High blood pressure takes a devastating toll on African Americans. Better control can go a long way to closing the “mortality gap” between African Americans and white Americans. But which strategies are best to address this complex problem?
In this report, we review the evidence on practice-based approaches to improving blood pressure control, from new styles of patient education to home blood pressure monitoring, focusing on studies in African Americans (Table 1).1–11
BETTER CONTROL IS NEEDED
Patient-related barriers24–40 include:
- Poor knowledge about hypertension and its consequences31,32
- Poor adherence to drug therapy (a major factor,24–26 as African Americans have poorer adherence rates than whites,27–29 which may explain some of the racial disparity in blood pressure control30)
- False health beliefs34–37
- Inability to change one’s lifestyle
- Side effects of antihypertensive drugs32
- Unrealistic expectations of treatment (eg, a cure33)
- Demographic factors (eg, socioeconomic status, educational level, age, sex).24,38–40
Perhaps the most salient and easily modifiable of these factors are patients’ reluctance to modify their lifestyle and their misconceptions about the causes, treatment, and prevention of hypertension. Patients whose beliefs are discordant with traditional biomedical concepts of hypertension have poorer blood pressure control than those whose beliefs are concordant.41 This may be more relevant to African Americans, since they are known to have cultural health beliefs that differ from those of Western culture (eg, that hypertension is a curable rather than a chronic illness, and that hypertension is a disease of nerves that often affects the blood and clogs the arteries).42
Barriers to effective blood pressure control at the physician level43–48 include:
- Nonadherence to treatment guidelines44
- Failure to intensify the regimen if goals are not met45
- Failure to emphasize therapeutic lifestyle changes.43,46–48
When primary care physicians do not follow evidence-based guidelines, the reason may be that they are not aware of them or that they do not understand them. In a national survey of 1,029 physicians that was designed to explore how well physicians know the indications for specific antihypertensive drugs and how closely their opinions and practice agreed with national guidelines, only 37.3% correctly answered all of the knowledge-related questions.49
Other reasons for nonadherence are that physicians may disagree with the guidelines, may not be able to follow the guidelines, may not believe that following them will achieve the desired effect, or may have no motivation to change their practice.50
Whatever the reason, Hyman et al51 reported that as many as 30% of physicians did not recommend treatment for patients with diastolic blood pressures of 90 to 100 mm Hg, and a higher proportion did not treat patients with systolic blood pressures of 140 to 160 mm Hg.
BARRIERS IN HEALTH CARE SYSTEMS
Although health care systems present barriers to optimal blood pressure control,20,27,31,52 there is evidence that most cases of uncontrolled hypertension occur in patients with good access to care.32,53,54 For example, an NHANES study53 suggested that most patients with uncontrolled hypertension had in fact seen a physician on average at least three times in the previous year. And this may be more pervasive in African Americans: one survey found hypertension was uncontrolled in 75% of hypertensive African American patients despite free access to care, free medications, and regular follow-up visits.41
Thus, the most significant barriers to blood pressure control appear to be patient-related and physician-related.
INTERVENTIONS AIMED AT PATIENTS
The most common approaches to improving blood pressure control at the patient level, regardless of race, are patient education,55–61 home blood pressure monitoring,62–67 and behavioral counseling to address misconceptions about hypertension,68 to improve adherence to drug therapy,69–73 and to encourage lifestyle modifications.74–78