Symptomology of Elevated Blood Pressure in Black Women with Hypertension

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1 Symptomology of Elevated Blood Pressure in Black Women with Hypertension Devita T. Stallings, Joanne Kraenzle Schneider Journal of Health Care for the Poor and Underserved, Volume 28, Number 1, February 2017, pp (Article) Published by Johns Hopkins University Press DOI: For additional information about this article Accessed 30 Apr :53 GMT

2 BRIEF COMMUNICATION Symptomology of Elevated Blood Pressure in Black Women with Hypertension Devita T. Stallings, PhD, RN Joanne Kraenzle Schneider, PhD, RN Abstract: Understanding factors that influence hypertension self- management may improve blood pressure control in Black women; however, little is known about Black women s perceptions of symptoms associated with hypertension. In this study, using the revised version of the Illness Perception Questionnaire (IPQ- R), we examined Black women s perceptions of symptoms that they associate with hypertension. While over half (52.5%) reported no symptoms of high blood pressure, 41.3% of the women reported one to six symptoms they attributed to high blood pressure. This study has the potential to increase clinicians understanding of patients perceptions of the symptomology of hypertension. Key words: African Americans, hypertension, cardiovascular disease, health knowledge, symptoms, practice, women s health. Hypertension affects more than 70 million people in the United States and is one of the most reliably preventable causes of cardiovascular disease morbidity and mortality worldwide. 1 Understanding factors that influence blood pressure control is a major public health concern, especially among Blacks who are disproportionately affected by hypertension. From a medical standpoint, hypertension is considered a silent disease; however, many patients believe that hypertension is a symptomatic illness 2 7 and these perceptions influence their health behavior including medication adherence. The purpose of this study was to understand Black women s perceptions of symptoms that they associate with hypertension. Methods This is a secondary analysis of cross- sectional data collected from December 2010 to April 2011 to explore the relationship between high blood pressure (HBP) perceptions and lifestyle behaviors (exercise and diet) among 204 Black women. Only women were included in this study because perceptions may differ between women and men. The women were recruited from churches and a hair salon in Tennessee and Mississippi. DEVITA T. STALLINGS and JOANNE KRAENZLE are affiliated with the School of Nursing, Saint Louis University, St. Louis, MO. Please address correspondence to Devita T. Stallings, PhD, RN, School of Nursing, Saint Louis University, 3525 Caroline Street, St. Louis, MO, 63104; dstallings@slu.edu. Meharry Medical College Journal of Health Care for the Poor and Underserved 28 (2017):

3 Stallings and Schneider 59 Women were included if they were between the ages of 18 to 65 years, could read, write, and speak English, and reported that they had been diagnosed with hypertension. All women were on prescribed medication for hypertension. Among the various instruments completed by the women, two were of interest for this report, the demographic form and the revised version of the Illness Perception Questionnaire (IPQ- R) which included nine subscales reflecting women s experiences with hypertension. Other instruments and study details are reported in another study. 8 The IPQ- R was developed by Moss- Morris 9 to quantitatively measure cognitive and emotional representations (perceptions) of illness. The developers intended for researchers to substitute the name of the particular condition (e.g., high blood pressure) for the word illness throughout the instrument. The nine subscales include, identity, cause, timeline- chronic, timeline- cyclical, consequences, personal control, treatment control, emotional representations, and coherence. Hagger and Orbell 10 showed support for the construct and discriminant validity of the IPQ- R. For this report, we were interested in only the Identity subscale. The Identity subscale (19 items) represents the women s symptoms that they attributed to HBP. The list of symptoms included on the subscale represent commonly reported symptoms attributed to hypertension. Women responded yes or no to whether or not they personally: 1) experienced this symptom recently, 2) believed this symptom was related to their HBP, and 3) believed this symptom was related to their HBP medicines. The identity subscale was scored by summing the number of symptoms reported as relating to HBP or HBP medicines. Using SPSS (version 22, Armonk, NY: IBM Corp) we summarized the data using descriptive statistics. Results The majority (67.2%) of women were between 40 and 59 years old (mean ± 10.3 years). Most (52.9%) were married. Half of the women had college or higher education, 4.9% had less than a high school education. The majority of women were employed, 61.8% full- time and 9.3% part- time. About a tenth (10.3%) reported being retired. The highest proportion of women (26.5%) reported a yearly income between $15,000 and $29,999; 21.6% reported less than $15,000; 17.2% reported $30,000 to $44,999; and 12.3% reported $45,000 to $59,999. Mean systolic and diastolic blood pressures were 138.4±15.0 mmhg and 83.5±9.9 mmhg, respectively; 43.6% of the women had systolic blood pressures 140 mmhg); 26.5% had diastolic blood pressures 90 mmhg. Mean heart rate was 76.6±9.8. Mean BMI was 34.1±8.0; 143 women (70.1%) had a BMI in the obese range of In this study, 41.3% of the women reported a range of one to six symptoms they attributed to HBP (overall range 0 19); 52.5% reported no symptoms of HBP. Clearly 47.5% of women reported that they perceived at least one symptom they attributed to HBP. Among the most common symptoms (Table 1) were headache (57, 27.9%), dizziness (33, 16.2%), and breathlessness and fatigue (each 27, 13.2%).

4 60 Symptomology of elevated blood pressure Table 1. FREQUENCY AND PERCENT OF BLACK WOMEN WHO REPORTED HBP SYMPTOMS Symptom n % Pain Sore throat Nausea Breathlessness Weight loss Fatigue Stiff joints Sore eyes Wheeziness Headache Upset stomach Sleep difficulties Dizziness Loss of strength Loss of libido Impotence Feeling flushed Fast heart rate Pins and needles Discussion Overall nearly half of the women believed that hypertension was symptomatic. The women commonly reported headache, dizziness, breathlessness, and fatigue as perceived hypertensive symptoms. The hypertensive symptoms reported are consistent with previous research reports. 4 7 Franklin and colleagues 5 reported that headache, dizziness, and vision changes were the primary symptoms attributed to hypertension among 51% of participants in their study. Wilson and colleagues 6 found that common symptoms attributed to hypertension were headaches, dizziness, weakness or fatigue, ear pain, and nose bleeds, while Schoenberg and Drew 4 reported most participants in their study agreed that having a headache and feeling faint were symptoms of hypertension. Previous researchers linked patients perceived hypertension symptomology with medication adherence While some researchers showed that patients experiencing HBP symptoms were more likely to change their prescription, 10 others showed that hypertensive patients believed that they only needed to take medication when they perceived signs and symptoms of HBP Additionally, when patients concluded that their medication was not improving their symptoms, they were less likely to take it. 11 These findings emphasize the importance that health care providers deliver appropri-

5 Stallings and Schneider 61 ate education to ensure their patients understand enough to self- manage their disease. Health care providers may provide patients with a way to monitor their blood pressures objectively, e.g., a home blood pressure monitors, to reinforce this education and further enhance self- management. This will be especially useful for patients who self- manage based on symptoms as they will be able to see their elevated blood pressures despite the absence of symptoms. This study has several limitations. Women volunteered through self- selection that may bias the study results and limit generalizability. The results of the study best generalize to middle- aged, educated Black women from the South and not Black women everywhere. Because this analysis was from a cross- sectional dataset, causal relationships cannot be implied. We relied on the women s self- report of physician- diagnosed hypertension. However, despite prescribed antihypertension medication, many of the women in this study had systolic and diastolic blood pressures above the Eighth Joint National Committee (JNC 8) recommendations of less than 140/90 mmhg. 12 In addition, the data were collected from and perceptions of HBP symptoms may change overtime. For decades, public health campaigns have focused on educating and informing the public about hypertension as a silent killer 13 and the seriousness of heart disease in women, especially with Go Red for Women. 14 The Go Red for Women s initiative raises awareness of heart disease as the number one killer of women and also recognizes the symptom differences between men and women in regards to heart diseases (i.e., heart attacks). 15 More initiatives and studies that include women are needed to reduce the morbidity and mortality associated with hypertension and heart diseases. Health care providers should make every effort to make patients feel comfortable enough to express their beliefs and experiences with hypertension. Then through collaborative communication, providers can correct misperceptions and emphasize the use of medications even when not perceiving symptoms. Future researchers might test collaborative interventions with Black women to improve better understanding, medication adherence, and ultimately blood pressure control. References 1. Go AS, Mozaffarian D, Roger VL, et al. Executive summary: heart disease and stroke statistics 2014 update: a report from the American Heart Association. Circulation Jan 21;129(3): American Heart Association. What are the symptoms of high blood pressure? Dallas, TX: American Heart Association, Available at: /HEARTORG/Conditions/HighBloodPressure/SymptomsDiagnosisMonitoring ofhighbloodpressure/what- are- the- Symptoms- of- High- Blood- Pressure_UCM _301871_Article.jsp. 3. Kronish, IM, Leventhal, H, Horowitz, CR. Understanding minority patient s beliefs about hypertension to reduce gaps in communication between patients and clinicians. J Clin Hypertens (Greenwich) Jan;14(1): Epub 2011 Nov 18.

6 62 Symptomology of elevated blood pressure PMid: PMCid:PMC Schoenberg, NE, Drew, EM. Articulating silences: experiential and biomedical constructions of hypertension symptomalogy. Med Anthropol Q Dec;16(4): PMid: Franklin MM, Allen W, Pickett S, et al. Hypertensive symptom representations: a pilot study. J Am Assoc Nurse Pract Jan;27(1): Epub 2014 Aug 5. PMid: Wilson RP, Freeman A, Kazda MJ, et al. Lay beliefs about high blood pressure in a low- to- middle- income urban African American community. Am J Med Jan;112: Fongwa MN, Evangelista LS, Hays RD, et al. Adherence treatment factors in hypertensive African American women. Vasc Health Risk Manag. 2008;4(1): PMid: PMCid:PMC Stallings DT. Illness Perceptions and Health Behaviors of Black Women. J Cardiovasc Nurs Nov/Dec;31(6): PMid: Moss- Morris R, Weinman J, Petrie KJ, et al. Revised illness perception questionnaire. Psychology & Health. 2002;17(1): Hagger MS, Orbell S. A meta- analytic review of the common- sense model of illness representations. Psychology & Health. 2003;18(2): Ross S, Walker A, MacLeod MJ. Patient compliance in hypertension: role of illness perceptions and treatment beliefs. J Hum Hypertens Sep;18(9): PMid: Baumann LJ, Leventhal H. I Can Tell When My Blood Pressure Is Up, Can t I?. Health Psychol. 1985;4(3): Griffin BR, Schinstock CA. Thinking beyond new clinical guidelines: update in hypertension. Mayo Clin Proc Feb;90(2): PMid: American Heart Association. Why Blood Pressure Matters. Dallas, TX: American Heart Association, Available at: /HighBloodPressure/WhyBloodPressureMatters/Why-Blood-Pressure-Matters_UCM _002051_Article.jsp#.VxO5HPkrKUk. 15. American Heart Association. About Heart Disease in Women. Dallas, TX: American Heart Association Available at: -heart-disease-in-women/.