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

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

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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).

18 J Community Health (2012) 37:15–24

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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

J Community Health (2012) 37:15–24 19

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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

20 J Community Health (2012) 37:15–24

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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

Unadjusted PR (95% CI) 1.64 (1.07–2.20) 1.00 (Referent)

Adjusted PR (95% CI) N/A N/A

Physical activity adherence

Unadjusted PR (95% CI) 1.27 (1.08–1.39) 1.00 (Referent)

Adjusted PR (95% CI) N/A N/A

Non-smoking

Unadjusted PR (95% CI) 1.10 (1.01–1.15) 1.00 (Referent)

Adjusted PR (95% CI) N/A 1.00 (Referent)

Alcohol abstinence

Unadjusted PR (95% CI) 1.08 (0.87–1.23) 1.00 (Referent)

Adjusted PR (95% CI) b

1.05 (0.81–1.21) 1.00 (Referent)

Weight management adherence

Unadjusted PR (95% CI) 1.63 (1.30–1.87) 1.00 (Referent)

Adjusted PR (95% CI) N/A N/A

J Community Health (2012) 37:15–24 21

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

22 J Community Health (2012) 37:15–24

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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