Caroline Zimmermann, Rachel Grover, Ph.D., Patti Ephraim

Patient Activation, Perceived Stress, and Medication Adherence in Urban African American Patients with Uncontrolled Hypertension: the Achieving Blood Pressure Control Together (ACT) Study

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Having hypertension, blood pressure levels ≥ 140 mm Hg systolic and ≥ 90 mm Hg diastolic, can be life-threatening because it increases one’s risk for stroke, heart attack, and organ damage (e.g., kidney damage and vision loss; AHA, 2014). Approximately 70 million individuals in the U.S. have been diagnosed with hypertension, with prevalence rates higher among African Americans compared to other racial groups (Gillespie, Kuklina, Briss, & Hong, 2011; Go et al., 2014; Gu, Burt, Dillon, & Yoon, 2012; Yoon, Ostchefe, & Louis, 2010). Of hypertensive patients that have uncontrolled hypertension (i.e., diagnosis of high blood pressure at least two doctor visits) many of them do not adhere to their medication regimen (Bosworth et al., 2008; Braverman & Dedier, 2009; Forsyth, Schoenthaler, Chaplin, Ogedegbe, & Ravenell, 2014; Holt et al., 2013).

Perceived stress, the degree to which situations in one’s life are appraised as stressful, may hinder his or her willingness to prioritize taking antihypertensive medications, and thus contribute to one’s non-adherence (Forsyth et al., 2014; Holt et al., 2013; Wiernik et al., 2013). On the other hand, patient activation, the degree to which a patient engages in self-management of his or her disease through education, building problem-solving skills, and improving physician-patient communication, allows a patient to gain control of his or her treatment (Hibbard, Stockard, Mahoney & Tusler, 2004). Activating a patient may have positive outcomes such as instilling confidence and improving self-efficacy, and perhaps ultimately, promoting a likelihood of medication adherence in the face of perceived stress (Kinney, Lemon, Person, Pagoto, & Saczynski, 2015; Parchman, Zeber, & Palmer, 2010; Skolasky, Green, Sharfstein, Boult, Reider, & Wegener, 2011).

This study utilizes data from the Achieving Blood Pressure Control Together (ACT) Study (Principal Investigator: Ebony Boulware, MD, MPH; Supervisor: Patti Ephraim, MPH), a randomized controlled trial designed to test the effectiveness of behavioral interventions to increase self-management in African Americans with uncontrolled hypertension receiving primary care in Baltimore, MD (N = 159). Data were collected during a telephone interview at enrollment assessed participant’s perceived stress, patient activation, and medication adherence. Perceived stress was measured using the 14-item Perceived Stress Scale (PSS), designed to assess experiences with stress in the past month (Cohen, Kamarck, & Mermelstein, 1983). Patient activation was assessed using the Patient Activation Measure (PAM), a 13-item questionnaire that addresses key psychosocial constructs of self-efficacy, motivation and knowledge regarding the management of one’s disease (Hibbard et al., 2004). The 8-item Morisky Medication Adherence Scale was used to assess habits in taking prescribed medication as instructed by a physician (Morisky, Ang, Krousel-Wood, & Ward, 2008). High scores indicate a patient who is non-adherent.

In a cross-sectional analysis, this study will investigate the relation between perceived stress to the outcome of medication adherence, the relation between perceived stress and patient activation, and if patient activation is associated with medication adherence for this sample of uncontrolled hypertensive urban African Americans. Lastly, this study aims to investigate if patient activation mediates the relation between perceived stress and medication adherence.