) fasting blood glucose ≥ 100 mg/dL or greater, and (d) being on a stable medication regimen for at least 3 months. Participants were recruited from various community practice networks that include a socioeconomically diverse group of predominantly African American patients with an estimated 300 000 patient visits annually, located in a southeastern metropolitan city.

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Demographic data were collected to describe the sample including gender, age, income, marital status, children, and education. In addition, blood pressure, body mass index, and number of comorbidities were measured. The measures that will be examined were selected based on the theoretical framework underpinning this analysis.

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Medication Adherence

The outcome variable medication adherence, was measured using the Hill-Bone Compliance to High Blood Pressure Therapy Scale. The scale was formulated for use in a hypertensive African American male population but has been used successfully in both African American men and women with a diagnosis of hypertension.13,16,46,47 The Hill-Bone consists of 3 subscales including reduced sodium intake, appointment keeping, and medication taking.48 This study will only examine the medication-taking subscale scores. The total scale and medication taking subscale has Cronbach’s α value of .71 and .75.48–50 Item responses are scored on a 4-point Likert scale ranging from 1 to 22, with lower scores reflective of better medication adherence behaviors.

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Beliefs Related to High Blood Pressure in African Americans Scale

Hypertension beliefs will be measured using 3 subscales from the Beliefs related to High Blood Pressure in African Americans Scale.49 Of the 7 subscales, the 3 subscales used for this study include perceived susceptibility to high blood pressure, actions to reduce high blood pressure susceptibility, and perceived seriousness of high blood pressure. Items are scored on a 5-point Likert scale, with higher scores on the Beliefs Related to High Blood Pressure in African Americans subscales indicative of higher perceived susceptibility to hypertension, actions to reduce susceptibility to hypertension, and perceived seriousness of hypertension. The instrument has an acceptable level of reliability with a Cronbach’s α value of .84 when used in a pilot study of African American participants.49

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Enhancing Recovery in Coronary Heart Disease Social Support Inventory

Social support was measured using the Enhancing Recovery in Coronary Heart Disease Social Support Inventory; a 7-item self-report survey that measures social support and has been used in a variety of chronic diseases. The tool consists of 4 domains of social support: emotional, instrumental, informational, and appraisal with scores higher than 18 indicative of high social support.51 The tool has been well validated in cardiac patient populations.51

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Beck Depression Index

Depression was measured using the Beck Depression Index, a 21-item self-report inventory that measures attitudes and symptoms of depression.52 The Beck Depression Inventory has been used in a variety of patient populations and has demonstrated a high internal consistency, with α coefficients ranging from .81 to .86.52 Higher scores reflect greater depressive symptoms. The recommended cutoff score for mild depressive symptoms of the Beck Depression Inventory is 14.53

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Statistical Analysis

Data were analyzed using Stata/SE version 14.2. Descriptive statistics including percentage and frequency were used to summarize categorical measures and mean, standard deviation, minimum and maximum were used to summarize continuous measures. Bivariate correlations were also used and examined. Logistic regression using odds ratio was used to examine the odds of high blood pressure beliefs, social support, and depression on medication adherence. The outcome variable, adherence, was dichotomized into adherent or nonadherent using cut-point scores from the Hill-Bone Compliance to High Blood Pressure Therapy Scale. Adherence was entered into the model along with predictors (high blood pressure beliefs, social support, and depression), in addition to the covariates (age, education, gender, income, insurance, marital status, and number of comorbidities). In addition to the components of metabolic syndrome, the comorbidity variable was computed by creating a dummy variable based on participants self-reported comorbid conditions including arthritis, asthma, cancer, fasting blood glucose of greater than 100 mg/dL, elevated cholesterol, glaucoma, and irritable bowel syndrome. Multicollinearity was examined by checking model statistics, specifically variance inflation factors. A 2-tailed P value of less than or equal to .05 was considered statistically significant.

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Participant Characteristics and Demographics

Table 1 describes the demographic and clinical characteristics of the study sample. The mean (SD) age of the 120 study participants were 49.9 ± (8.6) years, with 77% of the study's participants being female. The baseline mean (SD) systolic and diastolic blood pressure was 128 ± (14) and 80 ± (10), and 54% of the sample had some other comorbidity in addition to hypertension. The majority of the sample was obese (82.5%) and overweight (11%). The sample was well educated, with 72% having a college education; 74% were employed full-time; and 62.5% reported an annual income of $40 000 or more. The mean time since diagnosis (or living) with hypertension was 9 years.



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Study Measures

Based on the sample mean scores for the Hill-Bone (median, 11.7; SD, 3.5), and dichotomizing scores less than or equal to 13 as non-adherent from the Hill-Bone, approximately 37.5% of the sample (n = 45) was considered nonadherent to their hypertension medication. Majority of the sample indicated a relatively high level of social support on the Enhancing Recovery in Coronary Heart Disease Social Support Index, with 93% of the participants reporting scores of 18 or greater. Using cut-point scores for the Beck Depression Inventory (median, 8.2; SD, 8.3), 17.5% of the sample (n = 21) had scores greater than 20, well above the recommended cut score of 14, indicating moderate depression. The mean (SD) scores for the High Blood Pressure Beliefs subscales were as follow: Perceived susceptibility to high blood pressure, 14.3 ± (4.8); actions to reduce high blood pressure, 15.7 ± (3.9); and perceived seriousness of high blood pressure, 21 ± (5.5), indicating a greater perception of the risk associated with hypertension and the necessary actions required to decrease high blood pressure.

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Bivariate Analysis

Table 2 provides the Pearson correlation matrix on possible associations of medication adherence. Adherence and comorbidities were positively correlated. A χ2 test of independence was performed to examine the relationship between adherence and comorbidities. The relationship between these two variables were significant, χ2(1,N = 120) = 4.85, P < .03. The hypertension beliefs subscale components of perceived susceptibility (r = 0.36, P ≤ .01) and actions to reduce susceptibility and perceived seriousness (r = 0.35, P ≤ .01) were correlated with one another. Age was positively correlated with perceived susceptibility to high blood pressure (r = 0.32, P ≤ .01) and inversely correlated with the total HB medication scale score (r = −0.19, P .04). Depression was inversely associated with social support (r = −0.48, P ≤ .01); however, there was not a significant relationship with adherence status.



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Multivariate Logistic Regression

Table 3 provides the results from the multivariable regression of medication adherence. Comorbidities were the only covariate that remained significant once entered into the regression model with adherence. The odds of adherence with blood pressure medications are 2.63 times greater for persons with multiple comorbidities than someone with less comorbidities in addition to metabolic syndrome. When gender was added to the model, males as the referent group, comorbidities remained significant (β = 0.95, P = .03). Due to concerns of multicollinearity, confirmed by high variance inflation factors (Table 4) for each of the 3 high blood pressure beliefs subscales, each scale was entered into the model separately for its effect on adherence. None of the scales had a significant relationship with adherence. Social support and depressive symptoms were entered both together and separately into the model for their effect on adherence, but neither was significant. Covariates including age, gender, year of hypertension diagnosis, and income were each entered into the model for their effect on medication adherence, but were not associated in this sample.



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This secondary analysis was conducted to identify the predictors of medication adherence in a population of African American men and women diagnosed with hypertension. In this study, majority of the participants reported lower medication adherence scores, indicating better adherence. Prior studies using the Hill-Bone Compliance to High Blood Pressure Therapy medication subscale in women reported similar mean scores as reflected in this study.13,47 Neither of the sociodemographic covariates had a significant effect on adherence; however, majority of the participants were college educated and employed, which may have had a protective effect in contributing to increased health literacy and improved access to care. This relationship can only be speculated as access to care and health literacy were not measured in the original study or this secondary analysis. A significant yet atypical finding in this study was the positive relationship between medication adherence and multiple comorbidities. Having multiple comorbidities has been known to contribute to worse adherence due to issues such as increasing out-of-pocket prescription cost, complexity of the medication regimen, and distrust of the pharmaceutical and healthcare system.5,54–56



The majority of the participants in this study were predominantly female, college educated, employed, reported an annual income of $40 000 or more; and had high self-reported medication adherence. Characteristics of younger age and female gender have been associated with worse medication adherence behaviors compared to men.5,56,57 These differences have been attributed to the idea that women may demonstrate lower levels or worse medication adherence due to subordinating their health priorities for more demanding priorities and caregiving roles.31,58

Many participants in this study had strong beliefs regarding the dimensions of perceived susceptibility, actions to reduce susceptibility, and perceived seriousness to high blood pressure. Although the relationship between high blood pressure beliefs and adherence was not significant in this study, the impact of belief systems regarding high blood pressure and decision making has been reported to have an effect on medication adherence.59,60

Neither social support nor depression had an effect of medication adherence. The majority of participants in this study reported high rates of social support and lower depressive symptom scores, suggesting that their social network system was adequate.

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This study had a few limitations that need to be acknowledged. Important key factors such as high blood pressure beliefs, depression, and social support did not show statistical significance with medication adherence as other studies have demonstrated; potentially, this could be due to the fact that there was not enough variability in the participants' scores for each variable tested. The findings from this study may be limited in generalizability across all African Americans with hypertension because most of the participants were of a higher socioeconomic status and female. Prior adherence studies involving African Americans tend to be less representative of higher sociodemographic participants,5,13,57 although gender and education have been considered weak and inconsistent predictors of medication adherence.55,61 Another limitation is the small sample size and the potential inability to detect a difference. Using self-reported data on the key measures examined in this study is a source of bias and could lead to fear of judgment resulting in an overexaggerated or underexaggerated response.

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African Americans have higher rates of morbidity and mortality as a result of poorly controlled cardiovascular risk factors. The results from this study further add to the existing body of literature surrounding factors that predict hypertension medication adherence among a vulnerable population. This study can provide important and beneficial information regarding the role that multiple comorbidities have in achieving medication adherence. Examining the relationship of multiple comorbidities and their effect on medication adherence in a population that is disproportionately affected by cardiovascular disease is a crucial area of focus.

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What’s New and Important?
  • Multiple comorbidities have a positive effect on hypertension medication adherence.
  • There is a need to explore the role that multiple comorbidities have in facilitating medication adherence despite the assumption that more comorbidities equates to worse medication adherence.
  • Examining the influence of hypertension beliefs and social factors on medication adherence may contribute to identifying areas where culturally targeted interventions may be appropriate.
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African Americans; hypertension; hypertension beliefs; medication adherence

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