Journal of Gerontological Nursing

Feature Article 

Medication Adherence and Spiritual Perspectives Among African American Older Women with Hypertension: A Qualitative Study

Lisa M. Lewis, PhD, RN

Abstract

The purpose of this qualitative study was to explore how African American older adults use spirituality to adhere to their antihypertensive medications. Data collection included in-depth individual interviews with 21 older African American women. Content analysis revealed five themes: The Lord Helps Those Who Help Themselves; Staying in the Lord for Guidance; God Is My Rock; Guardian Angels and Saints; and Brings Me Peace, Ease of Burdens, and Ability to Cope. Findings of this study suggest that spirituality is perceived as a positive resource that helps study participants adhere to their antihypertensive medication regimen. Possible faith-based interventions for nurses and other health care professionals to use with their patients are discussed.

Abstract

The purpose of this qualitative study was to explore how African American older adults use spirituality to adhere to their antihypertensive medications. Data collection included in-depth individual interviews with 21 older African American women. Content analysis revealed five themes: The Lord Helps Those Who Help Themselves; Staying in the Lord for Guidance; God Is My Rock; Guardian Angels and Saints; and Brings Me Peace, Ease of Burdens, and Ability to Cope. Findings of this study suggest that spirituality is perceived as a positive resource that helps study participants adhere to their antihypertensive medication regimen. Possible faith-based interventions for nurses and other health care professionals to use with their patients are discussed.

Dr. Lewis is Assistant Professor, School of Nursing, Division of Family and Community Health, University of Pennsylvania, Philadelphia, Pennsylvania.

The author discloses that she has no significant financial interests in any product or class of products discussed directly or indirectly in this activity. This research was funded by the Frank Morgan Jones Award from the Hartford Center of Geriatric Nursing Excellence at the School of Nursing, University of Pennsylvania.

Address correspondence to Lisa M. Lewis, PhD, RN, Assistant Professor, School of Nursing, Division of Family and Community Health, University of Pennsylvania, 418 Curie Boulevard, Philadelphia, PA 19104-4217; e-mail: lisaml@nursing.upenn.edu.

Received: January 28, 2010
Accepted: September 07, 2010
Posted Online: February 16, 2011

Despite numerous interventions to increase blood pressure control among African American older adults, hypertension remains a huge public health problem in the United States and a major contributor to health disparities between African Americans and Caucasian Americans (Wong, Shapiro, Boscardin, & Ettner, 2002). The latest heart disease and stroke statistics indicate that the age-adjusted prevalence for hypertension is 78% for older women and 64% for older men and that within the African American community, those with the highest rates are more likely to be older (Lloyd-Jones et al., 2010). One explanation for poorly controlled hypertension is nonadherence to prescribed antihypertensive medications (DiMatteo, Giordani, Lepper, & Croghan, 2002), an occurrence more commonly identified in African American older adults when compared with their younger and Caucasian American counterparts (Lee et al., 1996).

The use of culturally appropriate models of care may be one method to increase medication adherence and blood pressure control in older African Americans and thereby decrease this health disparity. There is evidence that individual beliefs are important to consider when developing interventions that address barriers to medication adherence among African Americans diagnosed with hypertension (Dunbar-Jacob et al., 2000; Heurtin-Roberts & Reisin, 1992; Lukoschek, 2003; Ogedegbe, Harrison, Robbins, Mancuso, & Allegrante, 2004; Scisney-Matlock, Watkins, & Colling, 2001). Spirituality has been identified as an important belief in the African American community (Newlin, Knafl, & Melkus, 2002).

Background

Regardless of racial and ethnic background, medication adherence rates among older adults are considered poor and range from 26% to 60% (Cooper et al., 2005; MacLaughlin et al., 2005). Reasons for these lower rates of adherence vary. Some older adults believe that antihypertensive agents are unnecessary because they do not cure hypertension. Inadequate functional health literacy may be another barrier. Other barriers to adherence among older adults include cognitive impairment, depression, and medical factors such as comorbid conditions (MacLaughlin et al., 2005; Osterberg & Blaschke, 2005). However, some barriers may be specific to an individual’s race and ethnicity. For older African Americans, barriers to medication adherence may also be rooted within culturally specific beliefs. Such beliefs include perceptions of racial prejudice and concerns that antihypertensive medications are experimental, resulting in a greater level of mistrust of health care providers (Boutain, 2001; Fongwa et al., 2008; Lukoschek, 2003). Other barriers identified are increased perceived stress associated with economic burden and decreased self-efficacy (Boutain, 2001; Fongwa et al., 2008; Lukoschek, 2003). In sum, medication adherence among African American older adults is a multifaceted issue influenced by a range of patient and medical factors.

Spirituality is a significant cultural experience and belief in the African American community, often conceptualized as a relationship with a transcendent force bringing meaning and purpose to one’s existence and affecting how one operates in the world (Armstrong & Crowther, 2002; Newlin et al., 2002). One of the reasons spirituality may be so important for older African Americans may be associated with their historical perspective of slavery. It has been reported that slaves used spiritual and religious practices to cope with their harsh conditions and that these spiritual practices have been handed down to subsequent generations of African Americans who have experienced racism and discrimination (Frame, Williams, & Green, 1999; Noel & Johnson, 2005). As a consequence, many African American older adults have consistently used their spirituality when facing adverse conditions, such as health care challenges (Thomas & Cohen, 2006). Indeed, researchers have found that spirituality influences their health beliefs, practices, and outcomes as they manage their chronic illnesses (Harvey, 2006; Parker et al., 2002). Yet, there is a gap in the literature pertaining to African American older adults’ perspectives of how they view their spirituality in relation to hypertension and, in particular, their medication adherence. If these perspectives could be identified, then important insights could be gained and used to tailor interventions that increase medication adherence in African American older adults with hypertension. The purpose of this study was to explore how African American older adults use spirituality to adhere to antihypertensive medications.

Method

Qualitative methodology is useful in understanding the subjective meaning of experiences and thus is suitable for this study (Fereday & Muir-Cochrane, 2006). Participants were encouraged to freely express their thoughts, beliefs, and actions about their perspectives on spirituality and medication adherence through open-ended questions. It is these perspectives that are missing from the current literature examining hypertension and medication adherence among older African Americans.

Setting and Sample

The study was conducted at a Program of All-Inclusive Care for the Elderly (PACE) located in a Northeastern urban area serving primarily African American and low-income frail older adults. The program has more than 300 members, most of whom are women (99%). PACE is a long-term comprehensive model of care designed to address the needs of older adults who have disabilities and are eligible for nursing home care. Using a multidisciplinary team of care providers, the comprehensive services provided in PACE programs allow members to receive services in an adult day health center rather than be institutionalized (Mui, 2001). PACE provides medical, psychological, and social care to its participants, including administration of medications during the hours they attend the program.

Study participants were recruited using purposeful sampling. Purposeful sampling is defined as the intentional recruitment of participants who are best suited to provide a full description of the phenomenon being studied (Strauss & Corbin, 1998). Participants were eligible for the study if they were a member of a PACE program and met the following inclusion criteria: self-identified as African American, self-reported diagnosis of hypertension, and self-reported prescription of at least one antihypertensive medication.

Approval by the university human subjects review board was obtained prior to collecting data for the study. Short presentations were conducted at the PACE site describing the study to PACE members and staff. At the end of the presentations, invitations to participate in the study were extended to PACE members; those who were interested in participating contacted the author.

Data Collection

Informed consent was obtained prior to data collection. Data were generated through in-depth individual interviews that were audiorecorded. Each interview lasted 45 minutes to 1 hour. The complete interview guide is presented in Table 1. Demographic data were collected by self-report. Information on study participants’ adherence was also documented. Each study participant was asked to respond yes or no to the question: Do you take your blood pressure medication the way the doctor has told you to every day? Each participant received $10 at the completion of the interview.

Interview Guide

Table 1: Interview Guide

Data Analysis

Data were analyzed using content analysis (Miles & Huberman, 1994). Interview recordings were transcribed verbatim. The author and one trained research assistant independently coded each transcript, forming lists of initial themes using line-by-line coding of each transcript. Theme-related transcript passages were collected as code exemplars. These preliminary themes were discussed during a series of weekly meetings. Coding discrepancies were resolved through discussion. Only themes identified and agreed on by both the author and research assistant are reported. Each theme is described using participants’ unedited quotes.

Trustworthiness of Findings

Several steps were taken to ensure the trustworthiness of the study’s findings. Detailed notes of each interview were maintained and reviewed throughout the coding process. The author and research assistant independently reviewed and coded each interview transcript. When differences in coding arose, the raw data were reviewed and new themes were derived until a consensus was reached. The author verified the themes with 3 study participants as a final step in this process.

Findings

Participant Characteristics

Twenty-one older African American women with a mean age of 73.7 participated in the study. Most of the sample were at least high school graduates (86%) and divorced or separated (43%). Participants had been diagnosed with hypertension an average of 16.7 years and prescribed an average of 1.8 antihypertensive medications. See Table 2 for a summary of participants’ demographic characteristics.

Characteristics of the Sample (N = 21)

Table 2: Characteristics of the Sample (N = 21)

Themes

Data analysis revealed five themes describing participants’ perspectives of how they used their spirituality to adhere to their antihypertensive medications:

  • The Lord Helps Those Who Help Themselves.
  • Staying in the Lord for Guidance.
  • God Is My Rock.
  • Guardian Angels and Saints.
  • Brings Me Peace, Ease of Burdens, and Ability to Cope.

The Lord Helps Those Who Help Themselves. This theme described participants’ belief that a person should be held accountable for his or her blood pressure control. Statements such as “You have to take your medications if you want to live” and “It’s important to take your medications to maintain a normal blood pressure” confirmed that participants understood the health implications of medication adherence. Participants explained that if they put some effort into managing their blood pressure, then God would take care of them. They often stated, “The Lord helps those who help themselves” and “If you do your part, then God will do His.” A 63-year-old participant stated:

When it comes to taking care of my high blood pressure, I recognize that I have to do my part. God is there to help you but you need to put in the effort. There is no magic cure. You have to take your medicines and trust that God will take care of you.

Another quote by a 74-year-old participant highlighted this theme:

I do believe that God sends help to us in all forms. Sometimes He helps us directly. The direct help are in the miracles we see every day. Most times, though, the help is indirect. He expects you to make some sort of effort in solving your problems. The medication is His opportunity for me to control my blood pressure. I need to do my part, seize the opportunity, and take the medicine.

Staying in the Lord for Guidance. This theme described participants’ spiritual practices. These practices included praying and reading Bible scriptures and were considered to be important for medication adherence guidance. One participant stated, “You got to stay in the Lord by reading His word and praying.” Praying for guidance was described by a 69-year-old participant in the following quote:

Praying is important to maintain your relationship with God but it’s also important to help guide you. One of the things I do daily is to pray for guidance to keep me on the path to taking care of my blood pressure. When I’m done praying, I feel guided to do what I need to, such as take my medication, even though I may have to deal with some stressful family situations. I know some people may not understand it but this is what works for me.

A 65-year-old participant stated:

You need to be directed by the Lord through prayer. You need to pray and ask for guidance. You need that direction from our Father above. I live by that. It’s how I define my spirituality.

Participants also described that the Bible provided a framework for managing their hypertension. They made statements such as “The Bible can tell you how to take care of your health,” “There are guidelines and principles of living in the Bible,” and “There are a whole lot of Bible scriptures pertaining to health.” One 72-year-old participant said, “The Bible is God’s word. It says that my body is the temple of the Holy Spirit. And that means that I am not supposed to do anything that is going to cause it harm. Not taking my medicine is causing it harm.”

God Is My Rock. Many participants reflected that they had to contend with obstacles to their medication adherence and often used the phrase “God is my rock” in reference to managing those obstacles. “Dealing with family issues” and “financial burdens” were frequently mentioned as barriers to medication adherence. One participant stated, “Sometimes I can’t do it, but He can do it for me.” An 82-year-old participant stated:

When you are done dealing with all of your family issues, the last thing you want to do is take your medicines. You just feel so weak but you have to remember that the Lord is your rock and fortress. You have to remember to lean on Him because He’s there for you when you are feeling weak.

Another participant, age 75, stated:

I can’t do this without God. I’ve had high blood pressure for years and I take my medications but I ask God to give me the strength for that because it ain’t easy. In Philippians it says, I can do all things through Christ who strengthens me. He’s my rock!

A 59-year-old participant described this theme by singing the lyrics to one of her favorite religious songs:

“On Christ the solid rock I stand and all other ground is sinking sand”…. There is no way that I could have the strength to continue taking my medications everyday without God the rock.

Guardian Angels and Saints. Many participants believed that God provided support networks. They described these support networks as “guardian angels” or “saints.” For some participants, guardian angels were their health care providers. A 66-year-old participant stated, “God sends guardian angels. I believe in guardian angels. He put the doctors and the nurses here for a reason; they are here to help you. They are my guardian angels.”

For other participants, supportive family members were described as guardian angels. One 69-year-old participant explained how her daughter was helpful in ensuring that she remained adherent to her antihypertensive medication:

I do believe my daughter is an angel sent to me by God. She calls me every day when I get home from the center. It makes me feel good to know that there is someone who is looking out for me. She gives me the encouragement to take care of my health and continue taking my medication as I am supposed to do. She is my angel from Heaven.

Participants also reflected on their fellowship with other church members. They described other church members as “saints” and shared that when they connected with others who had hypertension, they were able to share both good and bad experiences. Most participants found comfort in sharing these experiences. One 77-year-old participant said:

Most of us have high blood pressure where I go to church. We help each other out. We talk about what medications our doctors prescribed. We talk about the different side effects. I feel like if I didn’t have anyone to talk to about these things and to encourage me, I might get depressed. The saints at my church are amazing and a blessing to me.

Brings Me Peace, Ease of Burdens, and Ability to Cope. Participants emphasized that the medication side effects contributed to feelings of fear, anxiety, and distress. Examples of such statements included, “It makes me go to the bathroom all the time,” “My legs swell up so bad,” and “I’m tired all of the time.” Participants reflected that their spirituality “eased their burdens” because it provided a way to cope with medication side effects and provide peace from the anxiety. Sometimes participants felt as if a weight was being lifted after prayer, as noted by a 79-year-old participant:

When you pray, your burden is lifted from the side effects of the medication and the symptoms of the high blood pressure. That weight gets lifted because you know that His will is being done.

A 57-year-old participant described that her spirit was eased as a result of her spirituality:

In the Book of Timothy, it says it there: I am not given a spirit of fear but of power and a sound mind. I remind myself all of the time about these words God gave to us. It brings me peace, I can cope.

Other participants reflected that their spirituality gave them the ability to cope with medication side effects. An 81-year-old participant stated:

There is different allergies and such that the medicines give to you. Sometimes there ain’t nothing you can do but trust and have faith about it because you have no choice but to take your medicines if you want to live. My almighty God helps me to deal and cope with these allergies and side effects.

Discussion

The five themes identified in this study revealed insights into participants’ perspectives of how they used their spirituality to adhere to their antihypertensive medications. Specifically, these themes described a set of beliefs, practices, and support systems they believed were helpful in adhering to their medication regimen. Some of these beliefs and practices have been described in other qualitative studies examining spirituality and chronic illness. The theme The Lord Helps Those Who Help Themselves describes how participants chose to accept accountability for adhering to their antihypertensive medications. A theoretical model proposed in Polzer and Miles’ (2007) qualitative study exploring how the spirituality of 29 African Americans affected the self-management of their diabetes confirms this theme. Polzer and Miles described a typology of relationship and responsibility where participants described varying levels of personal responsibility for managing their diabetes. In this typology, participants self-managed their diabetes and used God to manage difficult situations.

The theme Staying in the Lord for Guidance described participants’ spiritual practices. Participants prayed and read Bible scriptures for guidance about their medication adherence. Although not used entirely for guidance, praying has been identified in other research studies as a common theme and spiritual practice among African Americans (Brown, 2000; Harvey, 2006; Holt, Caplan, et al., 2009; Holt, Schulz, & Wynn, 2009; Polzer & Miles, 2007). In Harvey’s (2006) study exploring the role of spirituality in the self-management of chronic illness among 10 African American women, participants indicated that prayer was used prior to and during medical procedures. The theme of prayer is also supported in Holt, Schulz, and Wynn’s (2009) mixed-methods study examining perceptions of the religion-health connection among 400 African Americans in urban and rural areas. Further support for Staying in the Lord for Guidance was found in a study examining the role of religion in coping with cancer among 23 African Americans diagnosed with the disease (Holt, Caplan, et al., 2009). Those participants described that scripture study provided comfort and reassurance and was often done in conjunction with prayer.

This study’s participants also described various forms of individual support that were helpful for adhering to their medications. In the theme God Is My Rock they described how they relied on God for support when they had to manage obstacles to their medication adherence. This theme is similar to findings from Schulz et al.’s (2008) study examining spirituality among African American cancer survivors. Their participants described a theme of relying on and conversing with God when no one else was available. However, they did not describe the relationship in terms of managing obstacles.

Participants described support provided by health care providers, family members, and fellow church members through the theme Guardian Angels and Saints. This theme, too, has been confirmed in other qualitative research studies (Holt, Caplan, et al., 2009; Schulz et al., 2008). Participants described support as being associated with God and other individuals, which suggests that they perceived different forms of support. However, it is unknown which participant demographic characteristics may identify the different ways in which they perceive and use the support. Further research is warranted to identify these characteristics. Knowing these characteristics could help to tailor medication adherence interventions that capitalize on the spirituality of individuals with a similar demographic background.

In the theme Brings Me Peace, Ease of Burdens, and Ability to Cope, study participants described that their spirituality brought them the ability to cope with medication side effects. In a study examining the meaning of spirituality for men with prostate cancer, coping was an important category of their spirituality (Walton & Sullivan, 2004). A review of 27 studies on spiritual beliefs and treatment decisions among African Americans found that using spirituality to cope with illness was the most common theme identified (Johnson, Elbert-Avila, & Tulsky, 2005). Other research studies have revealed themes of peace and coping in regard to spirituality (Harvey, 2008; Holt & McClure, 2006). At present, the association between spirituality and coping is not well understood. Research studies that explore this association would provide important information regarding the mechanism by which spirituality may be useful for helping older African Americans with hypertension adhere to their medications.

Limitations and Strengths

The findings of this study must be interpreted within the context of some limitations. First, study participants were members of the same PACE program and may not be representative of the larger populations of older African Americans with hypertension. Second, study participants represented the Christian faith, and thus findings may not be generalizable to members of other religious faiths. In addition, study participants received their medications during the days they attended the PACE program. Nonetheless, the findings provided insight about the spiritual perspectives they associated with their medication adherence. These findings could enhance current understanding of how African American older adults with hypertension use spirituality to manage their antihypertensive medication regimens.

Implications for Nursing

Nurses and other health care professionals may benefit from the findings of this qualitative study. The study participants described positive experiences associated with their spiritual beliefs. The findings from this study suggest it would be beneficial for nurses and health care professionals to consider establishing environments in which patients feel comfortable discussing their spiritual belief systems, including how their spiritual beliefs may influence their attitudes and beliefs toward medication adherence. It also seems reasonable that nurses may help spiritually involved African American older adults adopt positive coping methods, such as prayer and scripture reading, for negotiating their barriers to medication adherence.

Given that support from church members was so important for participants in this study, African American older adults with hypertension may also benefit from faith-based interventions such as weekly church group sessions to address barriers to medication adherence. There is evidence that faith-based interventions are successful in improving health among African Americans (Fitzgibbon et al., 2005; Oexmann et al., 2000; Smith, Merritt, & Patel, 1997; Walker, 2000; Yanek, Becker, Moy, Gittelsohn, & Koffman, 2001). For older African Americans, the church has served as an infrastructure for support, political, and social welfare programs (Giger, Appel, Davidhizar, & Davis, 2008). For the subpopulation of older African Americans who mistrust health professionals, it could provide a space where they may be more comfortable learning about how to manage their hypertension and strategies for increasing their adherence to antihypertensive medication. Health care providers are beginning to recognize the role the church may play in improving the health status of the African American community. Indeed, the church would be worth examining as an intervention site for older African Americans with hypertension.

Conclusion

Interventions that are consistent with African American cultural beliefs are more likely to be successful in promoting healthy behavior, such as medication adherence. For many African American older adults, spirituality is an important cultural belief. These findings may be used to implement and enhance faith-based support services to meet the needs of older African Americans who are diagnosed with hypertension and who have difficulty adhering to their medications. Further studies on the role of spirituality and medication adherence in older African Americans should include non-PACE members, men, and individuals from nonreligious traditions to allow for a broader understanding of spiritual issues.

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Interview Guide

1. How does your high blood pressure make you feel?
2. How does taking your high blood pressure medicine make you feel?
3. How do you define your spirituality? In what ways, if any, is your spirituality different from religion?
4. In what ways do you use your spirituality to make decisions about your health?
5. Can you provide me with specific examples of how you use your spirituality to make decisions about your health?
6. In what ways do you use your spirituality to make decisions about taking your high blood pressure medications?
7. Can you provide me with specific examples of how you use your spirituality to make decisions about taking your high blood pressure medications?
8. What are some other factors that help you make decisions about taking your high blood pressure medications?
9. In what ways can your health care provider (physician or nurse) help you use your spirituality to make decisions about taking your medication for your high blood pressure?

Characteristics of the Sample (N = 21)

Characteristic Mean (Range)
Age 73.7 (57 to 86)
Years diagnosed with hypertension 16.7 (8 to 26)
Number of prescribed medications 1.8 (1 to 3)
n(%)
Gender
  Women 21 (100)
Marital status
  Divorced/separated 9 (43)
  Widowed 7 (33)
  Married/in a relationship 5 (24)
Educational level
  Less than high school 3 (14)
  High school graduate 14 (67)
  Some college/technical school 4 (19)
Religious affiliation
  Baptist 9 (43)
  Church of God in Christ 5 (24)
  Pentecostal 4 (19)
  African Methodist Episcopal 2 (10)
  Other 1 (5)

Lewis, L.M. (2011). Medication Adherence and Spiritual Perspectives among African American Older Women with Hypertension: A Qualitative Study. Journal of Gerontological Nursing, 37(6), 34–41.

  1. Medication adherence among African American older adults with hypertension is a multifaceted issue influenced by patient cultural beliefs.

  2. Spiritual perspectives were described as a set of beliefs, practices, and support systems believed to be helpful in adhering to antihypertensive medications.

  3. Nurses should consider establishing environments in which patients feel comfortable discussing how their spiritual beliefs may influence their attitudes toward medication adherence.

  4. Nursing interventions should focus on helping spiritually involved older African American patients adopt positive coping methods, such as prayer and scripture reading, for negotiating their barriers to antihypertensive medication adherence.

Keypoints

Authors

Dr. Lewis is Assistant Professor, School of Nursing, Division of Family and Community Health, University of Pennsylvania, Philadelphia, Pennsylvania.

The author discloses that she has no significant financial interests in any product or class of products discussed directly or indirectly in this activity. This research was funded by the Frank Morgan Jones Award from the Hartford Center of Geriatric Nursing Excellence at the School of Nursing, University of Pennsylvania.

Address correspondence to Lisa M. Lewis, PhD, RN, Assistant Professor, School of Nursing, Division of Family and Community Health, University of Pennsylvania, 418 Curie Boulevard, Philadelphia, PA 19104-4217; e-mail: .lisaml@nursing.upenn.edu

10.3928/00989134-20100201-02

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