Disparities Among African Americans and Antihypertensive Medications, Research Paper Example

A prerequisite for the effectiveness of a drug is its correct use; however, patients often do not adhere to the prescribed treatment regimen, for various reasons. Therefore, if the pharmacotherapy prescribed by the doctor does not give an effect, the decisive factor for determining further actions is to understand why the treatment was unsuccessful. It is necessary to understand what is the reason for the insufficient effectiveness of the drug or its complete absence: a drug itself, the individual characteristics of the organism, or the patient’s behavior. Research on patient behavior in relation to the prescribed drug has received increasingly more attention, especially in recent years, when new pharmaceuticals with high specificity appear in the arsenal of doctors, but at the same time, they can provoke adverse reactions of the body or, on the contrary, do not provide necessary effect due to improper intake and deviations in the pharmacotherapy regimen.

This is especially true for chronic diseases such as hypertension. In the United States, about 75 million people suffer from hypertension. About 81% of these people are aware that they have hypertension, only 75% are receiving treatment, and only 51% have adequate blood pressure control. Among adults, hypertension is more common among African Americans (41%) than among Caucasians (28%) or Mexican Americans (28%), and African Americans have higher morbidity and mortality (Flynn et al, 2017).

The chronic diseases so common in the African American community are the result of poverty caused by decades of racial discrimination. Poverty has made many blacks unable to pay for health care; in addition, a number of studies show that American doctors are often inattentive to the complaints of black patients (Shuey et al., 2018). Community living conditions, gaps in the social safety net, unequal access to education and career opportunities, and finally, systemic and institutional racism leading to inequality for many years ? all these are systemic latent causes of not only higher morbidity and lower quality of life among African Americans, but also their low trust in the healthcare system, which, in turn, leads to low compliance rates in the treatment of chronic diseases, including hypertension. The rate of hypertension and associate complications and mortality are much more prevalent in African Americans ? a 1.5 to 2 times higher than in Whites (Adinkrah et al., 2020).

The prevalence of non-compliance among African Americans is extremely high. Thus, for chronic somatic diseases, it is 30-60% (McQuaid & Landier, 2018). The highest percentage of non-compliance is observed predominantly in economically disadvantaged underserved African Americans (Adinkrah et al., 2020). As a consequence, “For African American middle-aged and older adults with hypertension, poor adherence to medication and lifestyle recommendations is a source of disparity in hypertension outcomes including higher rates of stroke” (Adinkrah et al., 2020, p 1). These authors, in their study, determined an array of predictive factors of African American older adults adherence to both recommendations concerning lifestyle and antihypertensive therapy medication. Besides demographic factor, the factors include beliefs, behaviors, knowledge of hypertension. Patients with a higher level of hypertension knowledge appeared more likely to adhere to both lifestyle recommendations and antihypertensive medication regimens (Adinkrah et al., 2020).

Studies testify racial inequity in medication adherence in patients with hypertension. This problem was revealed in the end of 20^th century. In early studies conducted among the population of Blacks and African-Americans in comparison with White patients that only race and ethnicity was related significantly to low medication adherence ? 60% of African Americans appeared to be repeatedly nonadherent compared to 34% of Whites, that is, the index of non-compliance among African Americans is twice higher than in Whites. Other studies found that African Americans are twice more inclined to nonadherence than Whites (Shiyanbola et al., 2018).

At the same time, those who stated about more experiences of racial discrimination showed less adherent to hypertensive medication programs, and perceived racial disparity in society was correlated with lower medication adherence in African Americans samples (Shiyanbola et al., 2018).

A whole range of factors is at the heart of problems with the implementation of medical prescriptions. There are five groups of factors that influence the level of compliance (Shuey et al., 2018):

• Social factors, which include financial situation, cultural level, economic illiteracy, age, distance to the health care facility.
• Systemic (related to the health care system), which include the doctor-patient relationship, the education of paramedics, the capabilities of the health care system, the duration of medical consultation, and the distribution of drugs.
• Disease-related factors ? the severity of symptoms, stress associated with physical suffering, stage of disease progression, comorbidity, and the availability of effective therapy.
• Treatment-related factors ? the complexity of the regimen, the duration of treatment, difficulties in the selection of therapy, adverse drug reactions, ineffectiveness of the prescribed therapy.
• Patient-specific factors ? fear of unwanted side effects, premature termination of treatment, unreasonable expectations, forgetfulness, knowledge of the disease.

In the works devoted to African American compliance in antihypertensive therapy, it is said that, along with the indicated groups of factors, in studies of compliance and attitudes towards patient responsibilities, one should not underestimate the specific mental characteristics, often due to the system of views and perceptions of people, including those prevailing in certain communities and territories (Shiyanbola et al., 2018).

However, the very agreement with therapy (its adoption), depending on an extremely large number of factors, is highly unstable. Thus, the loss of trust in the doctor or iatrogenism can change compliance to non-compliance in one day, which indicates the subjective significance of a certain factor at a certain point in therapy (Shiyanbola et al., 2018). Conceptual models of compliance, reflecting a variety of research approaches to studying this problem, are no less contradictory: 1) a biomedical model with a focus on aspects such as treatment regimen and side effects; 2) a behavioral model with an emphasis on environmental influences and the development of behavioral skills; 3) an educational model centered on improving the relationship between the patient and the doctor; 4) a model of popular ideas about health in society, based, first of all, on a rational assessment of the usefulness, as well as obstacles to treatment; 5) a model of self-regulating systems, within which cognitive and emotional responses to the threat of a disease are analyzed. Analysis of these compliance models shows that some of them are based on belief in recovery, others on alternative adaptations, or on cognitive functions, etc. The lack of any comparability between them, as well as absence of a unified theory of compliance development, causes justified criticism from opponents of both these models themselves and the results obtained when using them.

In addition to behavioral reasons for compliance, researchers pay great attention to health system reasons. The patient’s compliance level directly depends on some of the personal characteristics of the doctor (enthusiasm, range of acceptability), his age and experience, as well as the time spent talking with the patient. Moreover, if patients feel that they were “heard” and “fully” discussed their concerns about the forthcoming therapy, they subsequently speak out more frankly about the treatment, rather than passively shy away from taking medications (Shiyanbola et al., 2018). In treating African Americans, doctors should manifest good cross-cultural skills and sensitivity. Subsequent refusals of treatment are often caused by the authoritarian manner of prescribing therapy by the doctor.

This is also related to the fact that the patient’s attitude to therapy within the framework of a therapeutic union with a doctor is largely determined by a subjective assessment of the benefits and risks of the therapy. In the event of complications or side effects leading to a decrease in the level of social functioning, representatives of African American communities, despite the simultaneous presence of even significant positive results, often tend to assess the negative consequences of therapy as more significant for themselves, which ultimately often leads to a decision to interrupt the therapy course of treatment (Adinkrah et al., 2020). At the same time, the tolerability of therapy significantly depends on the patient’s initial attitude to treatment as a whole, the quality of his/her relationship with the doctor, the level of awareness about the action of the drug and its side effects.

It should be noted here that factors that increase patient adherence to treatment include a high level of education, higher income, married status, and a high level of culture (Kang et al., 2018).

At the moment, the biopsychosocial ethical model of the phenomenon of compliance prevails in clinical psychology, which explains its occurrence not only through biological (the nature of the disease (acute/chronic, side effects of drugs, etc.) and social factors (the system of relations between the doctor and the patient), but and adds psychological and spiritual factors to them.

Compliance has a complex structure, which consists of three functional blocks: the sensory-emotional block includes direct impressions and experiences caused by the treatment situation; logical represents a system of judgments and judgments to explain the need for treatment and its effects; behavioral is formed by motives, actions and deeds for the implementation of the therapeutic program.

It is also important to determine compliance with a psychological approach. It is necessary to take into account the structure of a person’s mental activity, which, of course, includes the personality’s attitude to treatment, adherence to the doctor’s prescriptions and adherence to recommendations, and in this case, this phenomenon can be attributed to the category of mental properties. Mental properties are stable formations that provide a certain qualitative and quantitative level of activity and behavior, typical for a particular person. The mental properties include the life position of a person, consisting of a system of needs, interests, beliefs, ideals, and determining selectivity, and the level of activity, which are derivatives of the concept of compliance (Kang et al., 2018). This allows interpreting it as follows: compliance should be understood as a part of the personality’s beliefs in frames of the structure of mental activity, which determines the behavior of a person, regarding his/her attitude to the therapeutic measures, recommendations and prescriptions from the doctor. When it comes to compliant behavior, the most stable and unchanged ones in the process of assimilating life experience are the patient’s personal characteristics. They can be subjected only to psychocorrectional influences that can modify human behavior. The least stable is the emotional component of the personality. Mood background influences adherence to therapeutic measures in some way, which can lead to incomplete and poor adherence to medical prescriptions (Kang et al. 2018). For example, the study of Kang et al. (2018) revealed that stress belongs to the list of crucial factors of non-adherence to anti-hypertensive medication and life-style recommendations simultaneously in almost 60% of Black women. At the same time, stress is often related to social disparities, caused by systemic racism – thus, even the problem of stress in African Americans has complex nature, which necessitates application of interdisciplinary approach.

Study by Pettey et al. also notes stress as the cause of hypertension in African Americans. The participants in interview conducted in frames of their study, also mentioned wrong nutrition habits and non-healthy life style: “Maybe problems with not eating right, bad eating habits passed down… unhealthy actions…, including drinking alcoholic beverages” (Pettey et al., 2016). The participants evidently showed their cultural patterns determining non-adherence to anti-hypertension medications: “alternative treatments including mustard, apple cider vinegar, garlic, and pickle juice…My grandfather would tell you about BP, old Black people didn’t go to the hospital and they had to make their own remedies” (Pettey et al., 2016).

Also, based on modern research on the problem of non-compliance, one can indicate that compliance is the result of a process unfolded in time, which includes (Shiyanbola et al., 2018):

• The patient (with his personal model of health, medical awareness, problem-solving style, socialization, internal picture of the disease, opinion of the immediate environment, etc.);
• The doctor (with his own characteristics of professional socialization, special medical knowledge and skills, style of consultation, style of prescribing, etc.);
• The actual peculiarities of interaction in the doctor’s office (for a doctor, this is a readiness for therapeutic cooperation, a language of communication understandable for a patient, an understanding of intercultural differences; in a patient, it is response to suggestive questions, attention to detail, completeness of presentation of complaints, etc.);
• Experience and understanding (maturity of intrapersonal reflection) of the symptoms of the disease by the patient;
• The doctor’s understanding of the patient’s complaints and the choice of treatment resources; instructing the patient at the end of the consultation (prevention of low compliance);
• Acceptance of the doctor’s prescriptions by the patient and the formation of a recovery plan by the patient.

Thus, summarizing the theoretical analysis of the above studies, we can conclude that the problem of compliance in different populations with specific social background, and in African American population in particular, today is poorly understood, acquires relevance, theoretical and practical significance, and occupies a worthy place in the problem field of medical psychology and medicine. In medical science, compliance is a problem of great practical importance, since non-compliance with the drug regimen makes a very significant contribution to the frequency of recurrence of diseases and the increase in the severity of their exacerbations.

Given the serious consequences of non-compliance for patients on their health and well-being, as well as due to the additional economic burden on the health care system, it should be considered appropriate to stimulate compliance with the help of special measures. Such measures should be aimed at improving patient safety while at the same time reducing the cost of pharmacotherapy and eliminating the consequences caused by non-compliance with the drug regimen. Today these measures for African American patients and communities can be divided into 4 groups:

• Educational ? training, informing and consulting patients, especially non-compliance risk groups.
• Influencing the patient’s behavior ? various ways that help patients take medications, signals and devices on time, reminding them of such a need, individual packages for a week or for a course of treatment, etc.
• Compliance monitoring ? patient diaries, regular monitoring of key health indicators, etc.
• Adaptation of therapy ? first of all, simplification of complex therapy regimens, for example, transferring a patient to retard forms, to combined drugs, etc. (Shuey et al., 2018).

Targeted compliance improvement measures should be based on valid, i.e., reliable and confirmed, compliance data, as well as reliable information about the degree of patient compliance required for the effectiveness of a particular treatment.

References

Adinkrah, E., Bazargan, M., Wisseh, C., Assar, S. (2020). Adherence to hypertension medications and lifestyle recommendations among underserved African American middle-aged and older adults. International Journal of Environmental Research and Public Health, 17. http://dx.doi.org/10.3390/ijerph17186538

Flynn, J.T., Kaelber, D.C., Baker-Smith, C.M., et al. (2017). Subcommittee on Screening and Management of High Blood Pressure in Children: Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics, 140(3):e20171904. doi: 10.1542/peds.2017-3035.

Kang, A. W., Dulin, A., Nadimpalli, S., Risica, P. M. (2018). Stress, adherence, and blood pressure control: A baseline examination of Black women with hypertension participating in the SisterTalk II intervention. Preventive Medicine Reports, 12, 25-32.

McQuaid, E. L., & Landier, W. (2018). Cultural issues in medication adherence: Disparities and directions. Journal of General Internal Medicine, 33, 200-206.

Pettey, C. M., McSweeney, J., Stewart, K. E., Cleves, M. A., Price, E. T., Heo, S., Souder, E. (2016). African Americans’ perceptions of adherence to medications and lifestyle changes prescribed to treat hypertension. Sage Open, 6(1). doi:10.1177/2158244015623595.

Shiyanbola, O. O., Brown, C., & Ward, E. (2018). “I did not want to take that medicine”: African Americans’ reasons for diabetes medication nonadherence and perceived solutions for enhancing adherence. Patient Preference and Adherence, 12, 409-421.

Shuey, M. M., Gandelman, J. S., Chung, S. P., Nian, H., Yu, C., Denny, J. C., Brown, N. (2018). Characteristics and treatment of African American and European-American patients with resistant hypertension identified using the electronic health record in an academic health centre: a case?control study. BMJ Open, 8. doi:10.1136/bmjopen-2018-021640