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Hypertension knowledge, heart healthy lifestyle practices and

medication adherence among adults with hypertension
Hawa Ozien Abu
University of Massachusetts Graduate School of Biomedical Sciences

Et al.

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Abu HO, Aboumatar H, Carson K, Goldberg RJ, Cooper L. (2018). Hypertension knowledge, heart healthy
lifestyle practices and medication adherence among adults with hypertension. University of
Massachusetts Medical School Publications. https://doi.org/10.5750/ejpch.v6i1.1416. Retrieved from
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 European Journal for Person Centered Healthcare 2018 Vol 6 Issue 1 pp 108-114

ARTICLE

Hypertension knowledge, heart healthy lifestyle practices and

medication adherence among adults with hypertension
Hawa O. Abu MBBS MPHa, Hanan Aboumatar MD MPHb, Kathryn A. Carson ScMc, Robert J.
Goldberg PhDd and Lisa A. Cooper MD MPHe
a PhD Student, Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA,
USA
b Associate Professor of Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD,
USA
c Senior Research Associate, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health; Department of
Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
d Professor, Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
e Bloomberg Distinguished Professor, James F. Fries Professor of Medicine, Department of Medicine, Johns Hopkins
University Schools of Medicine. Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public
Health. Director, Johns Hopkins Center for Health Equity, Baltimore, MD, USA

Abstract
Objective: To assess patients’ knowledge about hypertension and its association with heart healthy lifestyle practices and
medication adherence.
Methods: We conducted a cross sectional survey of 385 adults with hypertension treated at 2 primary care clinics in
Baltimore, Maryland, USA. We used an 11-item measure to assess hypertension knowledge and obtained self-reports on
dietary changes, engagement in aerobic exercise and medication adherence.
Results: Approximately 85% of patients properly identified high blood pressure, but more than two-thirds were unaware
that hypertension lasts a lifetime once diagnosed; one-third were unaware that hypertension could lead to renal disease.
Patients with low hypertension knowledge were less likely to reduce their salt intake (OR=0.44 [95% CI: 0.24-0.72]) and
eat less to lose weight (OR=0.48 [95% CI: 0.26-0.87]) than patients with high hypertension knowledge.
Conclusion: In general, patients were knowledgeable about hypertension, but most were unaware that hypertension is a
lifelong condition and could lead to kidney disease. High knowledge of hypertension was associated with healthy lifestyle
practices including eating less to lose weight and dietary salt reduction.
Practice Implications: Intensifying education strategies to improve patients’ knowledge of hypertension may enhance their
engagement in heart healthy lifestyle practices for optimal blood pressure control.

Keywords
Blood pressure control, heart healthy lifestyle practices, hypertension knowledge, lifestyle modification, medication
adherence, patient awareness, patient counseling, patient education, person-centered healthcare

Correspondence address
Dr. Hawa Abu, Clinical and Population Health Research Program, Department of Quantitative Health Sciences, University
of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01605, USA. E-mail: [email protected]

Accepted for publication: 28 August 2017

Introduction in stroke and heart disease [4]. Approximately one half of

adults with hypertension were aware they had high blood
pressure and only 10% of those treated had good blood
Hypertension is a major modifiable cause of cardiovascular
pressure (BP) control [4]. In more recent surveys, more
disease which affects more than one billion individuals
than three quarters of American adults were aware that
worldwide [1,2]. Due to its asymptomatic and persistent
stroke and heart disease are complications of hypertension,
nature, hypertension is referred to as “the silent killer” [3].
over 70% knew they had high BP and more than one half
In the United States, hypertension affects approximately 1
of those treated for hypertension achieved optimal BP
in 3 adults despite considerable improvements in the
control [4,5].
detection and management of high blood pressure over
The reasons for uncontrolled hypertension are
time [4,5]. Several decades ago, less than one quarter of
multifactorial with a number of patient and provider
American adults were aware that hypertension could result

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 European Journal for Person Centered Healthcare 2018 Volume 6 Issue 1

contributory factors [6]. Insufficient knowledge about developed to ascertain knowledge about hypertension in a
hypertension could lead to less optimal BP control through population of patients with low literacy [18]. Since our
lower rates of adherence to prescribed antihypertensive study was designed to address other aims in addition to
medications and engagement in heart healthy lifestyle patients’ knowledge about hypertension, to reduce
practices which have been shown to promote adequate BP participant burden we adapted a shorter version with 11
control and prevent complications resulting from high BP questions about the definition, prevention, management
[7,8,9]. Clinical trials have consistently reported that and complications of hypertension. Patient responses were
reduction in the dietary intake of sodium favorably affects recorded as either “true”, “false” or “uncertain”, from
BP control among older adults [10,11]. Furthermore, which we created binary codes of “correct” for true
observational studies and randomized trials have shown responses or “incorrect” for false and uncertain responses.
that weight loss lowers BP in hypertensive individuals, as One point was allocated to each question and we generated
does increasing levels of regular physical activity [12,13]. summary scores ranging from 0-11. Based on the
Adherence to recommended antihypertensive medications distribution of knowledge scores (Figure 1), we chose cut-
is central to adequate hypertension control resulting in off values for hypertension knowledge; patients with
reduced cardiovascular morbidity and mortality and lower scores < 9 were classified as having low knowledge
healthcare costs [14,15]. whereas patients with scores ≥ 9 were classified as having
A previous study showed that patients have good high knowledge. Internal reliability of the knowledge
knowledge that lowering their BP will improve their health scores using Cronbach’s alpha was 0.7 indicating adequate
status [16]. However, among the limited number of studies internal consistency [19].
that have evaluated patient’s knowledge about
hypertension; most failed to explore the relationship Figure 1 Distribution of hypertension knowledge
between hypertension knowledge and the adoption of heart scores from the 11-item measure
healthy lifestyle practices and adherence to
antihypertensive medications. The purpose of the cross
sectional study presented here was to examine the extent of Distribution of hypertension knowledge scores
knowledge about hypertension among adult hypertensive
100

patients and the association between hypertension

knowledge and engagement in heart healthy lifestyle
80

practices and antihypertensive medication adherence for

more effective BP control.
Frequency
60

Methods
40
20

Study design and participants

0

0 5 10 15
A cross-sectional self-administered survey was conducted Hypertension knowledge scores
in 2012 at 2 primary care clinics in Baltimore, MD. This
survey was used to obtain baseline data for a quality
improvement pragmatic trial (Project ReD CHiP; 2010- Outcome variables
2015) designed to address multilevel factors known to
contribute to disparities in the management of adults with Patient engagement in heart healthy lifestyle modification
hypertension. The recruitment methods and interventions practices was assessed from patient self-reports which
used in this pragmatic trial have been described in detail included questions about; reduction in the amount of
previously [17]. In brief, consent was obtained by an dietary salt consumed, eating less to lose weight and
introductory statement on the survey instrument informing engagement in weekly aerobic exercises. Patients were
participants that by responding to the survey they were asked about their salt consumption and dietary changes
participating in a research study. The eligibility criteria with the following statements “I reduce my salt intake as
included adult patients ≥18 years of age, who had been much as possible” and “I eat less to help me lose weight”
diagnosed with hypertension and had been seen by a with responses of “Disagree Strongly”, “Disagree”,
primary care provider in the prior 6 months. The Johns “Neutral”, “Agree” or “Agree Strongly”. We created
Hopkins Medicine Institutional Review Board approved binary responses from the questions on dietary salt intake
this observational study. and eating less to lose weight as follows; Agree and Agree
strongly were coded as “Yes” and the other responses as
“No”. Patients were asked about their engagement in
Measurement of Hypertension Knowledge aerobic exercise with the question: “Do you engage in any
regular exercise such as brisk walking, jogging or
Hypertension knowledge was assessed using questions bicycling.” The responses were “No”, “Yes, 1-2 times per
adapted from a 21 item questionnaire on individuals’ week” or “Yes, 3 times a week or more”. We created a
knowledge of hypertension [18]. The questionnaire was

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Abu, Aboumatar, Carson, Goldberg & Cooper Hypertension knowledge and medication adherence

binary response of “No” for those who responded “No” Model results are shown as odds ratios (OR) and
and “Yes” for all other responses. accompanying 95% Confidence Intervals (CIs)
Medication adherence was assessed with a 4-item
medication adherence questionnaire based on its Results
simplicity, availability and validation in a previous study
[20]. Patients were asked questions about their
antihypertensive medication-taking behaviors with binary Characteristics of study participants
responses of “yes” or “no”: (1) “Do you ever forget to take
your blood pressure medicine?”, (2) “Are you careless Overall, the mean age of study participants was 59.5 years,
about taking your blood pressure medicine?”, (3) “When 72.5% were women and more than one-half were Black.
you feel better do you sometimes stop taking your blood The majority had greater than a high school education and
pressure medicine?” and (4) “If you feel worse when you approximately three quarters had adequate health literacy.
take your blood pressure medicine do you sometimes stop The average age of patients with low and high knowledge
taking it?” We dichotomized patient responses as of hypertension was relatively similar (Table 1).
“adherent” if they responded “No” to all 4 questions and Approximately two-thirds of patients with low knowledge
“non-adherent” if they responded “Yes” to at least one of hypertension had adequate health literacy whereas 77%
question [20]. of patients with high knowledge of hypertension had
adequate health literacy.
Covariates
Hypertension knowledge
Patient demographic characteristics included age, sex, race,
highest level of education attained and annual household More than 80% of respondents correctly specified high
income. We categorized the highest level of education as < blood pressure as readings ≥ 140/90mmHg and knew that
high school degree or ≥ high school degree. Annual hypertension is asymptomatic (Table 2). Approximately
household income was categorized as < $50,000 and ≥ 90% of patients were aware of the complications
$50,000. Patient’s health literacy was assessed with the associated with hypertension including stroke, heart attack
question: “How confident are you filling out medical forms and heart failure. However, one third of participants did
by yourself?” Consistent with prior health literacy studies, not know that hypertension could cause kidney disease.
we categorized health literacy as adequate if the More than two-thirds of the patients were unaware that
participants answered “quite a bit confident” and hypertension “usually lasts for a lifetime” once diagnosed.
“extremely confident” or as inadequate if they answered At least 90% of participants correctly answered the
“not at all confident, “a little confident” and “somewhat questions about the role of heart healthy lifestyle
confident” [21]. These variables were adjusted for in the modifications in lowering BP including dietary salt
multivariable models based on prior reports of their reduction, consumption of fruits and vegetables, exercising
association with knowledge about hypertension and regularly and losing weight. Figure 1 shows the
patient’s adoption of heart healthy lifestyle behaviors and distribution of hypertension knowledge scores ranging
medication adherence [8,16,18]. from 0-11 with an asymmetric distribution and left
skewness. Approximately 1 in 5 patients had low
hypertension knowledge scores (< 9).
Data Analysis

We analyzed data from a total of 313 study participants Engagement in heart healthy lifestyle
who did not have missing values for the knowledge practices and antihypertensive medication
questions and other covariates. We compared differences adherence
in various patient characteristics for those with low versus
high hypertension knowledge scores, using chi-square Over half of the study participants were engaged in heart
analysis for binary variables and student’s t-test for healthy lifestyle practices; 65% reported adherence to their
continuous variables. In examining the association between antihypertensive medications, 75% reduced salt in their
the level of hypertension knowledge and engagement in diet and approximately one half engaged in regular aerobic
lifestyle modification practices, we conducted several exercise and ate less portions to lose weight. After
univariable and multivariable logistic regression models accounting for the potential confounding effects of
for each outcome (dietary salt intake, eat less to lose patients’ sociodemographic characteristics and health
weight, engagement in weekly aerobic exercise and literacy, persons with a high level of knowledge about
antihypertensive medication adherence). Multicollinearity hypertension were significantly more likely to reduce salt
was evaluated and ruled out by using a variance inflation in their diet and eat less to lose weight than patients with
factor of 3 or more to detect correlations between the low hypertension knowledge (Table 3). Although not
covariates included in the models. All analyses were done statistically significant, we found that patients with low
using STATA 13 (StataCorp, College Station, Texas). knowledge of hypertension had a lower odds of being

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 European Journal for Person Centered Healthcare 2018 Volume 6 Issue 1

Table 1 Characteristics of Study Participants according to hypertension knowledge scores (n= 313)

Participants with low Participants with high

Characteristics P-value
knowledge* (n=64) knowledge* (n=249)
Sociodemographic characteristics, n (%)
Age mean, yrs. (SD) 58.5 (11.7) 59.8 (13) 0.49
Female 46 (71.9) 181 (72.7) 0.9
Black 31 (48.4) 139 (57.8) 0.18
>High school Education 60 (95.2) 216 (90.1) 0.21
Annual Income ≥$50,000 32 (50) 153 (61.4) 0.1
Adequate health literacy 41 (64.1) 192 (77.1) 0.03
*Low hypertension knowledge (score <9); High hypertension knowledge (score ≥ 9)

Table 2 Frequency of correct responses to hypertension knowledge measure (definition, prevention,

complications and management)

11 item Hypertension knowledge measure Correct (n) % Correct

1. A blood pressure reading of 140 over 90 or higher is considered high blood pressure. 263 85.1

2. High blood pressure is especially dangerous because it often has no warning signs or 278 88.8
symptoms.

3. High blood pressure can cause heart failure. 267 89.3

4. Once high blood pressure develops, it usually lasts a lifetime. 106 33.9

5. High blood pressure can cause kidney disease. 199 64.2

6. High blood pressure can lead to stroke. 297 96.1

7. High blood pressure can lead to heart attack. 292 94.2

8. A person who has high blood pressure should eat less salt. 294 94.8

9. A person who has high blood pressure should eat more fruits and vegetables. 286 92.3

10. Exercise can lower a person’s blood pressure. 282 90.1

11. Losing weight can lower a person’s blood pressure. 300 95.8

Table 3 Prevalence of self-management practices according to hypertension knowledge and

association between hypertension knowledge and self-management practices

Self-management Self-management
prevalence among prevalence among Low vs. High Knowledge Low vs. High Knowledge
Outcome variables
patients with low patients with high Unadjusted OR (95% CI) *Adjusted OR (95% CI)
knowledge (n=64) knowledge (n=249)
Reduce dietary salt 60.9% 78.3% 0.43 (0.24-0.77) 0.44 (0.25-0.86)
Eat less to lose weight 37.5% 54.2% 0.51 (0.29-0.89) 0.48 (0.29-0.96)
Weekly Exercises 57.8% 55.4% 1.1 (0.63-1.92) 1.31 (0.74-2.38)
Medication Adherence 60.9% 65.9% 0.81 (0.46-1.42) 0.8 (0.45-1.5)
*Each model was controlled for participant’s age, sex, race, education, annual income and health literacy.

adherent to their antihypertensive medication and a higher Discussion

odds of engaging in regular aerobic exercise than patients
with adequate hypertension knowledge. (Table 3).
In this population of adults with hypertension who
attended two primary care clinics in the city of Baltimore,
we found that patients were very knowledgeable about
some aspects of their condition, but the majority were
unaware that hypertension is a lifelong condition and that
high BP could lead to kidney disease. Overall, more than

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Abu, Aboumatar, Carson, Goldberg & Cooper Hypertension knowledge and medication adherence

one half of the patients adopted recommended self- high knowledge about hypertension. Our findings are
management practices for hypertension. Patients with low consistent with a cross sectional study conducted in
knowledge about hypertension were less likely to be Ethiopia that examined factors associated with adherence
engaged in heart healthy lifestyle practices compared to to recommended lifestyle modification practices among
patients with high knowledge about hypertension. 404 patients managed for hypertension. The results of this
The majority of our survey respondents could correctly study showed that knowledge about hypertension was an
identify that BP levels ≥ 140/90mmHg are defined as high independent predictor of adherence with heart healthy
and were aware of the asymptomatic nature of lifestyle practices including dietary changes, smoking and
hypertension, as well as the complications due to high BP alcohol consumption [27]. Although our study showed
including stroke and heart attack. Our results are consistent trends between patients’ knowledge of hypertension and
with the findings from a geographically and ethnically antihypertensive medication adherence, prior studies have
diverse cross sectional study which assessed the extent of shown significantly better adherence among patients who
knowledge about hypertension among 530 patients were more knowledgeable about their condition [23,27]. In
attending 24 primary care practices throughout North addition to insufficient knowledge of hypertension, other
Carolina. This study found that 86% of respondents factors that may cause low medication adherence including
correctly identified high BP readings as values ≥ pill burden and costs of medication [28], were not
140/90mmHg and the vast majority of patients were aware accounted for in this present study. Although the majority
that high BP can be life threatening [22]. The finding that of our study participants were knowledgeable about the
most patients have good general knowledge about lifestyle modifications required for optimal BP control, we
hypertension emphasizes the increases in the general recognize that patient knowledge may not necessarily
public’s awareness of high BP through increased translate into actions due to low self-efficacy, cultural
educational efforts and public campaigns over the past dietary practices, social support and other external factors
several decades in the United States by major voluntary [27]. Effective patient-provider communication is crucial
organizations and the National Institutes of Health [4]. for identifying the potential reasons why patients may not
Worldwide, improvements in hypertension awareness are adopt recommended lifestyle practices and in providing
not widespread and recent observational studies report a person-centered counseling sessions tailored to the
low level of knowledge about the definition, treatment and individual patient’s needs.
complications of hypertension among hypertensive patients To our knowledge, this is the first observational study
in developing countries [23,24]. to examine the association between hypertension
In the present study, we identified two major gaps in knowledge and engagement in various heart healthy
patient knowledge about hypertension. One third of study lifestyle modification practices and adherence to
participants were unaware that renal disease is a antihypertensive medication. We used adapted questions
complication of hypertension and two-thirds did not know from a validated measure to assess patient knowledge
that hypertension lasts a lifetime once diagnosed. about hypertension and had good internal reliability of the
Similarly, a cross sectional telephonic survey which questions. However, our study has several potential
assessed knowledge of hypertension among adults limitations that need to be considered. First, since we
diagnosed with high BP reported that more than one collected information on heart healthy lifestyle practices
quarter of patients were unaware that a diagnosis of through patient self-reports, this could have resulted in
hypertension lasts for a lifetime and that renal failure is a recall bias and social desirability bias. Second, there is a
complication of hypertension [25]. In the United States, possibility of selection bias since we included patients who
uncontrolled high BP has not only been linked with the had seen their primary care physician within six months of
development of chronic kidney disease, but has been completing our survey and these patients may be more
identified as the second leading cause of end-stage renal knowledgeable about their condition. The hypertension
disease after diabetes mellitus [26]. These results should knowledge questionnaire was originally used for a
encourage physicians to emphasize the chronic nature of population with low literacy compared to our study
hypertension to patients during regularly scheduled clinic population in which the majority of respondents had more
visits and the possibility of renal complications resulting than a high school degree. Although we examined a
from uncontrolled hypertension. Patients who do not number of potential explanatory factors which may
understand the persistent nature of hypertension or the influence the association between hypertension knowledge
consequences of uncontrolled high BP may be less likely and adoption of heart healthy lifestyle practices and
to adhere to long term antihypertensive medication and antihypertensive medication adherence, we acknowledge
sustain various heart healthy lifestyle practices that have that there may be unmeasured confounders not accounted
been shown to lower BP. In addition, patients may hold for in our study including patient motivation, cultural
certain beliefs about being cured from their illness despite dietary practices, access to healthy food sources and
being informed that hypertension lasts a lifetime. To physical activity resources and opportunities.
address this problem, it may be necessary to increase
public education beyond the clinic setting about the
persistent and asymptomatic nature of hypertension.
We found that patients with low hypertension
knowledge were less likely to reduce salt in their diet and
eat less to lose weight compared with patients who had

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 European Journal for Person Centered Healthcare 2018 Volume 6 Issue 1

Conclusion Health and Nutrition Examination Survey, 2011-2012.

NCHS data brief, no 133. Hyattsville, MD: National
Center for Health Statistics.
We found that patients diagnosed with high BP have
[6] Borzecki, A. (2006). The effect of age on hypertension
adequate knowledge on some aspects of their chronic
control and management. American Journal of
condition. However, important gaps exist in patients’
Hypertension 19 (5) 520-527.
knowledge of hypertension including the “life-long nature”
[7] Chobanian, A., Bakris, G., Black, H., et al. (2003). The
of this condition and potential renal complications. Patients
seventh report of the Joint National Committee on
with low knowledge about hypertension were less likely to
Prevention, Detection, Evaluation, and Treatment of High
change their dietary practices such as eating less to lose
Blood Pressure. Journal of the American Medical
weight and reducing the amount of dietary salt consumed.
Association 21 (289) 2569-2572.
Future educational intervention studies to improve
[8] Appel, L.J. (2003). Lifestyle modification as a means to
patients’ knowledge are recommended, as are studies
prevent and treat high blood pressure. Journal of the
which would assess longitudinal associations between
American Society of Nephrology 14 (2) 99-102.
knowledge of high BP and long-term adherence to
[9] Stamler, J., Rose, G., Stamler, R., Elliott, P. & Dyer, A.
hypertension management and lifestyle practices.
(1989). Marmot Michael: INTERSALT study findings:
The results of our study have clinical implications for
Public health and medical care implications. Hypertension
patient management, given our identification of important
14, 570-577.
gaps in patients’ knowledge about hypertension. We
[10] The Trials of Hypertension Prevention Collaborative
recommend that educational programs be tailored to the
Research Group. (1997). Effects of weight loss and sodium
needs of patients with hypertension and that provider
reduction intervention on blood pressure and hypertension
communication skills training programs should target
incidence in overweight people with high-normal blood
education and counseling skills in order to promote
pressure. The Trials of Hypertension Prevention, Phase II.
increased awareness of the chronic nature of hypertension.
Archives of Internal Medicine 157, 657-667.
We suggest that physicians can use open-ended questions
[11] Whelton, P.K., Appel, L.J., Espeland, M.A.,
to assess patients’ knowledge of hypertension as well as
Applegate, W., Ettinger, W., Kostis, J.B., Kumanyika, S.,
the teach-back method to ascertain how well patients
Lacy, C.R., Johnson, K., Folmar, S., Culter, J. & The
understand the education messages provided by physicians.
TONE Collaborative Research Group. (1998). Efficacy of
sodium reduction and weight loss in the treatment of
hypertension in older persons: Main results of the
Acknowledgements and Conflicts of randomized, controlled trial of nonpharmacologic
Interest interventions in the elderly (TONE). Journal of the
American Medical Association 279, 839-846.
We are grateful to Darleen Lessard for her statistical input [12] NHLBI. (1998). Clinical guidelines on the
as we prepared the manuscript. This work was supported identification, evaluation, and treatment of overweight and
by grants from the National Heart, Lung and Blood obesity in adults: The evidence report. Obesity Research 6
Institute (P50HL0105187 and K24HL083113). The (Supplement 2) 51S-209S.
funding source had no involvement in the study design, [13] Whelton, S.P., Chin, A., Xin, X. & He, J. (2002).
data collection, analysis and interpretation and in writing Effect of aerobic exercise on blood pressure: A meta-
this article. We declare no conflicts of interest. analysis of randomized, controlled trials. Annals of
Internal Medicine 136, 493-503.
[14] Psaty, B.M., Lumley, T., Furberg, C.D.,
Schellenbaum, G., Pahor, M., Alderman, M.H. & Weiss,
References N.S. (2003). Health outcomes associated with various
antihypertensive therapies used as first-line agents: a
[1] World Health Organization. (2011). Global status network meta-analysis. Journal of the American Medical
report on non-communicable diseases 2010. Geneva: Association 289, 2534-2544.
World Health Organization. [15] Hansson, L., Lloyd, A., Anderson, P. & Kopp, Z.
[2] Causes of Death. (2008). Geneva: World Health (2002). Excess morbidity and cost of failure to achieve
Organization. Available at: targets for blood pressure control in Europe. Blood
http://www.who.int/healthinfo/global_burden_disease/cod Pressure 11 (1) 35-45.
_2008_sources_methods.pdf. (Accessed 30 May, 2017). [16] Oliveria, S.A., Chen, R.S., McCarthy,. B.D., Davis,
[3] Arima, H., Barzi, F. & Chalmers, J. (2011). Mortality C.C. & Hill, M.N. (2005). Hypertension knowledge,
patterns in hypertension: Journal of Hypertension 29, 3-7. awareness, and attitudes in a hypertensive population.
[4] Department of Health and Human Services, National Journal of General Internal Medicine 20, 219-225.
Heart, Lung, and Blood Institute. National High Blood [17] Cooper, L.A., Marsteller, J.A., Noronha, G.J., Flynn,
Pressure Education Program. Available at: S.J., Carson, K.A., Boonyasai, R.T. & Huizinga, M.M.
http://www.nhlbi.nih.gov/about/nhbpep/nhbp_pd.htm. (2013). A multi-level system quality improvement
(Accessed 10 June, 2017). intervention to reduce racial disparities in hypertension
[5] Nwankwo, T., Yoon, S.S., Burt, V. & Gu, Q. (2013). care and control: study protocol. Implementation Science 8,
Hypertension among adults in the United States: National 60.

113
Abu, Aboumatar, Carson, Goldberg & Cooper Hypertension knowledge and medication adherence

[18] Williams, M.V., Baker, D.W., Parker, R.M. & Nurss,

J.R. (1998). Relationship of Functional Health Literacy to
Patients' Knowledge of Their Chronic Disease. A Study of
Patients with Hypertension and Diabetes. Archives of
Internal Medicine 158, 166-172.
[19] Cronbach, L.J. (1951). Coefficient alpha and internal
structure of tests. Psychometrika 16, 297-333.
[20] Morisky, D.E., Green, L.W. & Levine, D.M. (1986).
Concurrent and predictive validity of a self-reported
measure of medication adherence. Medical Care 24, 67-74.
[21] Chew, L.D., Griffin, J.M., Partin, M.R.,
Noorbaloochi, S., Grill, J.P., Snyder, A., Bradley, K.A.,
Nugent, S.M., Baines, A.D. & Vanryn, M. (2008).
Validation of Screening Questions for Limited Health
Literacy in a Large VA Outpatient Population. Journal of
General Internal Medicine 23 (5) 561-566.
[22] Viera, A.J., Cohen, L.W., Mitchell, C.M. & Sloane,
P.D. (2008). High blood pressure knowledge among
primary care patients with known hypertension: A North
Carolina Family Medicine Research Network (NC-FM-
RN) study. Journal of the American Board of Family
Medicine 21 (4) 300-308.
[23] Jankowska-Polańska, B., Uchmanowicz, I., Dudek, K.
& Mazur, G. (2016). Relationship between patients’
knowledge and medication adherence among patients with
hypertension. Patient Preference and Adherence 10, 2437-
2447.
[24] Dzudie, A., Kengne, A.P., Muna, W.F., et al. (2012).
Prevalence, awareness, treatment and control of
hypertension in a self-selected sub-Saharan African urban
population: a cross-sectional study. BMJ Open 2 (4) 1-10.
[25] Sanne, S., Muntner, P., Kawasaki, L., Hyre, A. &
DeSalvo, K.B. (2008). Hypertension knowledge among
patients from an urban clinic. Ethnicity and Disease 18,
42-47.
[26] United States Renal Data System. (2014). 2014
USRDS annual data report: Epidemiology of kidney
disease in the United States. National Institutes of Health,
National Institute of Diabetes and Digestive and Kidney
Diseases, Bethesda, MD.
[27] Tibebu, A., Mengistu, D. & Negesa, L. (2017).
Adherence to recommended lifestyle modifications and
factors associated for hypertensive patients attending
chronic follow-up units of selected public hospitals in
Addis Ababa, Ethiopia. Patient Preference and Adherence
11, 323-330.
[28] Osterberg, L. & Blaschke, T. (2005). Adherence to
medication. New England Journal of Medicine 353, 487-
497.

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