An Internet Survey Investigating Relationships among Medication Adherence, Health Status and Coping Experiences with Racism and/or Oppression among Hypertensive African Americans Presented by Dr Charles Olufemi Daramola Western Oregon University

Background Heart disease and stroke are first and third leading causes of death for both men and women in the US About 80 million Americans have one or more types of cardiovascular disease, out of which 73 million have high blood pressure African Americans have poorer cardiovascular health status (including hypertension) relative to Whites The 2003 age-adjusted death rate for heart disease per 100,000 was for African Americans, compared with for all populations—a relative health disparity of 135.3%

Statement of the Problem Chronic stress brought about by racial discrimination has an adverse effect on the cardiovascular health of African Americans Non-adherence is linked to poorer health outcomes, including higher mortality rates, and adherence with hypertensive medication is very poor

Purpose of the Study To investigate among a sample of African Americans their level of adherence to medication, perceptions of racism, stages of change for actively coping with racism, and patterns of coping and responding when racism happens to them To investigate the potential relationships between medication adherence, health status, and experiences with racism and/or oppression among hypertensive African Americans.

Sample, Procedures and Study Setting Sample –Convenience sample of African American Internet users (N=134) –Inclusion criteria Taking medication for hypertension Ages 18 and above Males and females Procedures –Initial IRB approval was obtained February 26, 2007 –Addendum request to IRB allowing researcher to place a laptop in an area with a large concentration of potential participants and offer an incentive of $10 to encourage participation –Final IRB approval obtained March 22, 2007

Sample, Procedures and Study Setting Setting –Respondents to the survey were obtained by the following methods: –A list of African American Internet users was purchased from “listsyoucanafford.com” –A laptop computer was placed in a medical outpatient clinic in Irvington, New Jersey –A laptop computer was also placed in an adult community health center in northeast Philadelphia where participants could respond to the survey

Sample, Procedures and Study Setting Setting –participants were required to complete the online survey at

Instruments Morisky Medication Adherence Scale (MMAS) Perceptions of Racism and Oppression Scale (PROS-10) When Racism or Oppression Happened to Me Scale (WROOH-TMS-33) Coping and Responding to Racism and/or Oppression Staging Scale (CRROSS-20) When Racism or Oppression Happened to Me Scale (WROOH-TMS-33) Coping Responses to Racism and Oppression Scale (CRROS-53) Medical Outpatients Demographic Scale (MODS-14)

Internal Consistency of Scales ScaleCronbach’s AlphaNumber of Items TOTAL SCALE SCORE Perception of Racism and Oppression Scale SUBSCALES Perception of Racism and Oppression towards Me SUBSCALE Perception of Racism and Oppression towards Others.693 3

Internal Consistency of Scales cont. WHEN RACISM AND OPPRESSION HAPPENED TO ME SUBSCALES Affective Responses Behavioral Responses Bodily Responses Cognitive Responses Passive Responses COPING AND RESPONDING TO RACISM SUBSCALES Adaptive Affective Responses Adaptive Behavioral Responses Maladaptive Behavioral Responses Adaptive Cognitive Responses Adaptive Spiritual.920 6

Sample Demographics The final study sample of hypertensive African Americans in this study was 134 The mean age was 64.03, with participants’ ages ranging from 27 to 88 The majority of participants were born in the United States (85.1%), and were mostly female (65.7%) Mean annual household income was in the $30,000-39, 999 range About two-thirds of participants (65.7%) were unemployed.

Demographic Group Comparisons T-test were performed comparing medication adherence: Morisky Medical Adherence Scale (MMAS) scores for females were not significantly different from the males The MMAS scores for those who did not have a partner were significantly different from those who had a partner The MMAS scores for those who were unemployed were significantly different from those who were employed The MMAS scores for U.S.-born participants were significantly different from non-U.S.-born participants

T-test demographic group comparisons (n=132) DemographicsMeandftSig (2-tailed) GENDER Female 7.98 Male7.70 HAS A PARTNER * No8.34 Yes6.77

T-test demographic group comparisons contd. DemographicsMeandftSig (2-tailed) EMPLOYED ** No8.45 Yes6.80 BORN IN THE U.S *** Yes8.05 No6.90 *P<.001 **P<.005 ***P<.050

Research Question #1 Using demographic data, what is the prevalence of hypertension? This research focused on African Americans who self- reported as currently taking medication for hypertension and not just being treated for hypertension However, the prevalence of those being treated for hypertension was important because it provided insight into the number of respondents being treated for hypertension, compared with other disease states in this data set

Results of Research Question #1 What is the prevalence of hypertension? –Participants were asked to list the conditions for which they were being treated –The data indicated that a total of 138 respondents (72.3%) were being treated for hypertension. –The remaining 27.7% were being treated for diseases other than hypertension such as high cholesterol and diabetes –The final n of 134 indicates participants who were taking medication for hypertension

Research Question #2 How do participants rate themselves with regards to medication adherence Results of Research Question #2 Morisky Medication Adherence Scale Scores (n=134) N% LOW ADHERERS MEDIUM ADHERERS HIGH ADHERERS2 1.5

Research Question #3 Do medical outpatients report being able to perceive racism and oppression? Results of Research Question #3 A total score was calculated and the results showed a range mean of 4.16 (SD.624), with scores ranging from 2.10 to 5 Results suggest that overall, participants have a high perception of racism and/or oppression

Results of Research Question #3 contd. Perception of Racism and/or Oppression Scale (PROS-10) (n=134) DescriptionMeanSDMinMax Perception of Racism and Oppression

Research Question #4 In what stage of change/readiness for actively coping with racism and/or oppression are participants to be found (i.e., precontemplation, contemplation, preparation, action or maintenance stage)?

Results of Research Question #4 StageNValid % Contemplation 17 Preparation 17 Action Low 17 Maintenance Low Maintenance Medium Maintenance High N=131 due to missing data for 3 participants. Stages of coping with racism (n=131)

Question # 4 continued How do participants rate their level of knowledge about how to cope with and respond to racism and/or oppression? How do participants rate their ability level or the skills they have to cope with racism and or oppression

Results of Research Question #4 contd. Knowledge, skills and Resources Coping and Responding to Racism and Oppression Staging Scale (CRROSS-20) (n=134)* MeanSDMinMax KNOWLEDGE, SKILLS, RESOURCES Knowledge of Coping with Racism Skills to Cope with Racism Things Available to Cope with Racism Use of Resources to Cope with Racism *varied n due to missing participant data

Research Question #5 For those reporting experiences of racism and/or oppression, to what extent do participants report affective, behavioral, and cognitive responses that are maladaptive as well as adaptive, including the extent to which they experienced physiological and/or psychological arousal that persisted to the point that it was disturbing to them?

Results of Research Question #5 contd. To what extent do participants report using affective, behavioral, and cognitive responses, both adaptive and maladaptive: An overall mean score was calculated; values ranged from a minimum of 1 (lesser use coping style) to a maximum of 5 (greater use of coping style) The coping response utilized most by participants was the affective response, with a mean of 3.46 There was also a greater utilization of cognitive and behavioral responses, with a mean of 3.22 and 3.21, respectively Responses utilized to a lesser extent were the passive response, with a mean of 2.90, and the bodily response, with a mean of 2.84

Results of Research Question #5 contd. When Racism and/or Oppression Happened to Me Scale (WROOH-TMS-33) (n=130) MeanSDMinMax WHEN RACISM AND OPPRESSION HAPPENED TO ME SUBSCALES Affective Response Behavioral Response Bodily Behavioral Response Cognitive Response Passive Response

Research Question #6 For those reporting experiences of racism and/or oppression within the past week, month, 6 months, or past year, in what ways did they respond— whether with adaptive or maladaptive affective, behavioral or cognitive coping responses? Results of Research Question #6 Coping and responding to racism and oppression scale (CRROS-53 (n=129) MeanSDMinMax COPING AND RESPONDING TO RACISM AND OPPRESSION SUBSCALES Adaptive Affective Responses Adaptive Behavioral Responses Maladaptive Behavioral Responses Adaptive Cognitive Responses Adaptive Spiritual Responses

Research Question #7 What is the relationship between medication adherence, and selected demographics, being treated for hypertension, overall health status, quality of medical care received, race, skin color, country of birth, years living in the United States, age, gender, sexual orientation, socioeconomic status, education, employment status, type of health insurance, extent of ability to perceive racism and/or oppression, stage of change/readiness for actively coping with racism and/or oppression, adaptive or maladaptive responses to racism and/or oppression (affective, behavioral, and cognitive, whether with or without psychological and physiological arousal that persists), and adaptive or maladaptive coping response to racism and/or oppression?

Results of Research Question #7 Correlation between Morisky Medication Adherence Scale (MMAS) and selected demographic variables (n=134) DemographicsMorisky Adherence Scale Pearson Correlation Sig. (2- tailed)P Participant’s age * Household income ** Overall health status **** Quality of health care **** Perception racism and oppression *** More skills to cope with racism and oppression **** Adaptive behavioral responses to cope with racism and oppression **** Adaptive cognitive responses to cope with racism and oppression * Adaptive spiritual responses to cope with racism and oppression **** *p<.001 **p<.005 ***p<.01 ****p<.05

Research Question #8 What is the best predictor of medication adherence? Results of Research Question #8. Medication adherence predictors (n=134) B Std. ErrorP DEMOGRAPHIC CHARACTERISTICS Has a partner Employed Better health status More skills to cope with racism More psychological disturbance More adaptive behavioral responses

Discussion There was a significant positive correlation between medication adherence and age; this is consistent with the work done by Dunbar- Jacob et al. (2003) There was a positive correlation between medical adherence, overall health status, and quality of care; this is consistent with the work of Bosworth et al. (2006) There was a significant negative correlation between medication adherence and adaptive behavioral responses; the results from this is consistent with the work of Williams and Franklin (2007)

Discussion contd. There was a significant negative correlation between medication adherence and annual household income; the is not consistent with the outcomes obtained by Dunbar-Jacob et al. (2003) There was a significant negative relationship between medication adherence and adaptive spiritual responses; this is consistent with a related clinical study by Villagomeza (2006) There was a significant negative correlation between medication adherence and adaptive behavioral responses; this is consistent with the work of Williams and Franklin (2007)

Limitations and suggestions for future research Small Sample Sporadic and slow recruitment Incentives Internet survey Age of sample

Implications Adds to the literature on medication adherence, racism, health disparities and coping responses utilized by African Americans Adds to the literature a survey of scales that can produce information and key insights into factors which may create and manifest disparities in healthcare Findings will help health educators develop new and innovative programs to reduce health disparities

Acknowledgements Dr. Barbara Wallace Dr. Robert Fullilove Dr. Jose Nanin Dr. Laura Smith