Research paper Blacks managing high blood pressure while maintaining a quality lifestyle

© 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% If high blood pressure is caused by the environment/ behavioral factors, is physical activity effective in lowering

high blood pressure? 73% 8% 16% If high blood pressure is caused by the environment/ 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%

263Campbell, Rodríguez, Nowakowski, and Gotrace

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

265Campbell, Rodríguez, Nowakowski, and Gotrace

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.

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