Running Head: MEDICATION ADHERENCE IN AFRICAN AMERICAN ADULTS
Antihypertensive Medication Adherence in African American Adults
State of Knowledge
Nympha Charles
Florida International University
NGR 1178 Scientific and Theoretical Foundation
December 3, 2017
MEDICATION ADHERENCE IN AFRICAN AMERICAN ADULTS
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Abstract
Antihypertensive medication non-adherence is a subject of concern to all stakeholders
in the management of hypertension in African American adults. Non-adherence to medication
has caused often results in uncontrolled hypertension that leads to cardiovascular complications
of varying severity. This paper aims to understand the challenges and assess solutions
surfacing in the care of hypertensive African American adults through the critical review of the
literature. Results of the study suggest that the challenges in the adherence to antihypertensive
medication are socioeconomic, psychosocial, and interpersonal factors causing difficulties for
both the patient and the healthcare providers. The proposed solution is to adopt a
comprehensive health promotion procedure that would ensure both short-term and long-term
care to patients. Thereby it will enable healthcare workers to provide holistic and rehabilitative
care to patients with the pre-existing condition of hypertension while making sure those
healthcare sectors to provide necessary support to institutionalize quality and accessible for all.
MEDICATION ADHERENCE IN AFRICAN AMERICAN ADULTS
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Introduction
Hypertension is a universal health crisis that affects people of all races, ethnicities, sex,
and walks of life. In the United States, it is considered as one of the major concerns in public
health having about 78 million cases for 20 years old and over (Buis et al., 2015). The statistics
also contribute to the concern on hypertension as it is known to be one of the leading primary
or secondary causes of death in the modern age. Studies of Roger et al., (2012) and Danaei et
al., (2010) suggest that cardiovascular mortality is caused predominantly by hypertension and
claims to be the primary source of disparities in all-cause mortality (as cited in Young et al.,
2015). One of the contributors to this disparity according to previous studies of Egan et al.
(2010), Mensah et al., (2005) and Douglas et al., (2003) is the early onset, high prevalence,
great severity, and high rate of inadequate treatment of the disease among African Americans
(as cited in Young et al., 2015). This is consistent with the study of Wong et al., (2002) that
African Americans have been observed to exhibit cardiovascular mortality; half of the cases
are attributed to hypertension (as cited in Cené et al., 2012). The National Center for Health
Statistics (2009) and the Centers for Disease Control and Prevention (2010) reported that
African Americans, especially men, suffer hypertension at a disproportionately higher rate in
comparison to any other race or ethnic groups as reported by (as cited in Cené et al., 2012).
Inadequate patient education, self-efficacy, and self-management skills also significantly
impact the prevalence of uncontrolled hypertension in African American (Buis et al., 2015).
While antihypertensive treatments are widely available and sometimes accessible to
hypertensive patients, non-adherence to medication and treatment regimens undermines the
effectiveness of antihypertensive therapy in African Americans. Improving patient-care
provider interaction and promoting self-efficacy in patients have been suggested to be crucial
to successfully increase adherence to antihypertensive treatment and reducing hypertensionrelated mortality in African Americans.
MEDICATION ADHERENCE IN AFRICAN AMERICAN ADULTS
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Many studies have researched the prevalence of hypertension in African
American communities to determine the driving factors behind non-adherence to
antihypertensive treatment among Blacks and identify potential interventions to improve
adherence to treatment and reduce the risk of complications. Several factors including cultural
perception of hypertension, racial discrimination on the access or lack of health care, and the
quality of care provided influences the management of hypertension in African American
adults and impacts on the rate of uncontrolled hypertension in this population (Buis et al.,
2015). Thus, it can suggest that the rate of prevalence of hypertension in African American
adults is a multifactorial consequence that covers vast areas of health concerns from a personal
health view to multi-sector provision of care.
This paper reviewed existing literature including academic journals and articles on
hypertension, antihypertensive medication adherence and the factors that influence these
conditions in African American populations. These reviews explore the theoretical framework
and health models used in the research of adherence to medication in hypertensive African
Americans. It also evaluates for potential practice implication for care providers to address the
problem of medication non-adherence in patients. Furthermore, this paper also identified
common themes emerging from the results of the reviewed to propose an evidence-based health
promotion framework that can be utilized to support the needs of hypertensive African
American adults.
Component of the Literature Search
The student employed database research through CINAHL, Google Scholar, ProQuest,
and Ebsco databases. General headings on medication adherence were used for purposes of
online database search using keywords such as antihypertensive, drug adherence, medication
compliance, and African American patients. Specific headings include keywords such as
African American hypertension, African American drug adherence to medication, and
MEDICATION ADHERENCE IN AFRICAN AMERICAN ADULTS
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antihypertensive drug compliance. Other headings used to qualify relevant journal articles that
include keywords such as self-efficacy theory, health promotion theory, and health education
efficacy. A total of 17,700 academic journals, newspaper articles, and books resulted from the
initial database search.
Since the focus of the critical review was on antihypertensive
medication adherence, only articles cited between 2010 to 2017 considered. Excluded Books,
essays, and newspaper articles from the study. There are ten articles annotated and reviewed
from the online database research using the inclusion and exclusion criteria. All ten articles
were empirical quantitative descriptive studies most of which utilized frameworks to guide the
research process.
Historical Evolution of the Theory
Health Promotion is the process of supporting and empowering people to play active
parts in the control and improvement of their health (WHO, 2017). Health promotion focuses
on social and environmental interventions rather than individual behaviors as the primary tool
for improving health and wellness in any population. O’Donnell (1987) defines it as both
science and art where people are assisted towards lifestyle change to achieve optimum health
functioning (as cited in Edelman, Mandle, and Kudzma, 2013, p. 11). This definition suggests
that the core context of health promotion is the process that enables people to be able to take
control of their health to attain optimal functioning. The U.S. Public Health Service
commissioned Kreuter and Devore (1980) to formulate a more comprehensive definition of
health promotion that is supporting health-related advocacies (as cited in Edelman et al., 2013,
p. 11). They intended to encourage positive healthcare practices to be adopted by individuals,
businesses, and government institutions towards promoting health consciousness, a norm in
the society (Edelman et al., 2013, p. 11). The root of this theory covers various disciplines in
social sciences such as the theory of reasoned action by Ajzen and Fishbein (1980), theories of
behavior by Albert Bandura (1976, 1999, 2004), the health belief model by Rosenstock (Janz
MEDICATION ADHERENCE IN AFRICAN AMERICAN ADULTS
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et al., 2002), Pender’s health promotion model (Pender et al., 2010), and stages of change
theories by Prochaska (Prochaska et al., 2004) (as cited in Edelman, et al., 2013, p. 11).
These theories support the idea that health promotion, when aimed towards behavioral
change through social rather individual interventions, can result in the attainment of observable
behavioral outcomes of health promotion strategies. In addition, health promotion is not
limited to providing health education; it also serves as a platform for social change by
determining social issues affecting health and provides actual proactive solutions to address
these issues (Edelman et al., 2013, p.12). Collaboration among all participants including care
workers, community leaders, and patients is crucial in promoting a holistic health care attitude
in different communities.
Health promotion can either be active or passive depending on how the health care
providers view the patients. Passive health promotion views patients as receivers of health
information while active health promotion views patients as part of the implementation of a
health promotion program making them active collaborators of its goals and purposes
(Edelman et al., 2013). The student opted to adopt the integration of both passive and active
health promotion through the Transtheoretical model that integrates three concepts of change
in health promotion.
These include the conceptualization of change as a time-bound
perspective that moves on a continuum from readiness to action. Decisional Balance is another
concept considers the factors affecting change in behavior by reflecting the individual’s
weighing of the pros and cons of changing (Peterson & Bredow, 2017, p.286). Self-efficacy
defines a change regarding the intrinsic motivation of a person to change habits or actions while
the process of change outlines different mental, emotional, and behavioral actions affecting
change (Peterson & Bredow, 2017, p.229). The theory of self-efficacy developed by Bandura
claims that expectations and outcomes associated with self-efficacy are not only influenced by
the behaviors of individuals but also the expectations influenced by verbal encouragement from
MEDICATION ADHERENCE IN AFRICAN AMERICAN ADULTS
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others such as nurses, doctors, and family (Peterson & Bredow, 2017). The core purpose of
using the Transtheoretical framework is to be able to study and provide holistic and viable
means for the adherence to antihypertensive medication of African Americans. It also shifts
the focus of health promotion from a solely acute, hospital-based approach to a primary and
preventive, community-based care (Edelman et al., 2013, p. 15). This entails the active
involvement of nurses in making sure that desired changes are achieved and sustained by the
patients they serve. The goals of health promotion also require nurses to play various roles such
as advocates, care managers, consultants, deliverer of services, educators, healers, and
researchers (Edelman et al., 2013).
The framework used to explain, understand, and respond to the issues involving the
adherence to the antihypertensive medication of African American adults is valuable in the
proposing a process that results in possible actions. In turn, would enable healthcare providers
and related sectors to develop, implement, and evaluate different protocols to address the
increasing prevalence hypertension not only in the African Americans but also to the general
population of the country.
Conceptual, Theoretical, Methodological Issues
Six stages highlight the current conceptual issues that influence medication adherence
and non-adherence in hypertensive African Americans. The concept of Transtheoretical model
as a basis for health promotion is based on the six stages of change: pre-contemplative stage
(where individuals are not considering change); contemplative (where individuals are aware of
the problems but not considering change soon); preparation stage (where individuals are
planning to act soon); action (where individuals are beginning to show signs of recent
behavioral change); maintenance (where individuals are observed to continue exhibiting
favorable behavior that can be sustained for long term); and relapse (where individuals revert
MEDICATION ADHERENCE IN AFRICAN AMERICAN ADULTS
to old behavior) (Peterson & Bredow, 2017).
7
These stages are used to describe the
phenomenon of antihypertensive medications adherence in African American.
The key to the effective treatment and management of hypertension is the integration
of different care models and interventions to achieve maximum effectiveness. Some of the
interventions utilized in the management of hypertension in African Americans include
lifestyle modifications such as improved physical activity, dietary regimens, and controlled
smoking and alcohol intake. Martin et al., (2010) purports that hypertension is a cardiovascular
risk factor that is most commonly modifiable. Hypertension can be regulated to make sure it
does not progress into cardiovascular complications such as stroke or cardiovascular accidents.
The literature surrounding the antihypertensive adherence of the African American adults
talked about various issues and contexts, which were valuable in explaining how people in this
demography struggle to be adherent to the directives of taking their respective medications. It
also raises valuable concerns in the healthcare promotion and healthcare provision of the
different healthcare sectors and providers. Thus, in the review of the literature, the student
reported three issues discussed in the literature selected.
The first issue identified is the factors that contribute to the non-adherence to
antihypertensive medication of the African Americans. The pre-contemplative, contemplative
and event to some extent the planning stage where various factors explain the readiness of
specific population to change toward medication adherence. The second issue is the proposed
solutions of the different researchers towards reducing non-adherence to antihypertensive
medications in African American adults. This section falls on the preparation, action and
maintenance phase of health promotion as it utilizes the available responses of Black American
and recommendation to address solutions to medication adherence. The third issue discusses
the theoretical frameworks used in the research of antihypertensive medication adherence in
African American adults and their limitations that may offer valuable insight for future studies.
MEDICATION ADHERENCE IN AFRICAN AMERICAN ADULTS
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Factors of Medication Non-Adherence for Hypertensive Patients
Studies suggest that non-adherence to medication is one of the contributing factors to
elevated blood pressure among African Americans, (Young et al., 2015; Schoenthaler et al.,
2017; Cené et al., 2012). This may be attributed to three particular issues: socio-economic
factors (Young et al., 2015, Richardson et al., 2014), psychosocial status (Schoenthaler et al.,
2017; Schoenthaler et al., 2016; Abel & Efird, 2013; Cuffee et al., 2013; Cenè et al., 2012, and
Warren-Findlow et al., (2011), and health care provider factors (Schoenthaler et al., 2017;
Schoenthaler et al., 2016; Buis et al., 2015; Richardson et al., 2014; Abel & Efird, 2013;
Warren-Findlow et al., 2012; and Martin et al., 2010). These factors predispose African
American adults to complications of hypertension caused by high and uncontrolled arterial
blood pressure.
Socio-economic Factors
One of the most consistent findings of the literature studies is the prevalence of
antihypertensive medication non-adherence in African American adults who belong to lowincome families. The reason for their non-adherence to medication is caused by their relatively
weak access to medication and low self-efficacy. The failure of their health care insurance
coverages to sustain their access to antihypertensive medications is also a contributing factor
(Young et al., 2015). Thus, patients who need and want medications are forced to skip dosages
or entirely miss their medications as often recorded before admission to hospitals. In the study
of Martin et al., 2010, 60% of the adult participants reported being non-adherent to medications
due to limited access to free medications. Factors that influenced this phenomenon also include
inadequate patient-provider engagement and communication, forgetting to take medications,
and running out of antihypertensive medications. The findings indicated that more individuallevel intention is required to remedy the rates of non-adherence that occur mainly due to
individual factors such as negligence.
MEDICATION ADHERENCE IN AFRICAN AMERICAN ADULTS
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Psychosocial Factors
The psychosocial factor that contributes to medication non-adherence was
comprehensively studied in the research by Schoenthaler et al. (2016). Specifically, the study
centers on self-efficacy and depression as a key component of medication adherence among
hypertensive patients. Warren-Findlow et al. (2011) describe self-efficacy as a psychosocial
concept related to the ability of a person to manage a chronic disease. This self-management
practice according to Schoenthaler et al. (2016), has been applied and associated with the
adoption of and adherence towards specific health behaviors including consistent intake of
medication as a practice for patients with chronic illness. In addition, self-efficacy is also a
predictor towards self-management especially with adherence to medication. People who tend
to have high self-efficacy are inclined to exhibit confidence, especially in assigned tasks as
they tend to exert more effort in accomplishing responsibilities, take up challenging endeavors,
and are proven to persist longer in difficulties and obstacles (Schoenthaler et al., 2016). A
higher level of self-efficacy is directly found to influence an improvement in medication
adherence. The study of Richardson et al., (2014), proposed measuring self-efficacy towards
adherence to medication using a 26-item scale known as the Medication Adherence SelfEfficacy Scale with potential scores ranging from 0 to 78.
On the contrary, Richardson et al. (2014) claim that low self-efficacy is resulting from
experiences of discrimination regarding race or ethnicity and mental status results to adverse
effects in medication adherence. Depression is another psychosocial factor that is related to
medication adherence (Warren-Findlow et al., 2011). According to Howard et al. (2006),
hypertensive patients are associated to have poor adherence to medication, case in point is a
study conducted by Bosworth et al., (2008) among hypertensive African Americans with
depression symptoms were found out to have difficulty adhering to medications due to low
self-efficacy (as cited in Warren-Findlow et al., 2011). The claims of the role of depression to
MEDICATION ADHERENCE IN AFRICAN AMERICAN ADULTS
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non-adherence to medication support the idea that the psychological state of the person affects
health-related tasks such as regular intake of medicine. Thus, it can be reasoned that low selfefficacy is directly relational to depression and non-adherence to medications. Measuring
depression symptoms in patients who have medication adherence problems can be a challenge.
The study of Cené et al., (2012) suggest an instrument to be used to measure depression
symptoms through the Center for Epidemiologic Studies Depression (CESD) scale, which is a
20-item questionnaire using a 4-point Likert response format aiming to measure the symptoms
of depression pre-existing for one week.
Interpersonal Factors
Interpersonal factors were also part of the discourse whether it is affecting patient
adherence to medication. The relationship between the healthcare provider and the patient is
crucial in the delivery of care and communication of medication instructions. Schoenthaler et
al., (2017) conducted research that illustrated the importance of communication between care
providers and hypertensive patient. The patient-provider communication is hypothesized as
the mediating factor that influences antihypertensive medication adherence and plays an active
role in the management of hypertension in both African American and Caucasian hypertensive
patients. The study focused on the aspect of medication adherence and the factors that drive it
in the effective management of hypertension. Using a cohort research method, the researchers’
sampled 92 hypertensive patients (the majority of whom were African Americans) and 27 care
providers in three selected primary care centers for three months. During the research period,
every interaction between care providers and receivers were audiotaped and coded to form a
baseline data for the assessment of medication adherence in patients. Electronic monitoring
devices were used to connect medication adherence data in the participants all through the
period of the study. Findings of the study showed that more than half of the participants
presented with poor medication adherence levels at the conclusion of the study due to different
MEDICATION ADHERENCE IN AFRICAN AMERICAN ADULTS
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kinds of patient-provider interactions with varying degrees of patient-centeredness. One of the
key strengths of the study is that it objectively measured the influence of patient-provider
communication on medication adherence using empirical data.
Another factor in this interpersonal aspect of medication adherence is the trust value as
a significant element in the relationship between patient and health care provider as it generates
positive outcomes (Abel & Efird, 2013). Trust develops through extensive patient-provider
engagement and communication, promotion of patient education, honesty in patients, and
adherence to medications and treatment regimes. This concept was thoroughly discussed in the
quantitative cross-sectional study conducted by Abel & Efird, (2013). The study was conducted
with a sample population of African American women of the Piedmont, North Carolina region
who have been diagnosed with hypertension as participants.
Demographic and clinical
inclusion and exclusion criteria were used to screen the participants including age, language
ability, and current medication. Standardized instruments including the Trust in Physician
Scale and Hill-Bone Compliance to High Blood Pressure Therapy Scale were used to collect
research data from the participants. Data collected included demographic and socioeconomic
data such as education, income, and medical history as well as anthropometric measurements
such as blood pressure and weight. Three variables that predicted medication adherence in the
patients including age, the quantity of medication, and trust in care provider were measured
and analyzed. The study found that patients with a smaller amount of medications tend to be
more adherent to their treatment regimen compared to others who had to take more. The study
also found that patients who had the most trust in their care providers were also the most
adherent to their medication and treatment regimen.
Both the studies of Schoenthaler et al. (2017) and Abel & Efird (2013) suggest the need
for health care providers to assist, communicate with, and educate their patients in the
necessary details of their medication regimen. Social support is another aspect of healthcare
MEDICATION ADHERENCE IN AFRICAN AMERICAN ADULTS
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provision which has been identified to have a direct effect on adherence to medication. Studies
have identified that social support has positive effects on patient satisfaction to the care
provided (Schoenthaler et al., 2016). Social support impacts the adherence of patients to
medication as it fosters patient satisfaction encourages self-efficacy and alleviates depression.
Solutions to Adherence to Medication
Keenan and Rosendorf (2011) reported that hypertension affects about 40% of adults
between ages 45 to 64 and 70% of adults over 65 years old respectively (as cited in WarrenFindlow et al., 2011). This indicates the alarming prevalence of the disease in the aged
population, which requires intensive planning for intervention. There is a need for both shortterm and long-term interventions to efficiently improve antihypertensive medication adherence
in African American adults.
Health promotion has been the better option for health care providers to consistently
manage the condition and the lapses of the patients towards behavioral change. One short-term
solution is the recommendation of the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure (JNC7) instituting the practice of health
care activities that will enable people with hypertension to live healthy lives. The U.S.
Department of Health and Human Services (2004) advocates the following JNC7 practices:
adherence to health care medications and regimen, maintenance or losing weight, nutrition
regulation through low-salt diet, alcohol intake regulation, regular physical activity, and
elimination of tobacco use (as cited in Warren-Findlow et al., 2011). These activities can be
taught by health care providers to communities to encourage them to change their respective
lifestyles to alleviate hypertensive conditions. Another aspect that can be part of the health
promotion is through Counseling African Americans to Control Hypertension (CAATCH),
which includes patient intervention such as interactive patient education, regular monitoring of
blood pressure at home and monthly lifestyle coaching sessions on diet, exercise, and
MEDICATION ADHERENCE IN AFRICAN AMERICAN ADULTS
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adherence to treatment; physician intervention, on the other hand, includes medical education
of patients with hypertension and feedback sessions/consultations regarding blood pressure
records at home and audit of patient charts (Warren-Findlow et al., 2011). These solutions
may have a relative impact to the commitment of the patient and his/her ability to comply, but
most importantly, the communication between the patient and healthcare provider must be
maintained for this remedy to be satisfactory.
To institutionalize health care benefits and health care utilization of African American
patients with hypertension, a health reform agenda is needed to engage government officials
and respective healthcare organizations to enable management and maximization of
medication and insurance coverage and copays (Young et al., 2015). This will be a very
complicated debate and might take a long time for changes to occur, but it would have a
significant impact towards residents with low-income resources.
Measurement and Validity of Adherence
One apparent limitation in most of the literature reviewed is the fact that the studies
utilized low-income population as target subjects. In so doing, it poses a significant challenge
to the studies, as the results cannot reasonably be applied to other income populations. This in
itself poses a research bias that may have actual or potential effect on the results and
interpretation of the study. Another issue is the self-reporting measures utilized in the
collection of research data pose a few problems. As Young et al. (2015) noted, is inherent for
self-reported adherence to medication data to be imperfect. Warren-Findlow et al. (2011) also
noted that there is a high probability for researchers to incorrectly or inconsistently classify the
responses and behaviors reported by the patients. The most glaring weakness is the risk of
social desirability bias where participants overestimate or underestimate specific variables and
significantly impacting findings of studies in the process. Future researchers may want to take
into consideration using other forms of instruments to gather data to minimize errors and bias.
MEDICATION ADHERENCE IN AFRICAN AMERICAN ADULTS
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Studies who applied the instruments of previous studies may experience the same limitations
that limit the outcome and clinical implication of their studies. Another gap in the reviewed
studies is the failure to offer long-term monitoring of the adherence of patient to medications.
The studies explained the dynamics of the adherence and proposed solutions but were unable
to validate if the implemented solutions were feasible also for the long-term practice of
medication adherence to hypertensive patients. This may also highlight limitations of the study
that may offer, “relapse” to non-adherence of patients to medication.
Summary of the State of Science
A review of current literature on the prevalence of hypertension, its treatment
and management, and adherence to medication in African Americans provide valuable insights
in the different factors that affect the medication adherence in these groups and how it
influences patient outcomes. The theoretical frameworks used in the studies reviewed were
mostly based on the findings of other studies or general data. Three studies used the selfefficacy theory while others used the health promotion theory. Both studies are quantitative
studies that evaluated hypertension treatment in African American adults and the influence of
medication adherence on patient outcomes and hypertension mortality. A thorough analysis
and reflection, the transtheoretical model for health promotion, integrate self-efficacy theory
together with the stages of change, decisional balance, and the process of change (Edelman et
al., 2013).
It is important to note as well that the result of the studies was similar regarding the
impact of self-efficacy, health promotion, engagement, communication, and trust between
patients and care providers on medication adherence and patient outcomes in African American
adults. This confirms that medication adherence is a multifactorial and multi-dimensional
concept. To understand the dynamics of the phenomenon, one must understand that non-
MEDICATION ADHERENCE IN AFRICAN AMERICAN ADULTS
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adherence or adherence to medication occurs as an interconnected process that drives the
holistic performance and well-being of the person.
Conclusion
Medication adherence is a multifactorial and multidimensional phenomenon that is of
great concern to caregivers and hypertension patients in African American communities. The
socio-economic factors, psychosocial factors such as patient-provider engagement and
interpersonal factors of communication, patient education, and self-care behaviors play crucial
roles in medication adherence and patient outcomes in African American adults with
hypertension. However, there is a common weakness that undermines the strength of the
findings. The self-reporting measures utilized in the collection of research data pose a few
problems. The most apparent weakness is the risk of social desirability bias, where participants
overestimate or underestimate specific variables and significantly impacting findings of studies
in the process. Additional research and review of the current literature are needed to establish
a more precise theoretical framework in the context of health promotion through the
transtheoretical model for the study of medication adherence in hypertensive African American
adults to improve on existing knowledge and develop new hypertension treatment and
management measures that will reduce non-adherence in hypertensive patients.
MEDICATION ADHERENCE IN AFRICAN AMERICAN ADULTS
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