For the 24 '/2 million persons 65 years and older who are afflicted with hypertension, adherence to a medical regimen for the control of hypertension reduces the risks of concomitants such as coronary heart disease, cerebrovascular disease, and renal disease. Lack of compliance with a medical regimen is a major problem among clients with hypertension in all age groups because the condition is asymptomatic and the regimen is permanent.
Older individuals who have physical, psychological, or social limitations, such as impediments in hearing or eyesight, mental confusion, or if they are living alone, may have special problems with compliance. In addition, common misconceptions about old age, such as the belief that it brings loss of control over mind and body, may preclude involving the elderly in health education programs.
The recognition and identification of factors involved in compliance with medical treatment for individuals with hypertension form the basis for designing programs to foster increased compliance among those clients.1 The literature indicates that studies are needed to determine the factors that interfere with compliance to a medical regimen, a measure frequently utilized by researchers studying the outcomes of health education programs.
The purpose of this study was to examine the relationship between the self-reported compliance behaviors of elderly individuals having hypertension, to understand the extent of their knowledge about hypertension, and to establish baseline demographic variables. Specifically, this study sought to answer the following questions:
1. What is the extent of knowledge concerning hypertension in a group of elderly individuals with hypertension;
2. What are the degrees of compliance to hypertension regimens reported by elderly individuals with hypertension;
3. What is the relationship between the extent of knowledge concerning hypertension and the degree of compliance with a medical regimen reported by elderly individuals with hypertension;
4. Does degree of compliance to a medical regimen reported by elderly individuals with hypertension vary according to baseline demographic variables?
Baldini2 suggested that health care providers' inefficiency in instructing or communicating with elderly hypertensive clients "could be responsible for the lack of success in controlling hypertension. " However, a review of the studies that explored the relation between knowledge and\x)mpliance with a medical regimen reveals conflicting results. It is not at all clear whether there is a relation between compliance with a medical regimen and knowledge of disease, age, or even multiple disorders.
Green, Levine, Wolle, and Deeds found the correlation between knowledge and compliance was negligible and even slightly negative in persons (average age 55 years) having hypertension.3 Likewise, Kirscht and Rosenstock, using the Health Belief Model, reported that knowledge about high blood pressure was unrelated to compliance among 132 subjects having hypertension.4 Those having such knowledge were no more likely to comply with a medical regimen than were those without such knowledge. Bille found no relation between knowledge and compliance among elderly heart attack patients: although older patients were less likely to achieve a high score on the knowledge test, they were more likely to follow medical regimens.5
Conversely, Given. Given, and Simoni, in their sample ranging in age from 20 to 89 years, found a statistically significant relationship between the combined independent variables, diagnosis and compliance, and the dependent variable, knowledge.6 However, Kelman7 found that persons comply, or accept influence, when they want a favorable reaction from another person.7 This is especially the case, as Newcomb, Turner, and Converse found, if the person, or influencing agent, has skill, experience, and sophistication.8 As emphasized by Given et al, there is little evidence to suggest what effect health care professionals have on change in patient outcome.6
Both Given et al and Kirscht and Rosenstock suggested that knowledge was important as a means of achieving understanding and awareness of risks of noncompliance, and benefits of compliance. Such risks and benefits, according to Kirscht and Rosenstock, encompass one's belief in the severity of the disease and one's vulnerability, in the negative impact of the disease, in the effectiveness of compliance, and in the benefits outweighing the economic, social, and personal costs of compliance.
Although Bille found that older persons were more likely to comply with a medical regimen, Fletcher, Fletcher, Thomas, and Hammann found that age had a weak inverse association with knowledge.9 Furthermore, Fletcher et al found among their 143 elderly subjects, whose average age was 63 years, that as the amount of available knowledge increased, patients' knowledge about medical care decreased.
In general, studies of compliance with medical regimens have used different approaches, methods, and tools to measure knowledge and compliance of samples having varying ranges in age and differing diagnoses.
Operational Definitions - For the purpose of this study, the following definitions were used:
Hypertension. Blood pressure levels of 160 mm Hg systolic and/or 95 mm Hg diastolic or higher.
Elderly. Persons who identified themselves as age 65 years and older.
Compliance. Adherence to a medical regimen. In this study, compliance is represented by the score on the compliance questionnaire. Scores of 0-3 are rated as "low," 4-5 as "medium," and 6 as "high" compliance.
Degree of Compliance. Unit of compliance measurement.
Knowledge. The fact or state of knowing; clear and certain perception of fact or truth. In this study, knowledge is measured by scores on the knowledge questionnaire. Range of scores was 0-16.
Sample - The sample was composed of all elderly individuals who voluntarily attended blood pressure screening clinics at two southwestern senior centers during a four- week period. The sample included 93 individuals who met the following criteria:
1 . Age 65 years or older;
2. Currently under medical treatment for hypertension.
Data Collection - Data were collected using a compliance scale (C-scale), a general knowledge of Hypertension (Kscale), and a demographic questionnaire.
The patient-reported C-scale was first used by Green et al. (1975) to determine the kinds of education needed by staff and patients at Johns Hopkins University. This scale consists of six questions about taking medications, following a doctor's advice, and keeping appointments.
The K-scale is a 16-item scale with questions about heredity, weight, exercise, smoking, diet, medication, and the relationship of high blood pressure to other diseases.
The demographic questionnaire identified the variables of age, medical treatment status, sex, race, and marital status. Other variables in the questionnaire included education, occupation, and other illnesses of the respondent.
Results - A large majority (69%) of the respondents were female. The subjects' ages ranged from 65- 100 years with an average age of 73 years. A large majority (95%) of the respondents were white, and a majority of subjects (53%) were married. The latter percentage included 27 (42%) of the 64 women and 19 (76%) of the 25 men in the sample.
Many of the participants in this study had completed at least two years of high school (46%). The remainder of the subjects were divided between an elementary school or college education.
Four of the subjects, one of whom was 100 years of age, reported no formal schooling.
Almost all the subjects (93%) were retired from the work force; however, approximately 25% pursued some kind of volunteer work. All of the respondents were currently under treatment for hypertension and the prescribed regimens, as reported by the subjects, consisted of either medication, diet, exercise, or relaxation, or a combination of these treatments. Almost all (96%) of the subjects reported taking medications or medications in combination with diet and exercise. Thirtyeight (41%) of the respondents in the study also reported taking medicines for illnesses other than hypertension.
Knowledge questionnaire - The subjects' responses to the K-scale were analyzed descriptively. Respondents were directed to select one of the following responses to each item: true, false, or not sure. The latter choice was scored as an incorrect response. The total number of possible correct responses was 16. Results indicated that the distribution of scores was skewed and ranged from 5-16. The largest group of respondents (n = 20) achieved a score of 13. Analysis also revealed a mean score of 1 1 .63, which represented a 73% correct response rate, and a standard deviation of 2.62.
Items 1-10 on the knowledge questionnaire (Figure 1 ) were answered correctly by at least 60% of the respondents. Those items not answered correctly by a majority of the respondents were Items Il and 15. Sixty-three (68%) subjects did not know that some people feel worse when first beginning medications for hypertension and 54 (58%) of the respondents did not know that heredity may affect blood pressure.
The remaining fouf items on the knowledge questionnaire were answered correctly by a majority (58%) of the subjects in the sample.
Compliance Questionnaire - Analysis of the responses to the C-scale revealed that 81 subjects scored either high (score of 6) or medium (scores of 4 or 5) compliance and the remainder of the subjects scored low compliance (scores 0-3) or did not answer. The mean compliance score was 5.01 with a standard deviation of 1.48.
The highest percentage (33%) of non-compliance was reported for Item 1 of the questionnaire, which indicated that 31 subjects sometimes forgot to take medications for high blood pressure. However, the responses to the remaining items revealed that 85-90% of the sample group anwered "no," indicating a high degree of compliance.
Other results were as follows: No relationship was found between subjects' scores on the K- and C-scale questionnaires. However, significant inverse relationships were found between age of the subjects, number of years in retirement and degree of compliance to a hypertension regime. Further, subjects who attended high school, college, or graduate school had compliance scores significantly higher than those of subjects who had less than a, high school education. The variables of sex, marital status, volunteer status, and taking multiple medications for various disorders were not found to be significant in relation to compliance with a medical regimen for hypertension. (More detailed information about the results may be obtained by contacting the authors).
The results revealed that only a small majority of the respondents scored above the average on the K-scale despite the fact that all the respondents were undergoing treatment for their disease. However, two of the items, on which a majority scored below the average, concerned facts that health care personnel supervising treatment might not have stressed, or that the client might have forgotten.
Of the sample, 68% did not know that some persons feel worse when first beginning medications for hypertension. Without having experienced such worsening or having friends or family members who experienced it, most persons might tend to forget this fact even if health care personnel stressed it.
Fifty-eight percent did not know that heredity may affect blood pressure. In taking family histories, health care personnel might not state the possible relationship between a parent's history and a client's possible risk. It may be, however, that a number of respondents misinterpreted the item. Rather than considering the item to be a statement about the hereditary nature of hypertension, many respondents related the item to their own family history, stating that they did not know whether their parents had hypertension. Awareness that their disease may be hereditary might impress the clients that treatment is lifelong and that noncompliance incurs serious risks. Generally, however, the data indicated that among those elderly persons being treated for hypertension, knowledge is generally high except in the two aforementioned areas.
Responses to the C-scale generally indicated high compliance. Such selfreported high compliance may, as Marston stated, reflect an overestimation of compliance behavior.10 However, during data collection, several respondents stated that they always followed doctor's orders because "that is what he told me to do." Such a response supports the findings of Newcomb et al that compliance is an interpersonal response sequence aimed at complying with the perceived wishes of another person, especially if that person has skill, experience, and sophistication.
That 33% of an otherwise highly compliant sample sometimes forgot to take the prescribed medication indicates that health care providers need to devote some effort to helping elderly clients devise medication-taking routines that will reduce forgetfulness.
Although a majority of the respondents demonstrated a high level of knowledge and high compliance, statistical analysis revealed an insignificant correlation between knowledge and compliance.
The findings also revealed that compliance varied according to education: those with at least a high school education were more compliant than were those with no formal education or only an elementary school education. Furthermore, statistical analysis revealed that those respondents who attended high school or college were more knowledgeable about blood pressure than were those who had not.
The present study also found an inverse relationship between compliance and age: the older the individual, the less compliant. This finding does not support Bille's finding that older the individual, the more compliant. However, the ages of Bille's subjects ranged from 32 to 75 years, and the ages of the subjects of the present study ranged from 65 to 100 years. To resolve this discrepancy, future studies should focus on elderly populations to determine whether compliance decreases after age 75.
Future studies also need to determine the specifics of "sometimes" forgetful in taking medicine. For example, respondents could have been forgetful once a week, month, or year, a difference which may have influenced the discrepancy between this study and Bille's.
The findings of the present study did not support those of Lane and Evans that compliance was lower in the elderly due to multiple disorders, which tended to confuse the elderly. The present study found no significant difference in compliance between those taking medication only for hypertension and those taking additional medication. This area needs study.
Nurses need to be aware that the extent of the elderly client's knowledge about hypertension does not necessarily indicate the client's degree of compliance. They should also be aware that level of education may be one indicator of an elderly client's degree of compliance. Elderly clients having less than a high school education may need more thorough and frequent explanations.
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