This study is among the first to simultaneously examine racial differences in patients’ experiences with physicians, attitudes and beliefs about hypertension and antihypertensive medication, and the association of each of these dimensions with patients’ antihypertensive medication adherence. In our sample with similar BP control among Whites and African Americans, we found that African Americans believed BP to be a more serious health threat, suggesting that public health, VA system-wide, and clinician-provided messages about the significance of high BP, especially among African Americans, seem to be reaching their target. These results also suggest that African Americans are receiving enhanced BP care—their physicians counseled them more about blood pressure and prescribed more medications for their BP. Thus, these VA providers seem to have received and acted upon the message regarding poorer outcomes for African-American patients with hypertension. We conclude that such methods and strategies, when used by clinicians, may positively influence patients’ beliefs about antihypertensive medications.
Our findings differ from previous reports about racial/ethnic differences in specific knowledge and beliefs about hypertension23,24
, and suggest that in the VA setting, African Americans perceive BP to be a more serious threat to health than do White patients. In contrast, whereas earlier reports had noted that White patients were more likely to be counseled about hypertension by their providers25
, our findings suggest the opposite dynamic is occurring in the VA.
Our study was limited in several ways. First, we only studied regular users of the VA care system, which may have biased our sample toward more adherent patients (e.g., appointment keepers). However, we still observed a range of adherence behaviors. Also, the VA system cares primarily for male patients, so our results may not be generalizable to women, or to patients in non-VA settings. Further, racial disparities in health care may be minimized in the VA setting26
, which could limit our ability to generalize these findings.
These results suggest that several patient health beliefs and practices are associated with adherence, although we were unable to determine the causal direction of the associations. The fact that a patient’s understanding that his blood pressure was high was negatively associated with adherence, as were reports of providers counseling about medication taking suggests that providers may have been working harder with patients with harder-to-control BP, or with patients who did not seem to be adherent.
Notably, patients with greater perceived self-efficacy in medication taking had better adherence. Such beliefs can be fostered by primary care providers during clinic visits, using strategies developed for patient-centered counseling12
. Clinicians can ask open-ended questions of their patients about medication adherence such as, “What kinds of problems are you having taking your blood pressure medications?” Then, using barriers identified by the patients, clinicians can help to strategize ways to address such barriers, thus enhancing patients’ self-efficacy, and adherence. Indeed, our prior work has demonstrated that there is room for improvement in primary care clinicians’ antihypertensive medication adherence counseling skills27
African Americans are disproportionately affected by hypertension, with lower rates of blood pressure control in the general population, although not in this VA sample. Notably, less than half of this sample overall had controlled BP, indicating much room for improvement in BP care. Our findings suggest that patient beliefs are significantly associated with blood pressure medication adherence. Thus, we encourage providers to actively learn more about their patients’ beliefs about both hypertension and its therapies, to provide targeted counseling to help patients improve medication adherence, and ultimately, blood pressure control.