CALIFORNIA STATE
UNIVERSI~Y,
NORTHRIDGE
EDUCATIONAL INTERVENTION
IN
HYPERTENSION SCREENING
A thesis submitted in partial satisfaction of the
requirements for the degree of Master of Public Health
by
Charles Christopher Pace
June, 1981
is approved:
ObertaE: Hadison, Dr. P.H.
Co-Chairperson
Goteti Bala Krishnamurty, Dr. P.H.
Co-Chairperson
California State University, Northridge
ii
ACKNmVLEDGEMENTS
There are many people whose contributions to this
study were so essential that i t would never have come to
fruition without them.
First, I thank Al Bobb, my
liaison person at Teledyne, for his. support and confidence.
After months of looking for a setting such
as Teledyne provided, he said ••Yes," when I thought no
one would.
There were those who gave a day out of their lives
to help me assure the success of this program, sometimes
cancelling other commitments to do so:
Margaret Rose,
Rena Shpegel, Frank Morse and his people, and Jan Gilmore;
and my wife Elaine Newman, who stepped away from her own
successful career for a day to give love and support to
my research; and to Cindy Comarr, for the six years we
have shared, and for being there when the typing needed
doing.
A special thank you goes to my committee members
for their support throughout the entire ordeal; to
Goteti Krishnamurty, for his wise counsel, insight and
recognition of the significance of the study's results;
to Bobby Madison for her love, pragmatism, and constant
accommodation to my study, and for the joy of knowing
her; to Mitzi McClanahan who, as the Director of the
iii
High Blood Pressure Council of Los Angeles, and my field
study supervisor, kept me laughing when I wanted to
scream with frustration; and to the secretaries of the
Health Science Department -- Eunice Bagel, Vivian Bulick,
Betty Hill -- who were always encouraging and supportive.
Because of my studies of CSUN, all of these people,
and others, will always be a part of my life experience.
Fifty years from now I will remember them, their faces,
smile inside, and say "Thank you,'' for being a part of
my life.
iv
DEDICATION
The orchestration of a life experience reflects
the level of creativity and responsibility with which
the conductor plays out his life.
The choices are ours
for the taking, and the permutations of these
choice~
are infinite, as is the responsibility for such
freedom.
Our environment controls these choices, especially
when we're younger.
As we grow, the environment's
control lessens towards influence.
Eventually, the
control-influence begins to interact with the development of our individual creativity and responsibility
for self.
In my young life there were those who attempted
to dissuade me from great pursuits and higher levels of
achievement, sometimes only by withdrawing their support
and understanding.
There were those who attempted
(and for many years, I feared, successfully) to undermine the very foundation of my existence -- my sense
·of self, my autonomy.
Deep within the inner-most hollows of my being
there was an energy that did not trust what my senses
were perceiving.
I dedicate this work, then, to that
aspect of self that gave me the direction and the
v
strength and the persistence, the energy, that gave
me, and continues to give me, my life sustenance.
I
dedicate this thesis to me, and to its symbolic
representation that I
did not succumb to an environ-
ment of restraint and suffocation.
broken the shackles.
I
am free.
vi
At last I
have·
TABLE OF CONTENTS
Page
ACKNOWLEDGMENTS • • • •
DEDICATION
·~
.•
LIST OF FIGURES
1.
• • • • • • • • • • • •
v
xi
•
xiii
• • • • •
•
xiv
• • • • • • • • • •
• • • • • •
iii
• • • •
• • • • • • • • • •
• • • • • • • • • • • • •
INTRODUCTION
• • • • •
. . . . . .. . . . . .
• • • • • • • •
LIST OF TABLES
ABSTRACT
• • • • • •
1
Overview of the problem • • • • • • • • • • •
2
Awareness of hypertension • • • • • • • • • • •
3
Self-selection for screening
• • • • • • • • •
3
Follow-up, pre-diagnostic screening • • • • • •
4
Medical diagnosis • • • •
• • • •
• • • • • •
5
Compatible therapy regimen
• • • • • • • • • •
6
Patient compliance to prescribed regimen
Statement of the problem
Purpose of the study
• •
• • •
Statement of hypotheses
• • •
7
..•
. . .. •
10
• • • • • • • • •
10
• • • • •·
• • • • •
Overview of methodology • • • • •
8
• • • • • •
10
Limitations of the study
• • • • • •
• • •
11
Assumptions of the study
• • • • • • • • • • •
12
Definition of terms • • • • • • • • • • • • • •
13
Blood pressure levels
Hypertension • •
•
vii
• •
13
• • • • •
14
• • • • • •
• • • • •
Page
Essential hypertension • • • • • • • • • •
14
Secondary hypertension • • • •
14
. . . •. . . . . .
Systolic blood pressure
Diastolic blood pressure •
Control
14
• • • • • •
15
• • • •
15
. . . . •· •
hypertensive •
..
• • • •
• • • •
15
• • • • • • •
15
Educational intervention • • • • • • • • •
15
Compliance • • • • • •
16
Potential
•·
Screenee • •
2.
• • • •
• • • • • •
REVIEW OF THE LITERATURE
Introduction
• • • • •
•
• • • • • • •
17
17
• • • • • • •
• •
• •
• • •
A history of blood pressure and hypertension in
medicine •
• • • • • • • • • • • • • • • •
18
History of hypertensive sequelae
•
24
Contemporary prevalence of hypertension • • •
27
Distorted statistics
39
• • • •
. .. . . . . . . . . . .
-
• • • • •
41
Education during hypertension screening • • •
54
What's being done about it7 • • •
3.
METHODOLOGY • • • • • • • • • • • • • • • • •
Statement of purpose
•
Location/population • •
Nethods • • • • • • • • •
Instruments • • •
• • • • • • • • • •
59
• • • • •
• •
59
• • • • • •
60
• • • •
61
• • •
62
•
• • • • • •
•
..•
.
Screening personnel • • •
• • •
Screening program • •
• • • • • • • • •
•
viii
59
63
Page
Reception and holding • • • • • • • • •
65
Screening • • • • • • • • • • • • • • •
67
Counseling
.. ...........
69
Follow-up • • • • • • •. • • • • • • • •
72
Funding • • • •
Statistics
4.
RESULTS
•·
.. .
• •
• • • • •
•. . •
..
•·
73
• • • • • • • • • • •
73
• • • • • • • • • •
• • • • • •·
• •
• • • • • • •
. . ·- . . . . •
.•
•
75
• •
76
• • • • • • • • • • • • • • • • • • • •·
78
Smoking • • • • •
• • •·
Age, weight, height and education • • •
Race
Sex • • •
78
• • • • • • • • • • • • • • • •
. . . . . . . . . . . . . .. .
79
=
•
81
• • • • • • • • • • • •
82
Medical correlates of hypertension in blood
family • • • • • • • • • • • • • • • •
• •
83
Job categories
f'-1ari tal status
•
•
Perception of stress
•
•
•
a
•
e
e
~·
•
•·
•
Oral contraceptives • • • • • • • • • • • •
.
86
Health status • • • • •
•
86
• • • • • • • • • • • • • • • • • • •
87
Income
•
.. . •
Health attitude • • • • • • • •
Health value
Compliance
..
.
• • • • •·
.
• • • • • • • • • • • • • • • •
90
91
92
• • • •
93
• • • • • • • •
94
• • • • • • • • • • • • • • • • •
95
• • • • • • • • • •
Profile of compliance • • •
DISCUSSION
• • •
.
• • • • • • • • • • • •• • • • •
Blood pressure
5.
75
ix
Page
Conclusions • • • • • • • • • • • • • • • • •
96
e
o
• • • • • • •
96
•
• • • • • • • • • • • • •
97
Recommendations • • • • • • • • • • • •
103
Employee newsletter article • • • •
104
Matched-pair sampling • • • • • • •
104
Eliminate previous hypertensives
105
Response
Compliance
•
e
• • • •
.. . . . . .
105
Summary • • • • • • • • • • • • • • • •
105
• • • •
109
Question non-compliers
BIBLIOGRAPHY
•
• • • • • • •
• • • • • • • •
APPENDICES
APPENDIX A - COPY OF NEWSPAPER ARTICLE
• • •
APPENDIX B - COVER LETTER TO QUESTIONNAIRE
APPENDIX C - QUESTIONNAIRE
X
•
116
•
118
• • • • • • • •
119
LIST OF TABLES
Table
1.
Page
PERCENT OF WHITE AND BLACK ADULTS TtliTH
BLOOD PRESSURES OF AT LEAST 160 SYSTOLIC
OR 95 DIASTOLIC, BY SEX AND AGE:
UNITED
STATES, 1960-62 (NATIONAL EXAMINATION
SURVEY) •. • • • • • • •. • • • • • • • • • • •
2.
32
PREVALENCE OF DEFINITE AND SUSPECT HYPERTENSIVE HEART DISEASE FOR WHITE AND BLACK
ADULTS, BY AGE AND SEX:
UNITED STATES,
1960-62 (NATIONAL HEALTH EXAMINATION
SURVEY) • • • • • • • • • • • • • • • • • •. •
3.
PERCENT DECLINE IN DEATH RATES FOR SELECTED
CARDIOVASCULAR CONDITIONS BY AGE:
U.S.
.. . .
1970-1975 • • • • • • • • • • • • • • •
4.
33
37
SURVIVORSHIP OF APPLICANTS FOR LIFE INSURANCE WHO SHOWED ELEVATED BLOOD PRESSURE
READINGS AT THE TIME OF MEDICAL EXAMINATION
FOR INSURANCE (1959 BUILD & BLOOD PRESSURE
STUDY, SOCIETY OF ACTUARIES)
5.
• • • • • • • •
38
HYPERTENSION, HYPERTENSIVE HEART DISEASE
AND RISK OF DEATH, COHORT OF 1,465
~~N
AGE
40-59 IN 1958 (PEOPLES GAS CO. STUDY
1958-70)
• • • • • • • • •. • • • • • • • • •
40
6.
EMPLOYEE PARTICIPATION
. . •· . . . . . . . .
64
7.
DISTRIBUTION OF SMOKERS - IN PER CENT • • • •
76
8.
DISTRIBUTION OF AGE, WEIGHT, HEIGHT AND
9.
EDUCATION (MEAN AND STANDARD DEVIATION) • • •
77
RACIAL DISTRIBUTION - IN PER CENT • • • • • •
78
xi
Page
Table
10.
DISTRIBUTION OF SEXES - IN PER CENT • • • • •
11.
DISTRIBUTION OF JOB CATEGORIES - IN
• • • • •
79
PER CENT • • • • • • • • • • • • • • • • • •
81
PER CENT • •
12.
13.
..........•
DISTRIBUTION OF MARITAL STATUS - IN
RESPONDENT'S PERCEPTION OF STRESS -IN
PER CENT • • • • • • • • • • • • • • • • • •
14.
79
82
DISTRIBUTION OF HYPERTENSIVE SEQUELAE
AMONG RESPONDENTS AND THEIR BLOOD
FAMILIES - IN PER CENT.
HAVE YOU EVER
HAD THESE ILLNESSES? • • • • • • • • • • • •
15.
84
DISTRIBUTION OF HYPERTENSIVE SEQUELAE
AMONG RESPONDENTS AND THEIR BLOOD FAMILIES IN PER CENT.
FAMILY EVER
16.
B~D
DISTRIBUTION OF
CENT • • • •
17.
HAS ANYONE IN YOUR BLOOD
THESE ILLNESSES? • • • • • •
H&~TH
.....
DISTRIBUTION OF
INCO~m
STATUS - IN PER
• • • • • • • •
...
87
RANGES- IN PER
CENT • • • • • • • • • • • • • • • • • • • •
18.
85
89
DISTRIBUTION OF STATED ATTITUDE TOWARD
.........
91
19.
DISTRIBUTION OF COMPLIANCE - IN PER CENT • •
92
20.
DISTRIBUTION OF "BEFORE" BLOOD PRESSURES
HEALTH - IN PER CENT • • •
IN MM HG. CONTROL, EXPERIMENTAL - MEAN
AND STANDARD DEVIATION • • • • • • • • • • •
21.
93
DISTRIBUTION OF uBEFOREu BLOOD PRESSURES IN
MM
HG
• • • • • • • • • • • • • • • • • • •
xii
94
,
LIST OF FIGURES
Figure
1.
Page
CHANGES IN SYSTOLIC (LEFT) AND DIASTOLIC
(RIGHT) BLOOD PRESSURE IN CONTROL GROUP
OF PATIENTS GIVEN PLACEBOS AND EXPERIMENTAL GROUP OF PATIENTS TREATED WITH
HYDROCHLOROTHIAZIDE PLUS RESERPINE PLUS
HYDRALAZINE (ACTIVE DRUGS); MEN WITH
AVERAGE DIASTOLIC PRESSURE AT ENTRY IN
THE RANGE OF 90-114 MM HG (VETERANS
ADMINISTRATION COOPERATIVE STUDY ON
ANTIHYPERTENSIVE AGENTS)
2.
• • • • • • • • • •
45
CHANGES IN SYSTOLIC (LEFT) AND DIASTOLIC
BLOOD PRESSURE (RIGHT) AFTER FOUR MONTHS
OF TREATMENT IN 57 PATIENTS GIVEN PLACEBOS (ABOVE) AND 68 PATIENTS TREATED WITH
HYDROCHLOROTHIAZIDE PLUS RESERPINE PLUS
HYDRALAZINE (BELOW); MEN WITH AVERAGE
DIASTOLIC PRESSURE AT ENTRY IN THE RANGE
115-129 MM HG • • • • • • • • • •
3.
0
•
•
•·
•
•
46
ESTIMATED CUMULATIVE INCIDENCE OF MORBIDITY OVER A 5-YEAR PERIOD AS CPLCULATED BY
LIFE TABLE METHOD:
TERMINATING MORBID
EVENTS (ABOVE) AND ALL MORBID EVENTS (BELOW); MEN WITH AVERAGE DIASTOLIC BLOOD
PRESSURES 90-114 MM HG AT ENTRY
(VETER~~S
ADHINISTRATION COOPERATIVE STUDY ON ANTIHYPERTENSIVE AGENTS • • • • • • • • • • • • •
4.
47
FLOW CHART OF TELEDYNE HYPERTENSION
SCREENING PROGRAM • • • • • • • • • • • • • •
xiii
66
'
ABSTRACT
EDUCATIONAL INTERVENTION
IN
HYPERTENSION SCREENING
by
Charles Christopher Pace
Master of Public Health
June, 1981
Because of the volatile nature of blood pressure, a
history of several blood pressure readings is required before a referral for medical follow-up can be made.
A low
rate of individual compliance (30%) in obtaining a second
blood pressure measurement after initial screening is a
problem.
Attempting to raise this low rate of individual
compliance, this study tested the efficacy of individual
counseling at the screening site by using the percentage
of compliance as an indicator of counseling effectiveness.
Additionally, the development of a profile of the compliant screenee was also an objective of the study.
In an industrial setting of approximately 1100
employees, 820 employees volunteered to participate in a
blood pressure screening program sponsored by the High
Blood Pressure Council of Los Angeles and Teledyne
Systems, Inc.
One week prior to the screening an article
xiv
appeared in the company newsletter (Appendix A) in which
the screening was announced and in which hypertension
prevalence, incidence and sequelae were discussed.
At
the screening site, those with blood pressures in excess
of 139 mm Hg systolic and/or 89 mm Hg diastolic, after
two measurements, were randomly assigned (by coin toss)
to an experimental or control group.
Members of both
groups were asked to have an additional blood pressure
measurement taken within one week of the date of the
screening.
Experimental group members received one-to-
one counseling before this request was made.
group members did not receive the counseling.
Control
Members
of both groups were handed community referral lists for
the follow-up screening.
Each person in the study group
(control and experimental) was told to expect a phone
call so that compliance could be determined.
The control
and experimental groups had 36 and 28 people respectively
for a total population of sixty-four.
No sampling
techniques were utilized.
Not only were compliance rates high in both groups
(63.89% control, 64.29% experimental), there were no
significant differences of any kind, in terms of the
criteria used (Appendix C), between the two groups.
this reason, no profile of the compliant screenee was
identified.
XV
For
The article appearing in the company newsletter,
and other follow-up messages prior to the screening,
may have constituted an educational approach so effective
that compliance was raised significantly regardless of
the counseling received by the experimental group.
Testing such mass communication techniques in other industrial settings may validate this as an effective
educational tool.
xvi
CHAPTER I
INTRODUCTION
Not only is hypertension prevalence in the United
States one of the highest of the chronic diseases,
awareness and recognition of its severity have not come
into focus until just recently.
The success of hyper-
tensive medications was first realized in the fifties
and further research expanded their use and potential
in the sixties. (39:12)
It was not until the seventies,
however, following release of data from the Health and
Nutrition Survey, 1971-1974, the first prevalence study
on hypertension, that the magnitude of hypertension
began to emerge.
The response of medical and govern-
mental bodies was quick as they moved to inform the
American people.
The result of this effort culminated
in 1972 in the establishment of the National High Blood
Pressure Education Program, set up under the auspices of
the National Institutes of Health through the National
Heart and Lung Institute.
The National High Blood
Pressure Education Program (NHBPEP)
u • • • organized
to make
recommendations on criteria for screening, referral and
1
2
treatment, on educational programs for health pro,fessionals
and for the public, and on resources required to carry out
the program." (47:70)
Hypertension, also known as high blood pressure, is
frequently referred to as the "silent killer."
A hyper-
tensive person is usually asymptomatic until his hypertension manifests as renal failure, stroke, or heart
failure.
There is usually no symptomatology with hyper-
tension.
Its concept remains an enigma to those who are
conditioned to act only when symptoms are felt. (63:662;
17:626)
For the same reason health care professionals
tend to overlook its significance too.
Even hospitals
are reported to be lax in monitoring blood pressure.
(47:73)
Most deaths, certified to heart disease and
stroke, report hypertension as a contributory cause of
death.
These occurrences are not included in hyper-
tension mortality figures. (31:16)
Overview of the Problem
The process that culminates in the identification
of hypertension in an individual is well defined.
This
process begins with the individual's initial awareness
that there is a medical condition known as high blood
pressure or hypertension and leads one through subsequent
steps:
(1) awareness of hypertension; (2) self-
selection for screening; (3) a follow-up, pre-diagnostic
3
screening; (4) medical diagnosis; (5) a compatible
therapy regimen (e.g. exercise and/or diet modification,
and/or medication, and/or biofeedback, relaxation exercises, and other meditative techniques); and (6) patient
adherence to a prescribed regimen of treatment resulting
in a medically acceptable blood pressure level.
Each
component part of this process, which takes the patient
from initial awareness through medical diagnosis, to
a medically acceptable blood pressure, has problems
inherent within each aspect's unique contribution to the
total process.
Awareness of Hypertension
One of the first tasks
designated by the National High Blood Pressure Education
Program was to raise public awareness of the prevalence
and severity of hypertension.
Until high blood pressure
assumed a position of national prominence in health care,
the lay public equated high blood pressure with a state
of mere nervousness or excitability.
In fact, this myth,
and others, remain problematic.
Self-Selection for Screening
After the effective
arousal of public awareness, the next step is that of
screening.
This requires an integration of the personal
relevance of the disease to the individual; the establishment of the ttfelt need."
At this point the individual
must recognize the importance of having his/her blood
pressure checked.
If this determination is not reached,
4
failure to justify participation in a screening program
will occur.
Many people find it difficult to arrive at
such an admission with ease. (39:58-59)
Here, then motiv-
ation first enters the picture and remains a factor that
influences individual behavior throughout the remainder
of the process.
Avoiding fear, by not accepting the possibility of
having high blood pressure, may be a primary reason for
excusing oneself from a blood pressure screening.
Some
people, however, may fear the disease less than they fear
what the disease will do to their self image.
Podell
describes it this way:
We have all seen patients, particularly men,
who after uneventful recovery from a myocardial
infarction are profoundly depressed and no longer
feel like the men they once were. They have suffered a personal defeat, one that emphasizes that
they are not perfect, cannot be perfect, have left
youth behind, and with it the hopes they will
never achieve. For some, the diagnosis of high
blood pressure and its treatment connotes the
aging process, loss o~ attractiveness, and the
sense that from here on it is all down hill.
For some patients, therapy for hypertension
may be more of a threat to their social role -as leader in the community, as the breadwinner
of the family, as the no longer securely attractive
spouse. For many, the problem may be the specter
of dependence, of losing one's accustomed role in
the family structure, becoming a burden to others.
For many the threat may not be the disease or its
sequelae, but the therapy itself. (39:53-54)
The response described above could begin at the
very moment one begins to consider having a blood pressure
check.
Follow-Up, Pre-Diagnostic Screening
When the
5
result of primary screening is an elevated blood pressure
reading, screening protocols suggest that the individualbe
advised to have another blood pressure measurement.
Usu-
ally this should occur within the week immediately following the initial screening. (22:24)
Sometimes this is
prior to referral to a physician or clinic and sometimes it
is in conjunction with such a visit.
Of those who have an
initial elevated blood pressure reading, approximately 70%
do not return for the recommended second blood pressure
measurement.
As a point of clarification, here "second
blood pressure measurement" does not re£er to a second
measurement per se but to a second, follow-up measurement
protocol.
Within each protocol there should be two or
three measurements taken. (30:1)
Medical Diagnosis
Physicians use differentcriteria
and treatment protocols in hypertension control.
These
are determined by the physician's individual interpretation of the criteria to be used in determining commencement of therapy which is concomitant with a preference for
treatment regimens.
Some physicians begin with a direct
reduction of blood pressure through drug therapies, while
others prefer dietary adjustment, exercise, weight loss,
or meditative and bio-feedback techniques.
Sometimes a
combination of these is used.
When it was first estimated that 23,000,000 Americans had high blood pressure, 160/95 mm Hg was the
6
criterion used. (47:74)
This criterion was later age- and
sex-adjusted, recognizing different prevalence rates in
age- and sex-adjusted populations.
A newer trend, which
represents today's thinking, reduces the criterion to
140/90 mm Hg as the lowest limit for hypertension. (47:74)
This, then, increased the national estimate of hypertensive Americans from 23,000,000 to 59,000,000 as more
people were moved to the inclusive side of this parameter.
(21:1)
In medicine this presents a controversy of great
significance.
Some physicians find treatment of hypertension
boring relative to the stimulation and challenge of
successful responses to acute, curable illnesses.
In-
volvement in the plodding, long-term management of a
chronic, usually incurable condition, with the remote
goal of reducing or eliminating the probability of
severe organ damage or catastrophic events such as strokes
and certain cardiovascular episodes, is not appealing to
many physicians. (40:1)
Considering that many physicians still do not know
how to treat high blood pressure, and use somewhat archaic
modalities in their approach, physician selection becomes
a crucial element for the patient.
Most patients are
ill-equipped to handle this.
Compatible Therapy Regimen
Once hypertension has
been diagnosed the physician must determine his treatment
7
plan.
Will he/she try to lower blood pressure with diet?
exercise? medication? bio-feedback? meditation? a combination of these?
Is the patient obese?
sion in the patient's family?
Is there hyperten-
Does the patient smoke?
These are numerous variables which must be considered.
Another variable is the physician's preference for treatment, which is usually influenced by experiences of patient
response to a variety of treatment modalities.
Physician
interpretation and treatment of high blood pressure are influenced by current trends in treatment modalities and
other schools of thought.
The most efficient therapy in
terms of both physician and patient time and costs, patient
demographics, presenting pathology, the patient's apparent
desire and ability to assume a role of responsibility in
the doctor/patient relationship, and the physician's experience with patient side effects to certain medicines in
medicinal approaches must all be considered.
Patient Compliance to Prescribed Regimens
The last
and most problematic area is patient compliance to prescribed regimens.
This is referred to as patient compli-
ance because i t is post-diagnostic and is the main area
upon which compliance studies have focused.
This emphasis
ignores the crucial role of compliance prior to a medical
diagnosis of hypertension.
Even assuming a completely
successful flow through this entire process, it is only at
this point, with the issue of patient adherence to the pre-
8
scribed regimen, that the work begins.
The greatest
problem in hypertension, in terms of frequency, is convincing the patient that therapy of any kind must be maintained.
However, as demonstrated, each aspect of the above
process has specific problems.
Because traditionally, "patient complianceu in
hypertension studies refers to diagnosed hypertensives,
this study has adopted the term "screenee compliance" to
avoid confusion.
That part of this process, the component
upon which this study is focused, occurs before the
individual has become a patient.
Therefore, "patient
compliance" is inappropriate.
The focus of this paper is on (1) awareness of
hypertension; (2) self-selection for screening; and
(3) a follow-up, pre-diagnostic screening.
Statement of the Problem
The first step in detecting high blood pressure is
screening.
Those screened with an elevated blood pressure
reading are then referred for a second blood pressure measurement, which is the second step.
This second screening
should occur within one week of the first screening.
Per-
haps the greatest screening problem is getting those with
an elevated blood pressure at the first screening to show
up for the second screening. (4:37)
As many as 70% of
those who have an elevated blood pressure reading at the
first screening do not return for the second screening.
(63:654; 30:1; 33:166; 30:3; 4:38)
The importance of blood pressure education as a
preventive measure was first revealed by a series of epidemiological studies beginning in the sixties.
Of the
three critical steps in the prevention process (detection,
entrance into therapy, and treatment), the period from
referral to entrance into therapy is the most critical
time. (22:24)
This includes the series of blood pressure
checks one must pass through en route to referral.
The
drop out rate, which can be as high as 70%, becomes problematic for program planners.
dropouts?
Are these people really
or are they merely slow to follow the screening
clinic's recommendations?
This paper will focus on the 70% drop-out rate
occurring between the primary screening and the suggested
follow-up, pre-diagnostic secondary screening requested
of those who have elevated blood pressure readings in
the first screening.
What kinds of intervention will be
effective in raising compliance at this point? ·Apparently
little research has been directed toward this end.
Additionally, although this is beyond the immediate
scope of this paper, 50% of diagnosed hypertensives drop
out of their treatment regimen.
The problem of post-entry
dropout (i.e. following entry into a treatment regimen) is
closely associated with pre-entry delay and drop-out.
(22:24)
Is i t possible, then, that the faster hyperten-
10
sives are identified and entered into a treatment plan,
the longer they will remain with that treatment?
Purpose of the Study
Specifically, this study tested the efficacy of oneto-one educational intervention in a high blood pressure
primary screening program.
The study was designed to in-
crease the number of persons with an elevated blood pressure who, after initial screening, obtained a second blood
pressure reading within one week following the initial
screening.
Statement.of hypotheses.
1.
There is no significant difference in mean
compl~ance
between the control and experi-
mental groups; i.e., the educational intervention method tested will not affect
screenee compliance.
2.
The compliance of each group is independent
of smoking, age, weight/height ratios, sex,
race, occupation, marital status, medical
history (personal and familial), education,
household income, and stated personal
feelings about the value of health.
Overview of Methodology
This study consisted of a blood pressure screening
program conducted at Teledyne, Inc., Northridge, California.
The employee population approximated eleven hundred.
It
was initially estimated by Teledyne that 37% of this population would voluntarily participate in the screening.
The
study was sponsored by the High Blood Pressure Council of
Los Angeles which estimated that 10% of these would have
elevated blood pressure readings.
Those who were so
screened were randomly assigned (coin toss) into one of
two groups:
one control (with no individual counseling)
and one experimental (with individual counseling).
One
week later each member of the two groups was contacted to
determine "screenee compliance."
An actual blood
pressure measurement, either at the work site's
medical facility, by a private physician or clinic,
or at a community agency to which the screenee was
referred, constituted compliance for purposes of this
study.
Limitations of the Study
These are the study's limitations:
1.
Any possible side effect of the educational
message and/or methodology of the program
on screenee blood pressure was not considered.
Although this could easily increase
the number of false positives, it could
also increase the size of the universe
available for the study.
2.
Even though the content of the presentation
12
was standardized, individual characteristics of the health educator were not
controlled.
3.
The results of this study pertained only
to the control and experimental groups
and are not generalized to other populations,
including those employees who did not take
advantage of the screening.
4.
Because blood pressure screening was optional to each employee, such self-selection
may affect the results.
This was not
controlled.
5.
With those screenees who received a followup telephone call, it was recognized that
some might tell the researcher what they
thought he would want to hear, rather than
reporting the actual behavior.
It is
assumed, therefore, that the frequency
with which this occurred is evenly (i.e.
randomly) distributed across the control
and experimental groups.
There was no
control on this.
Assumptions of the Study
A frequently overlooked consideration in traditional health care is that of the individual's prerogative of
13
choice in entering a traditional health care delivery
system.
It is a casual assumption of many that one would
choose to do so when the need is indicated.
true.
Such is not
Although not readily visible, there are many who
choose to remain outside conventional health-care
delivery systems in recognition of other priorities, or
in preference for other health care resources which might
be less conventional.
The individual's right to self-
determination will not be usurped by the scientific .
concerns of this study.
The basic assumption of this
study, therefore, is that potential hypertensives would
be desirous of seeking follow-up services from traditional sources for purposes of health maintenance.
Definition of Terms
In order to assure a uniformity of understanding
and interpretation of terms used in this study, the
following definitions are offered for clarification:
Blood pressure levels --
The average normal blood
pressure is considered to be a
systolic of 120 mm Hg (millimeters
of mercury) and a diastolic of 80
mm Hg, usually recorded as 120/80
mm Hg.
This will vary with age,
sex, emotional and physiologic
states at time of measurement, etc.
14
Any blood pressure greater than
139 mrn Hg and/or 89 mm Hg is
considered to be above normal
limits for purposes of this
study.
Hypertension
is the medical term used for high
blood pressure and refers to a
condition in which the blood
pressure is constantly elevated.
Essential hypertension -- ''Essential" refers to
the fact that its etiology is
unknown and that it cannot be
cured.
This accounts for 85%
to 95% of all hypertension. (58:32)
Secondary hypertension
is a condition that
results from some other condition
such as renal tumor.
Secondary
hypertension is usually cured as
the result of treating its pathologic precursor, most frequently
by surgery.
Systolic blood pressure -- refers to the blood
pressure recorded as the heart
contracts.
This pressure is
created by the blood as it is
15
pushed out of the heart against
the walls of the arteries.
This is cardiac output.
Diastolic blood pressure -- refers to the blood
pressure recorded when the heart
is relaxed between contractions.
Note:
Definitions of the above terms are
accepted by the National High Blood Pressure
Education Program.
Control -- refers to a blood pressure that has
been reduced to a medically
acceptable level of maintenance.
Potential hvpertensive -- refers to an individual
who is initially screened with an
elevated blood pressure.
Screenee -- is an individual who is screened for
hypertension, who has a blood
pressure reading greater than
139/89 mm Hg, and to whom a
follow-up, pre-diagnostic
screening has been recommended.
Educational intervention -- is an intervention
whose purpose is to educate
potential hypertensives about
hypertension by providing them
with information about the
16
physiology of the causes and
consequences and the treatment of high blood pressure
vis ~ vis the achievement of
screenee compliance. (22:33)
Compliance
within one week following the
primary screening, screenees
will have had a second blood
pressure measurement taken.
CHAPTER II
REVIEW OF THE LITERATURE
Introduction
Hypertensive disease is controversial.
Some
aspects of this controversy concern physicians, while
others concern the hypertensive patient.
both.
Physicians are still asking:
high blood pressure?••
Some affect-
"What causes
"What is high blood pressure?••
••How, and when, should i t be treated?"
Patients,
however, are more concerned with the abstract nature
of this asymptomatic disease.
They ask:
"Why should
I alter my life style, or stop using salt, or take
medicine that makes me sick when I already feel well?"
Physicians too are concerned with this.
Another aspect of the hypertension problem has
been the attitudes of physicians.
Some physicians have
been slow in initiating screening programs for high
blood pressure, in instructing the patient about the
need for long-term care, or in providing hypertensive
patients with adequate follow-up care.
It was Paul's
observation before a world congress on heart disease
that ..... the physician often evades a diagnosis of
mild hypertension by recording blood pressures just
below significant levels." (15:15)
17
Some physicians
18
refuse to give consideration to anything but the most
severe hypertension.
Although recognizing that proper
treatment of extremely high blood pressure will reduce
morbidity and mortality, these physicians feel that
the same is not necessarily true with more moderate·
elevations of blood pressure. (13:681)
Some physicians
do not understand hypertension well enough to treat it
effectively.
To address these and other concerns, hypertension
will be reviewed through five sequential perspectives:
(1) the historical significance of blood pressure and
hypertension in the development of medicine; (2) history
of hypertensive sequelae; (3) the current prevalence
of hypertension; (4) solutions to the hypertension
problem evolving out of the last decade; (5) the need
for· education vis ~ vis high blood pressure screening.
A History of Blood Pressure and Hypertension in Medicine
Mention of high blood pressure first appeared
in the annals of Chinese medical research several millenia
ago.
It was Chinese physicians who offered the first
consideration of high blood pressure by observing some
connection between dietary salt and elevated blood
pressure.
In fact, in 2600 B.C., what is now a classic
Chinese treatise on internal medicine reported a relationship between too much dietary salt and a change in
19
" ••• the complexion, the appearance of tears, and a
hardening pulse." (15:23)
"When blood hardens," as the ancient physicians
described it, bloodletting and acupuncture were recommended by most respected medical texts.
North and
South American Indians used trepanning (boring a hold
in the skull) while Roman, medieval Arab, and Jewish
physicians used leeches for bloodletting. (15:23)
There are certain morbid events described in the
Bible
accounts of paralysis and rapid death -- which,
from the description of the event, could have been the
consequence of elevated blood pressure. (15:23)
Current
perspectives on time and medical progress now show
that many historical figures died as a result of
hypertensive events.
These include King Charles II and
his lover, Nell Gwynn, William Harvey, Louis Pasteur,
Woodrow Wilson, Franklin D. Roosevelt, and Joseph
Stalin. (15:23)
Harvey first identified the circulation of blood
in the early seventeenth century, but it wasn't until
over a hundred years later that Hales, in 1733,
conducted his classic experiment on a horse.
In December I caused a mare to be tied down alive
and on her back; she was 14 hands high, and about 14
years of age, had a fistula on her withers, was
neither very lean nor yet lusty; having laid open
the left crural artery about 3 inches from her belly,
I inserted into it a brass pipe which was fitly
adapted to it, I fixed a glass tube, of nearly
20
the same diameter, which was nine feet in length:
then untying the ligature on the artery, the blood
rose in the tube 8 feet 3 inches perpendicular
above the level of the left ventricle of the
heart; but it did not attain to its full height
at once; it rushed up about half way in an instant,
and afterward, gradually at each pulse, 12, 8, 6,
4, 2, and sometimes 1 inch; when it was at its
full height, it would rise and fall at and after
each pulse 2, 3, or 4 inches. (15:24)
One hundred years following the Hales experiment
a French student studying in Paris decided to carry the
Hales experiment one step further, resulting in the
feasibility of indoor blood pressure measurement.
Poiseuille connected a mercury-filled U-tube to an
artery.
Because mercury is 13.6 times more dense than
blood or water, the column in the tube was elevated
less drastically than the blood in Hales' tube.
This
experiment resulted in millimeters of mercury (mm Hg)
becoming the standard unit of blood pressure measurement.
(15:24-25)
However, convenient blood pressure measure-
ment as we know it today still was not perfected.
Seventy years following the acceptance of
millimeters of mercury as the standard unit of measure,
an Italian physician developed an instrument for
measuring arterial blood pressure.
He called it a
.. sphygmomanometer."
It had a rubber cuff, similar to
contemporary models.
In 1905, Korotkoff, a Russian
physician, developed a method of using a stethoscope
to listen to the pulse. (15:23)
Following this sequence
21
of events, today's method of measuring blood pressure
was being used about the time of World·War I.
Although an amalgamation of international
research was required to develop a method for measuring
blood pressure, and over a span of nearly three hundred
years, several more decades would be required before the
significance of hypertension would be determined.
Early research in hypertension resulted in several
popular "treatments:n
extract of watermelon and·
cucumber seeds, mistletoe and garlic, and one entrepreneur even sold nwhiffless garlic." (15:20)
meat and too much sex were forbidden.
Red
The first reported
drug to be used, in 1928, was potassium thiocyanate.
The efficacy of this drug was to plague researchers for
decades.
It proved to be highly toxic. (15:20)
In the early thirties physicians were more confident in their hypertension treatment modalities.
Treatment was etiologically oriented, and since the
etiology of elevated blood pressure was thought to be
a syndrome of worry, fear, lead, and rheumatic and
other infections, treatment consisted of "psychotherapy,
careful regulation of the mode of life, a well-balanced
diet, baths not below 34 degrees, ovarian gland preparations, iodides, and 'the bowels to be kept free.'
11
(15:20)
As unknown as the foregoing may sound to today's
22
health professional, there was an even greater problem in
the thirties.
Some physicians thought that hypertension
was a desirable physiological state which came after
hardening and narrowing of the arteries.
This rationale
was explained in terms of the body adapting to hardened
arteries (i.e. increased blood pressure was required
to force blood through narrowed arteries).
On this
basis it was feared that lowering blood pressure would
adversely affect the physiological integrity of the
body, resulting in a diminished blood supply to the
brain and other vital organs. (15:19)
So, while some
physicians in the thirties were promulgating a cause
for intense research in hypertension, others were
convinced that there was no need for such research
a controversy which continues to shadow current
physician attitudes.
The first clue as to the severity and consequence
of hypertension came in the 1930's.
At that time there
was no truly effective treatment for high blood pressure.
Medicine's first confrontation with high blood pressure
came from the identification of malignant hypertension,
which is relatively rare.
Blood pressure suddenly
increases drastically and often, within less than a
year from the initial diagnosis, the patient is dead.
Surgical sympathectomy (a nerve-cutting procedure) became·
the first medical treatment for hypertension. (15:19)
23
Because some physicians believed that reducing
elevated blood pressure would deprive the brain and
other vital organs of a required blood supply, and
because of medicine's exposure to cases of malignant
hypertension, "benign hypertension" became a popular
term during the thirties.
"Benign hypertension" was
used to describe all but malignant hypertension.
"Essential hypertension" also came out of this era.
It was used in reference to the increased blood pressure
required to push the blood through atherosclerotic,
diseased blood vessels. (15:19-20)
At that time there
were only a few physicians whose thinking differed
from professional consensus and who attempted to treat
their hypertensive patients.,
Prior to 1950 hypertension was treated with
doses of barbituates which made patients drowsy while
blood pressures remained high.
effects too.
There were other side
Large doses of hydralazine could produce
complications like lupus; reserpine in large doses
would sometimes produce depression and suicidal
tendencies.
Today, as the result of much intense
research, antihypertensive drugs can be prescribed in
combinations which minimize side effects, thereby
achieving a favorable benefit-to-risk ratio. (45:35)
Today, because it is known that even a mildly
elevated blood pressure has physiological consequences,
24
and because the term "essential hypertensiontt is
misleading, there is a trend in terminology to replace
ttessential" with "primary."
To this point the severity of hypertensive disease
has been presented in the abstract.
Specific patho-
genesis and subsequent sequelae have not yet been
discussed.
However, a slight digression will allow an
examination of the origin of hypertensive sequelae.
This will bring us to the following section.
There,
current medical knowledge of hypertension will be
explored.
History of Hypertensive Sequelae
One of the earliest references to "heart problems"
in medicine appeared in 1670.
At this time, England's
Lord High Chancellor, the Earl of Clarendon, experienced
chest pains so sharp he turned pale.
A seizure, some-
times lasting fifteen minutes, would give him a deathlike appearance and, during one of these attacks he did,
indeed, drop dead. (15:21)
It wasn't until nearly one hundred years later
that Heberden, a British physician, coined the name
"angina pectoris" for the chest pain experienced by
Clarendon.
It was Heberden's observation that the
pain would begin with physical activity and progress
with greater frequency until it also occurred during
25
periods of rest. (15:21)
In 1897 one of the foremost physicians in
medical history, Sir William Osler, made the first
attempt at relating blood pressure to angina pectoris:
ttwere the problem of blood pressure solved, angina
pectoris would be an open book to us." (15:22-23)
His specific thought, however, in terms of cause and
effect, remains unclear.
It would not be until the
end of the first decade in the twentieth century that
physicians would begin to relate repeated episodes
of chest pain, or angina pectoris, to heart disease.
Following this association, several more decades would
pass before the relationship between
hea~t
disease
and high blood pressure would finally come under
medical scrutiny.
The first diagnosis of a heart attack was made by
Herrick about 1918. (15:21}
Approximately ten years
later, following Osler's suggestion of an association
between angina pectoris and blood pressure, an American
cardiologist (Levine) authored a classic monograph on
coronary thrombosis.
In his practice he identified
60% of his heart attack patients (145) as being hypertensive.
Levine conjectured that elevated blood pressure
was " ••• probably the most common, single etiological
factor in the development of coronary thrombosis." (15:25)
In 1948 investigators reported a finding of more
26
than four times as many deaths due to heart attacks
occurring in soldier patients aged 18 to 39 with more
elevated blood pressures than heart attacks occurring
among those with normal blood pressure (i.e. normotensives). (15:25)
The first monumental study on the affect of
hypertension on mortality came as the result of a
report published by the Society of Actuaries in
1959. (15:26). This was an intercompany study on
blood pressure, analyzing data on 4,000,000 lives
and 102,000 deaths.
Several years prior to 1959
insurance companies had begun to collect retrospective
data on persons found to have elevated blood pressure
during insurance examinations.
The summary data
indicated an inverse relationship between blood pressure
levels and mortality; additionally, an adverse effect
was visible not only in people with severe hypertension
but in those with only modest blood pressure elevations
as well.
From the study it was clear that blood
pressures above 140/90 mm Hg were abnormal regardless of
(adult) age and that these elevated blood pressures
led to increased mortality.
This was the beginning of
the era of hypertensive disease.
"In the past 50 years,
the science of hypertension has become enormously
complex, and each year it becomes more so.
Most
physicians and even many specialists are unable to keep
27
up with the rapid advances •••• •• (37:2622)
Contemporary Prevalence of Hypertension - Why the sudden
alarm?
In less than ten years the statistics of hypertension in the United States have grown from almost
non-existence to near redundancy.
This reflects progress
in medicine's understanding of, and concern, for
hypertension and hypertensives.
It is now known that
high blood pressure is one of the most, if not the
most, important afflictions producing premature sickness,
disability, and death in our adult population. (20:962)
In fact, because hypertension is the only cardiovascular
disorder for which treatment has been shown to be
effective, it has emerged as the single most important
of the chronic cardiovascular diseases. (15:109)
Hypertension is also the single most important
risk factor in the production of atherosclerotic
phenomena (i.e. hardening and clogging of heart, brain,
leg and other arteries); in the development of strokes,
congestive heart failure, and kidney disease, heart
attacks, and angina pectoris. (15:11)
Additional risk
factors include excess amounts of blood cholesterol and
an excessive ingestion of certain fats; overweight;
heavy cigarette smoking; tension and stresses; little
or no exercise; and heredity.
However, some of these
28
risk factors are still controversial. (15:10-11)
Not only does the presence of hypertension raise
the probability of heart attack, it also increases
the severity of a heart attack when it does occur. (15:10)
In its role in kidney disease, leading to eventual
kidney failure, one can expect death at worst and the
need for a kidney transplant at best. (15:12)
It is
also recognized that not only is hypertension significant
in the loss of vision, " ••• there is even evidence now
that uncontrolled blood pressure elevation may be
responsible for some of the memory loss and other
phenomena long associated with aging." (15:12)
Hyper-
tension is even the single most important risk factor
in the "stroke" phenomenon of cerebrovascular disease,
both atherothrombotic (occlusive) and hemorrhagic. (45:24)
Generally there is a direct relationship between
blood pressure levels and the risk of developing blood
vessel disease.
People with higher blood pressures.
have a higher incidence of blood vessel disease. (51:24;
3:2)
One insurance study disclosed that hypertensive
male heart attack victims will experience twice the
mortality rate, within a one-month period of time, than
a normotensive male heart attack population.
Additionally,
male hypertensive survivors of a heart attack have
twice the risk of a repeat attack than normotensives.
Their risk of dying of heart disease within five years
29
following the heart attack is five times greater than
that of a normotensive, male, post-coronary population. (15:10-11)
Other insurance statistics tell that
even within the so-called normal range those with lower
blood pressure live longer. (47:74)
The textbook number for normal of 120/80 is
merely a median statistic, not an indicator of
healthiness; 110/70 is significantly better,
and 100/60 better still. Many 7th Day Adventists and other vegetarians have blood pressures even lower than 100/60 -- and as a group
7th Day Adventists have a strikingly lower
prevalence of C.A.D., stroke and cancer. (3:2)
In 1971 the results of the National Heart and
Lung Institute's study on hypertension in the United
States were released.
This was the country's first
prevalence study on hypertension.
Using a criterion
of 165/95 rnm Hg, i t was then estimated that approximately
23,000,000 Americans had high blood pressure, only half
of whom were aware of such. (54:396; 47:70; 26:2551)
Of those who were aware of their hypertensive state,
less than 10% were under control. (13:681)
Of these
approximate 23,000,000 hypertensive Americans, over
half had hypertensive heart disease (i.e. enlargement of
the heart and main pumping chamber).
This was shown
by the appearance of the heart enlargement on x-rays
or by electrocardiographic evidence of enlargement
of the left ventricle of the heart (the main pumping
chamber). (15:11)
30
Those surveys which constituted the first prevalence
studies revealed rough but reasonable measures of the
situation.
They also defined the challenge to our
health education and medical care delivery systems.
One half of the hypertensives were undetected.
One
half of the known hypertensives were untreated.
One
half of the treated hypertensives were inadequately
treated (i.e. not under control).
Eighty-eight
percent of the hypertensive population was being
inadequately treated in 1973. (47:70; 45:41)
To maximize prevention of complications, comprehensive care, not just drugs to lower blood pressure,
is necessary.
All the correlates of hypertension
( e •. g. cigarette smoking, diet, exercise, weight,
medical history, heredity) must be examined and
altered where indicated and possible. (45:48-49)
Use of non-drug therapies may be indicated.
As prevalent as hypertension is in the nation's
general population, it is twice as prevalent among
Blacks, afflicting 25% of our Black population. (48:22;
59:_)
In the 14th century it was the black plague
which devastated the population of Europe.
In the
20th century, it is hypertension which is so severe
in the Black population of the United States.
For
every Black who dies of sickle cell anemia, one hundred
die from hypertension. (47:73)
Not only is it more
31
prevalent among Blacks (Tables 1 and 2), it is also more
severe.
Totally, the ratio is about two to one
twice as high for Blacks as Whites. (45:12-13)
The pioneer Veterans Administration Cooperative
studies showed for the first time that control of
hypertension reduces mortality and morbidity from cardiaand cerebrovascular events. (26:2551)
To understand this, hypertension must be viewed
historically.
Modern medicinal therapies were not
standardized until the 1950s and 1960s.
In fact,
i t was not until the early 1970s that the prevalence
of high blood pressure was first determined. (39:12)
Not until just recently (1967 and 1970) were the
results of the Veteran Administration Cooperative
Study released.
This study clarified the theoretical
rationale for treating moderate and severe high blood
pressure as being correct.
At this time research in
meditation, relaxation, and behavior modification
(e.g. exercise, diet, smoking, weight) to reduce blood
pressure began.
One continuing problem comes, ironically, from
many physicians who indeed do recognize that drug
therapies are beneficial in treating malignant or other
severe or moderately severe types of hypertension.
However, these physicians do not believe in treating
TABLE 1
Percent of White and Black adults with blood pressures of at
least 160 systolic or 95 diastolic, by sex and age: United
Stc:ttes, 1960-62 (National Examination Suryey) J_45_;).~J
Sy11tollc at lea11t
160 mm. bg.
Dla11tollc at least
95 mm. bg.
Systolic at least 160
mm. bg. or diastolic
95 mm. bg.
Sex and Age
White
Negro
White
Negro
White
Negro
Percent
Both •exes - 18-79
10, 5
18.8
8.7
22.0
14.7
27 6
Total - 18-79 yean----------------
8.6
16.8
9.1
22.6
13.6
27.6
18-24yeara----------------------------
0.2
1.9
1.7
1.9
0.7
-4.6
1. 7
25-34yeara---------------------------
3.4
u.s
3.7
12.5
35-.Uyeara--------------------------
3.9
16.2
10,9
25.9
11.8
26.5
45-54years---------------------------
8.7
10.8
13.8
29.5
17.3
30.8
65-64yeara---------------------------
15.9
29.4
11.9
31.6
21 ••
44.6
85-74years----------------------------
26.1
63.2
12.3
40.5
27.3
66,0
75-79yeara--------------------------
39.1
59,8
13.3
21.2
40.2
59.8
12.3
20.4
8.3
21.5
15.6
27.8
0.7
0.8
3.4
0.8
3.4
year•-----------------------
!!!!.
~
Total - 18-79 yeara----------------18-24yeara---------------------------
-
15-34years----------------------------
0.7
3.4
2.1
8.5
2.3
8.5
35-.Uyeara---------------------------
2.3
14.3
5.3
24.1
6.2
25.6
45-54yeara---•----------------------
10.7
30.8
10.9
34.3
15.5
41.9
31.0
41.0
55-64yeara----------------------------
25.3
33.8
16.4
36.7
85-74,.ara----------------------------
45.4
68.5
17.9
32.1
75-Tt,.azw--------------------------
42.7
89.4
12.0
26.3
---
....
48.6
7:.0
89.4
----~
w
(\)
33
TABLE 2
Prevalence of definite and suspect hypertensive heart
disease for White and Black adults, by age and sex:
United States, 1960-62 (National Health Examination
Survey) (45:16)
Men
Women
Men
Women
Pressure in ·nm. hg.
White
Negro
White
Negro
Number of persona in thousands
Total---~-----------
46,561
Under 90-----------------90-99--------------------100-109------------------110-119-------------------
43
584
3,517
8,866
11,287
130-139------------------140-149------------------150-159------------------160-169------------------170-179---~---------------
9,290
5,558
3,382
1,734
1,060
180-189------------------190-199------------------200-209------------------210-219------------------220-229-------------------·
447
416
214
74
53
230-239------------------240-249------------------250-259-------------------
27
120-129---~---------------
260+--------~-------------
9
-
5,195
White
Negro White
Percent·distribution
51,184
6,219
100.0
100.0
167
2,258
99
434· 7,566
955 11,655
920 9,432
18
196
825
1,333
919
0.1
1.3
7.6
19.0
24.2
814
571
522
319
249
6,1)13
4,296
2,676
2,047
1,467
698
536
420
370
246
157
86
34
1,085
843>
465
172
91
236
127
61
152
88
19
-
-
25
--
9
-
11
2~
--
13
36
36
Negro
100.0
100.0
1.9
8.4
18.4
17.7
0.3
4.4
14.8
22.8
18.4
0.3
3.1
13.3
21.4
14.8
20.0
11.9
7.3
3.7
!2.3
15.7
11.0
10.1
6.1
4.8
13.3
8.4
5.2
4.0
2.9
11.2
8.6
6,8
6,0
3.9
1.0
0.9
0.5
0.2
0.1
3.0
1.6
0.7
2.1
0.5
0.9
0.3
0.2·
3,8
2.0
1,0
2.4
0.4
0.2
0.3
o.o
0.2
o.o
0.1
-
-
-
--
1.6
0.0
--
0.1
0.6
20.4
1.3
180+
,.,034
879
6,318
1,272
s.s
16.9
12.3
220+
89
34
239
80
0.2
0.7
0.5
34
the much more common, mild or moderate forms of the
disease.
This belief stems from deep within the
tradition and history of hypertension.
For fifty years there was no proof that
antihypertensive agents could reduce morbidity and
.
mortality.
to find out.
Understandably, physicians were loathe
They were too familiar with medications
that produced undesirable side effects.
Potassium
depletion, gastro-intestinal occurrences, exhaustion,
depression, and impotence were problematic among their
medicated hypertensive patients. (47:69)
Eighty-
five to 90% of all hypertensives have essential hypertension, and most of these are asymptomatic. (47:69;
45:28)
This is why old-school physicians are reluctant
to medicate; because of the side-effects produced by
early drug therapies.
The question continues to be disputed.
Some
believe that the answer to the whether-or-not-tomedicate issue depends on other patient factors.
Even
if the patient is not medicated, he still should be
kept under medical observation. (47:75)
Statistically, the distribution of blood pressure
levels throughout a given population is normal.
Any
division made is arbitrary, but such arbitration is
convenient in establishing guides for treatment protocols.
Exactly which criterion should be used is an issue which
35
is still controversial.
The World Health Organization
established an international criterion of 160/95 mm Hg.
(47:74)
The Hypertension Information and Education
Advisory Committee decided to adopt 160/90 mm Hg as its
standard.
Its rationale was based on picking up more
false positives and consequently overloading the
health care system. {47:75)
27:429)
Others concurred. (11:15;
But what were the priorities? economics?
politics? humanism?
The Veterans Administration Cooperative Study
demonstrated that a
thi~ty-five
year old man with a
blood pressure of 120/80 mm Hg is expected to have a
normal life span..
When that pressure increases to
130/90 mm Hg he will live four years less.
At
140/90 mm Hg nine years will be lost, and seventeen
fewer years will be lived if this typical thirtyfive-year-old has a blood pressure of 150/100 mm Hg.
(51:18)
Others agree.
(48:22; 47:74; 45:16)
Additional prevalence studies in the United
States conducted in the mid-seventies included populations not considered in earlier studies.
Those under
18, over 74, in the military, and institutionalized,
when included in subsequent studies, raised the
estimate to 35,000,000 in 1974. (53:1)
In response to the criterion controversy, the
trend in this country, over the last several years,
36
has been to lower the criterion to 140/90 mm Hg.
As a re-
_sult of this reduction, the National High Blood Pressure
Education Program estimated, in 1977, that there are now
59,000,000 Americans with high blood pressure (i •. e. a consistently elevated blood pressure greater than 139/89
mm Hg). (21:1)
An entire new population requiring ser-
vices has now been disclosed and will require consideration as the hypertension issue continues to be addressed.
High blood pressure is expected in geriatric
populations, but i t is also found in young and middleaged adults and, in some populations, as seen in
Table 3, an unexpected high number of young people •.
(20:962)
Table 4 shows that those hypertensives who
are young and middle-aged adults have an increased
risk of dying prematurely from cardiovascular complications.
As already demonstrated, this is even true
for only slight elevations of blood pressure. (45:15-16)
Considering the prevalence and sequelae of hypertension in the United States, one could justifiably
wonder why the hypertension problem has grown to such
magnitude.
One problem is that in hospitals the
taking of blood pressure is often neglected. (47:73)
In one study of undiagnosed/untreated hypertension, the
incidence of non-diagnosis was measured at 43% in a city
hospital, 39% in a university hospital, and 38% in a community hospital. (19:69)
Some consider the disregard with
37
TABLE 3
Percent Decline in Death Rates for
Selected Cardiovascular Conditions
by Age: u.s. 1970-1975 ( 21: 2)
Condition
Age'
15·24
25-34
3544
45 ..54
55-64
65;.74
84
All
Hypertensive
. Disease
Stroke
Coronary
Heart Disease
0
55.6
55.6
43.4
32.7
32.4
29.3
11.9
33.3
28.6
32.7
13.8
14.3
12.0
8.4
'35.4
17.8
14
12.5
22.2
43.4
22.6
20.8
14.2
TABLE 4
Survivorship of applicants for life insurance who showed elevated blood
pressure readings at the time of medical examination for insurance
( 1~59~~B'l,!j,.ld &~ I3J()pd~ l?~~essure ~tudy, Society of Actuaries) ( 45:17)
Standard Risks
Age 35
% Surviving, End of
5 yr.
10 yr. 15 yr. 20 yr.
89,0
98.6
96.6
93.5
Risks with Blood Pressure
Reading of
132/85
132/90
142/85
142/90
142/95
152/85
152/90
152/95
162/90
162/100
A'il.c 55
'l Surviving, End of
10 yr.
92.1
15 yr.
85.9
20 yr.
77.5
5 :v.r.
93.3
10 yr.
84.1
15 yr.
71.8
20 vr.
56.0
92.3
91.3
90.3
89.1
87.5
88.1
86.9
85.3
84.7
80,9
82.0
79.9
77.8
75.1
71.8
73.1
70.6
67.5
66.3
59.0
68.3
64.9
61.7
57.6
52.9
54.7
51.1
46.9
45.3
36.i
51.2
46.8
42.8
37.9
32.6
34.6
30.6
26.3
24.7
16.4
81.3
79.2
77.1
74.4
71.3
71,8
69.3
66.3
64.6
59,0
67.1
63.8
60.6
56.7
52.-0
52.9
49.4
45.3
43,0
36,1
49.7
45.4
41.5
36.8
·31.6
32.6
28.8
24.7
22.5
18.4
Men without Known Minor Impairments
98.4
98.0
97.9
97.5
97.0
97.4
97.0
96.3
95.9
94.9
94,8
93.8
92.5
93.6
92.5
90.9
92.2
90.3
90.0
88,2
85.8
87.9
85.8
63.0
86.9
83.9
83.4
80.6
76,8
80.1
76.8
72.4
-- -- -- --- -- -- --
Risks with Blood Pressure
Reading of
132/85
132/90
142/85
142/90
142/95
152/85
152/90
152/95
162/90
162/100
5 yr.
96.8
Age 45
% Surviving, ·End of
96.3
95.8
95.3
94.7
93.9
94.2
93.6
92,8
92.5
90.5
91.0
89.9
88.8
87.3
85.6
86.3
84.9
83,1
82.4
78.1
84.0
82.1
80,2
77.8
74.9
76.0
73.7
70.9
69.8
63.1
74.6
71.8
69.1
65.6
61.5
63.1
59.9
56.1
54.7
46.1
I
I
'
Men with and without Known Minor Impairments
98.2
97.7
97.7
97.2
'96.6
97.2
96.6
96.0
95.6
94.3
94.3
93.0
91.7
93.0
91.7
90.1
91.6
89.1
89.1
86.7
84.4
86.7
84.4
81.6
85.9
82.0
82.0
78.2
74.6
78.2
74.6
70.3
---- --- --- --
96.1
95,7
95.2
94.6
93.8
93,9
93.3
92.5
92.1
90.5
90.6
89.5
88.4
87.0
85.2
85.6
84.1
82.4
81.4
78.1
83.3
81.5
79.6
77.2
74.3
74.9
72.6
69.8
68.2
63.1
----
73.7
70,9
68.2
64.7
60.7
61.5
58.3
54.7
52,5
46.1
----
92.0
91.0
90.0
83.8
87.2
87.5
86.3
84.7
83.8
80,9
-
w
())
39
which hypertension has been viewed as negligent, especially
when such is related to the fact that during the last
twenty years physicians have had the means of achieving
definitive control of hypertension. (39:6)
Risks of morbidity and mortality increase when
hypertensive heart disease accompanys elevated blood
pressure. (45:22)
Note that in Table 5 those men with
hypertensive heart disease, actual or probable, after
twelve years of follow-up, mortality from all causes
was almost five times as high as for the group of men
at lowest risk.
Most of the excess deaths were due
to cardiovascular causes.
Distorted Statistics
Although these statistics give a valid insight
into the effect of hypertensive disease on mortality,
they can be, and frequently are, misleading.
The
cause-of-death coding procedures can be misleading too.
Many people with high blood pressure who die from cardiovascular events (produced at least partially by their
hypertensive disease) will be listed under an arteriosclerotic heart disease or a cerebrovascular disease
category.
disease.
The listing does not occur under hypertensive
Hypertensives for whom a myocardial infarct,
a cerebral hemorrhage, or cerebral thrombosis is the
precipitator of death will be coded under that
TABLE 5
Hypertension, hypertensive heart disease and risk of death, cohort
of 1,465 men age 40-59 in 1958 (Peoples Gas Co. Study 1958-70) (45:23)
--
1958 Findings
12-year Agf;!-Adjusted Mortality Rate per 1, 000,
No. of
Men
All
Causes
All
CVR
Sudden
Death
Myocardial
Infarction
Stroke
No Organ System
Abnormalities,
None of 3 Risk Factors
208
70
8
0
8
0
No Organ System
Abnormalities,
Hypertensive
147
156
53
22
30
12
Suspect
Hypertensive
Heart Disease
53
268
159
57
117
21
Definite
Hypertensive
Heart Disease
75
385
309
142
158
99
i
-
.~
0
41
precipitating event.
This happens even if hypertension
is identified as a secondary cause of death on the
death certificate, even if hypertension caused the
precipitating event.
This means that hypertensive
mortality data are significantly understated.
Consider
this, and then consider that hypertension affects at
least a third of premature heart attack deaths, and
even more premature stroke deaths. (45:25-26)
What's Being Done About It?
Major reasons for uncontrolled hypertension
include:
(1) the asymptomatic nature of the disease;
(2) controversy among physicians as to what
constitutes hypertension; (3) disagreement about
the level of blood pressure at which treatment
should begin; and (4) unpleasant side effects
from medications, decreasing patient compliance. (26:2551)
Up until the early sixties treatment modalities
available to hypertension were limited.
Standard
medications for anti-hypertensive therapy did not become
available until the fifties, and these were not without
serious side effects.
Because of the side-effects, these
medications were usually reserved for only the most
serious cases. (39:12; 15:15-16)
It would have been
exceptionally difficult, if not nearly impossible, to
convince patients with mild hypertension, who already
felt fine, and free of symptoms, to take drugs that
42
could possibly give them symptoms for the first time.
In this instance, the patient was asked to relate
the history of his experience with illness (i.e.
pain and/or a feeling of ill-health) to a state of
apparent good health.
He was asked to relate a near-
tangible to an abstract and simply could not.
Although
the drugs could be lifesaving in severe hypertension,
in addition to being considered impractical for
milder cases, there was no medical (or any other)
evidence that treatment for milder cases could prevent
strokes and heart and kidney failure. (15:15-16)
In 1965 two articles appeared on the appraisal
of anti-hypertensive drug therapy.
Goldring and
Chasis seriously questioned the clinical efficacy of
such therapy:
After about 15 years of assorted data
collecting, we believe that the alleged usefulness of antihypertensive drugs rests on conclusions drawn from notoriously uncertain statistical
compilations compounded by equally undertain estimates of morbidity and mortality in the natural
history of a disease of highly unpredictable
course. (51:19)
Pears~·
al., however, asked poignantly, "Does
anti-hypertensive therapy work? .. (51:19)
It was their
conclusion that in cases of malignant hypertension the
effectiveness of drug therapy was beyond question; but
that the same application to benign hypertension was
less convincing.
However, in their argument they
43
cited one carefully controlled study which offered a
distinct positive response in both male and female
patients with diastolic pressures greater than
110 mm Hg. (51:19)
Writing eight years later, Pears
offered, "At that time I would guess that most practicing
physicians in the western world would have sided with
Goldring and Chasis." (51:19)
As recently as twelve
years ago the need for antihypertensive therapy was
still unclear and highly controversial.
In the mid-sixties a sudden array of antihypertensive agents became available for use in treating
mild cases of hypertension.
Concomitant with the
availability of these drugs there began a study the
results of which would prove to be not only the most
significant finding in the entire history of hypertension,
but which would also give proof that anti-hypertensive
drugs could ward off complications and lengthen
life. (47:70)
Freis, conducting a study in seventeen
Veterans Administration hospitals across the country,
using two hypertensive groups (one on placebos,
the other on hypertensive medication), showed that
effective treatment of severe
~
moderate hypertension
could dramatically reduce mortality. (39:12; 15:16)
These studies became known as the Veterans Administration
Cooperative Study for which Freis was awarded the 1971
Lasker Award, one of the highest honors in American
44
medicine. (15:16)
Using a combination of thiazide, reserpine and
hydralazine, Figure 1 shows an average reduction of
30 mm Hg systolic and 16 mm Hg diastolic occurred in
men with average diastolic pressures at entry of
90 to 114 mm Hg.
The average decline for men with severe
hypertension (average diastolic pressures of 115 to
1.29 mm Hg at entry) were even greater.
Figure 2 shows
that those on placebos experienced no reduction in
blood pressure.
In fact, Figure 3 indicates that there was
even a tendency for blood pressures to rise on
placebos. (45:35-36)
Of the 186 men randomly assigned to the treatment
group, 22 developed morbid events, compared with 56
of the 194 men randomly assigned to the placebo group.
The risk of developing a morbid event over five years
was reduced from 55% to 18% by treatment.
There were
only 9 terminating morbid events in the treatment group,
and 35 in the placebo group.<
The treated group had 8
deaths related to hypertension or atherosclerosis.
The placebo group had nineteen.
Additionally, 20
patients, all in the placebo group, developed persistent diastolic pressures to 125 mm Hg or more.
The
benefit of treatment was greater in patients with higher
FIGURE 1
Changes in systolic (left) and diastolic (right) blood pressure in
control group of patients given placebos and experimental group of
patients treated with hydrochlorothiazide plus reserpine plus hydralazine (active drugs); men with average diastolic pressure at
entry in the range of 90-114 mm Hg (Veterans Administration Cooperative Study on A.nt:i.h_yp_E:_.t:'t~nt>_iye_ A_g_ept~_ (45:~7_) _____ _
«<
Matos
)I)
I
lllCIEASE
211
IL
~
nnn
ol
...
...z..."'
c
n
IL
lllCIEAS£
10
0
~
:!»
...z
...u
ACliV£ DIIUGS
...z
...u
...""
IL
«<
ACTIV£ DIIUGS
iI
)I)
20
10
0
...
0
-16
CltloNG( IN SYSTOliC flOOD PIES SUI£- mm Hrj
-·
-)2
-·
CltloNG£ Iff DIASTOliC llOOD I'IESSUII£- . . Ill
J::.
U1
FIGURE 2
Changes in systolic (left) and diastolic blood pressure (right)
after four months of treatment in 57 patients given placebos
(above) and 68 patients treated with hydrochlorothiazide plus
reserpine plus hydralazine (below); men with average diastolic
p.re~sl_lre a_t ent_ry _il'l__th~rang~ ).1_5-129 mm Hg. ( 45:36)
·f · · · ~. :n, · i
I'I.ACUO
i
i
l!i
l!i
~
IM:RIAS£
MCRUSE
INC RUSE
MCR£ASE
s...
!....
""
J:
~
...
~
ACTIVE DRUGS
ACTIVE DRUGS
·76
•..,
...
·21
+12
CHANG£ IN SYSTOliC ILOOO PRfSSUM • .,. HI
•21
·76
•..,
...
·ll
·12
0
•12
•21
CHANG£ IN DIASTOliC 1[000 PllfSSURI • "'"' HI)
*"
(J)
47
FIGURE 3
Estimated cumulative incidence of morbidity
over a 5-year period as calculated by life
table method; terminating morbid events
(above) and all morbid events (below); men
with average diastolic blood pressures
90-1.14 mm Hg at entry (Veterans Administration Cooperative Study on Antihypertensive
Agents) (45:39)
A. TERMINATING"MORBID EVENTS
40
Control group
1: 30
8
... 20
&!
10
00
1
-·-·----·-·....,.....---·-·
3
4
Treated group
5
Years at cmervatlon
B. All MORBI 0 EVENTS
60
Control group
50
40
"C!
8 30
.r··
10
10
Treated grtKq,
48
entry level pressures than those with lower entry level
pressures.
Treatment was more effective in the prevention
of congestive heart failure and stroke. than in preventing
clinical manifestations of severe coronary atherosclerosis. (45:39-40)
With the knowledge that early recognition and
control of hypertension could prevent damage to vital
organs and save lives, it wasn't long before the
significance of the study was recognized.
The results of the Veterans Administration studies
have brought about much change in physicians' attitudes
since their publication in 1967 and 1970.
Now hyper-
tension is a problem of first-rank importance in private
practice and in public health, and its early detection
and treatment are now seen as a vehicle of progress in
heart disease, stroke and kidney failure.
Today, more than fifty antihypertensive agents fall
into three broad categories:
diuretics that deplete body
fluids, sodium compounds that act on the arterioles to reduce peripheral resistance, and drugs that work by depressing the sympathetic nervous system. (47:76)
Since the development of these drugs, the demonstration of their optimal usage (often in combination),
and the determination of their efficacy in preventing
morbidity, the next step is that hypertensives should
be identified so they can be controlled.
Identification
49
begins with screening.
in scope.
Screening programs may vary
Some are concerned with public education,
others might just screen.
Some refer patients to
physicians or hypertension treatment clinics.
Some
programs monitor blood pressure in patients receiving
antihypertensive medications in cooperation with the
patient's physician.
Some are recommending that 20% of the hypertensive
population should be treated medicinally or with lowsalt diets as a beginning goal. (51:19)
More realis-
tically, others realize that although all hypertensives
(59,000,000) will not soon be converted to perfect
management and compliance, bringing in 10% a year may
be more operational. (47:76)
It has already been established that a majority
of hypertensives are being inadequately treated in
terms of effects on blood pressure compared with the
ability to lower and normalize blood pressure with
proper use of drugs and drug combinations. (45:37)
It is essential, therefore, that future physicians,
as well as those now practicing, who may have less
current information than their younger colleagues,
are educated.
The American Medical Association and
the National Medical Association have given this a
priority.
The American Medical Association has also
50
established a special committee to address the hypertensive problem.
Headed by Bogdanoff, chairman of
medicine at the University of Illinois and editor of
the "Archives of Internal Medicine," the committee
urges " ••• all physicians, irrespective of speciality,
to routinely measure the blood pressure of every
patient initially seeking care for any complaint." (47:71)
The committee also recommends that aggressive therapies
be directed toward hypertensive patients.
Traditional
and non-traditional treatment modalities are available.
The American College of Cardiology has conducted
symposiums for practitioners, as well as published
editorials and articles in the "American Journal of
Cardiology" to direct special emphasis on hypertension.
(47:71)
In 1972 both the Inter-Society Commission for
Heart Disease Resources and the Department of Health
Education and Welfare responded to the hypertension
problem.
The Inter-Society Commission for Heart
Disease Resources promulgated the need for a major
national effort designed to detect and control hypertension.
In its statement it identified 1972 prevalence
statistics and the inadequate identification of, and
therapies provided to hypertensives.
Acknowledging
the findings of the Veterans Administration studies,
it recommended programs to identify hypertensives
51
and to assure their continued treatment. (45:54)
The
Department of Health, Education and Welfare, however,
established the National High Blood Pressure Education
Program to enhance professional and public awareness
of the hypertensive statistics, sequelae, and treatment
modalities.
established.
Toward this end, two committees were
The Hypertension Information and
Education Advisory Committee and the Inter-Agency
Working Group of High Blood Pressure brought together
representatives of the National Institutes of Health,
the Health Services Administration, the Food and Drug
Administration and the Veteran's Administration.
Coordination was to be directed by the National
Institutes of Health via the National Heart and Lung
Institute.
Task forces were developed to make
recommendations on criteria for screening, referral,
and treatment, and educational programs for health
professionals and the public, and on resource development by which the entire program would be implemented.
In 1973 the National High Blood Pressure Education
Program had a $2,000,000.00 budget. (47:70-71)
It was
expected that several years would pass before the
affect of public health approaches on morbidity and
mortality rates would begin to emerge.
Any educational process requires that a point of
departure be ascertained first.
How much did the
52
general public already know about hypertension?
To
find out, the National Heart and Lung Institute contracted
with Louis Harris & Associates to survey current public
awareness and knowledge of high blood pressure.
The
sample population totaled 3,181 people over sixteen
years of age.
Drawn from 200 locations throughout the
United States, the sample was designed to represent
the civilian noninstitutional population of those over
sixteen.
The survey concluded that there was " ••• an
appalling lack of patient information on hypertension ...
(7:1249-1250)
The National Heart and Lung Institute also
responded by sponsoring the Hypertension Detection and
Follow-up Program.
This program has fourteen centers
throughout the country which are reaching out into their
communities to identify every possible hypertensive who
can possibly be reached.
Once these people are
recruited into the program they are randomly assigned
(after a work-up) to one of two groups.
In the first
group, members receive usual care through the usual
medical practice mechanisms.
The second group is
randomly assigned to a special care unit.
of this unit is experimental.
The purpose
The variables are changes
of medical personnel (physician plus non-physician health
worker), changes of place of administration of care
(home visits, etc.), improving long-term management of
53
hypertension, and subsequent program
ef~ects
on morbidity,
disability, and mortality across the respective communities. (45:40-41)
Figures released in 1976 by the National Heart
and Lung Institute indicated some measure of success
in attempts to detect and control hypertension.
More
people were aware of their blood pressure, and more
hypertensives were under treatment.
Since the American
Academy of Pediatrics recommended that blood pressure
be routinely recorded in every pediatric work up,
irrespective of age, the situation should improve
further. (26:2551)
Ideally, mass screening will
become uhnecessary as public awareness of hypertension
sequelae increases, as practicioners become more
successful in their treatments and as patients
experience more successful compliance.
In fact, in
the seventies, .the problem of non-compliance came to
be recognized as the critical missing element in the
successful treatment of hypertension. (39:12)
The seventies also saw a greater acceptance of
historically non-traditional treatment modalities.
Meditative and relaxation exercises, biofeedback, as
well as exercise, weight control and cessation of
smoking became recognized methods of treating hypertension.
Alternatives to drug therapies continue to
be researched.
54
As positive as these results sound, much work
remains.
Successful detection campaigns will require
extensive outreach endeavors.
It is crucial to
recognize that screening must go to the individual,
rather than relying upon his/her coming to the
screening.
Early attempts at placing the responsibility
for screening onto the individual have shown disappointing results. (58:32-33; 10:591)
Education During Hypertension Screening
Considering the asymptomatic nature of hypertension, its prevalence in the United States (59,000,000)
and the .high percentage of undiagnosed and/or uncontrolled cases (30,000,000/15,000,000), a public health
approach seems appropriate.
The entire history of
modern public health teaches that these problems
require mass public health solutions, i.e. community
instead of individual methods.
The doctor-patient
relationship as an individual entity is no longer
practical in solving mass public health problems.
Additionally, many physicians and patients
are schooled in less abstract diseases -- diseases with
a single primary etiology.
Acheson recognized that the
old models used to treat these diseases may not be
applicable in today's focus on non-infectious,
degenerative diseases.
Epidemiologists now recognize
55
that many of these new diseases have complex etiologies
and Acheson recognized that physicians and scientists
refused to yield to this knowledge " ••• because it is
uncomfortable and scientifically untidy ••••" (9:238)
As difficult as it is to persuade hypertensives
to comply with a prescribed treatment regimen, the
problem of first identifying hypertensives and then
convincing them (and sometimes their physicians too)
that the disease should be treated presents an even
greater problem.
"Controlling blood pressure requires
patients' understanding of hypertension and their
responsible involvement in their own care." (17:624)
Of all the diseases afflicting adults, only a
small number can be prevented by modifying the risk
factors.
Conversely, there is a small number of
diseases with which it is now established that detection in the early, presymptomatic stages will result
in an outcome different from that observed after the
symptoms appear. (29:549)
If risk factor modification
or early intervention are going to be successful,
more intense health education efforts will have to be
augmented.
But what is the relationship between health
education and hypertension?
Consider our focal problem:
that a high percen-
tage of unknown hypertensives don't have their blood
pressure rechecked after the initial screening.
56
Although easily performed and certainly a
laudable project for health care agencies,
hypertension screening must be coordinated
with intensified educational efforts. In
order to achieve the intended goal of getting
the hypertensive patient on therapy, followup examinations and the importance of therapy
must be stressed. It is our belief that
any screeni~g program must also provide an
educational service to the patient and that
screening programs should have a mechanism of
evaluation so that the results of these efforts
can be assessed and appropriate changes
instituted. (32:385)
Additionally, screening for hypertension is the
first goal of the "Report of the Inter-Society Commission for Heart Disease Resources." (62:17)
Making a
serious dent in the vast hypertensive population will
require massive efforts if millions are to be identified.
It has been suggested that a combination of
community screening programs, simplified diagnostic
evaluation and intense education and follow-up will
increase the percentages under continuous treatment
and control. (63:653, 662: 23:55)
The public's ignorance about hypertension
is regrettably profound, probably a reflection
of a general deficiency in community health
education. The very term 'hypertension' is
unfortunate, for i t creates confusion and false
notions. On survey, many individuals (of all
socio-economic and educational backgrounds)
failed to realize that 'hypertension' and
'h~gh blood pressure' are synonomous.
Hypertension carries connotations of 'hyper' and
'tense' and in layman's language frequently
means only emotional tensions (with or without raised pressure). Relief or cure of
the condition is often thought to derive
exclusively from relaxation, relief from tension, tranquilizers. Few appreciate that
57
hypertension can exist and persist without
unusual emotional stress. A disappointingly
small fraction of the population connects
hypertension with vascular damage:
strokes,
myocardial infarction, heart failure. Facts
about the treatment of hypertension and the
need for long-term medication and its documented
value are not widely known. The public is simply
very poorly informed about one of its most prevalent health hazards. (58:33)
The public's dissatisfaction with its health care
or the health care of others should be recognized.
Forty-three percent of one study felt that their
generation's health was better than that of their
parents and only 34% regarded their own health as
excellent. (40:22-23)
Also, most of the public has
had at least one experience which could have provided
the opportunity to learn about blood pressure.
Seventy-
seven percent of those responding to one survey had
had their blood pressure checked within the previous
twelve months; 99% reported having had it checked at
one time or another.
Twenty-three percent of this
population reported not knowing what high blood·
pressure was.
Others described it as the "heart
pumping too fast," "blood flowing too fast," "too
much blood, blood too thick," or "too much blood to
head ... (40:44)
This lack of education results not from a lack
of knowledge of what the individual needs to know to
maintain optimum health, it happens because a planned
58
approach is not developed to satisfy a population's
educational and informational needs.
While ultimate health satisfaction cannot be
defined, and certainly not achieved, the level of
discontent in the studied population is great enough
to assure the success of a well designed campaign
oriented to convince the public of the dangers of
high blood pressure. (40:22-23)
Educating each
screenee with elevated blood pressure levels during
screening is suggested as part of such a campaign.
CHAPTER III
METHODOLOGY
Statement of Purpose
The objective of this study was to ascertain if
one-to-one counseling (educational), conducted at the
time of the initial screening, would motivate potential
hypertensives to a second blood pressure measurement.
Additionally, the study attempted to develop a profile,
within a given population, of the compliant screenee.
Location/Population
Teledyne Systems, Inc. in Northridge, California,
is a manufacturer of electronic components and markets
its highly sophisticated merchandise in both commercial
and consumer markets -- missile systems to calculators.
The Northridge facility is one of approximately 260
corporations held by Teledyne.
The Northridge facility's
employee population on August 3, 1978, the date of the
initial screening was approximately eleven hundred.
In
addition to the standard admixture of business, maintenance, manufacturing and service departments typical
in such a facility, and their sundry personnel,
Teledyne also employs a large number of highly- and
semi-skilled, white-robed technicians.
59
60
Methods
From the Teledyne population approximately 820
employees volunteered to have their blood pressures
checked.
Sixty-four of the employees had elevated
blood pressures after two blood pressure measurements
(i.e. if greater than 119 mm Hg systolic and/or greater
than 79 mm Hg diastolic).
These 64 screenees were randomized into control
and experimental groups.
randomization.)
(A coin toss was used for this
The experimental group (N=28) was
·counseled on a one-to-one basis.
The control group
(N=36) had only their blood pressures taken and did not
receive counseling.
At the initial screening each subject completed
a data collection form (Appendix C).
One to three
weeks later each subject was contacted by telephone and
compliance was determined.
The study was conducted under the auspices of the
High Blood Pressure Council of Los Angeles.
This agency
has a library of written materials designed for education
of screenee populations.
All educational materials
used in the study came from this library -- leaflets,
booklets, pamphlets, and brochures.
were in English.
All materials
61
Instruments
The data collection form (Appendix C), electronic
sphygmomanometers, and written educational materials
were the chief instruments used.
The questionnaire requested the following:
1.
identifying information required for followup on the individual.
2.
information regarding known correlates of
hypertension in both the individual and
blood family;
3.
standard demographics;
4.
stated value and perception of health.
Identifying information consisted of respondent's
first name, and work and home phone numbers.
This
information was primarily for follow-up purposes.
Correlates of hypertension used in the study
were:
smoking, age, weight and height ratios (looking
for obesity), sex, race; medical information on self
and blood family about hypertension itself, heart
problems, diabetes, stroke and kidney disease; and use
of birth control pills as a precursor of elevated blood
pressure.
Demographics, in addition to overlapping with
some correlates, included job title, marital status,
education, and income level.
62
Perceptions and value of health concerned current
feelings of stress about physical/mental health, and
about the respondent's stated value of health.
Screening Personnel
Excluding the calibration of the electronic
sphygmomanometers and three personnel who were provided
by the leasing company, staffing was strictly and
appreciably volunteer and consisted of two social workers
(MSW), two graduate students in community health
education (including the author), the director of the
High Blood Pressure Council of Los Angeles (MPH), and
one lay person.
Four of the above were trained in high
blood pressure education and certified in the measurement of blood pressure by the High Blood Pressure
Council.
The excepted person (MSW) was considered to
have a professional background strong enough to allow
her to work within the parameters of the program,
blood pressure measurement excepted.
The three personnel provided by the lessor of
the sphygmomanometers included one licensed pharmacist,
one technician and one clerical person.
In total,
nine persons were required to staff the program
ninety person hours.
The screening began at 7:00 A.M.
and ran continuously until 5:00 P.M. on one day.
63
Screening Program
One of Teledyne's service departments, the Office
of Safety, served as entree into the Teledyne community.
This office functioned as an internal coordinator to
the program, primarily in communications.
In the initial presentation of the screening
program to Teledyne, the chief "sellingtt feature
was that the entire program would be executed by program
personnel, thereby minimizing demands imposed upon
Teledyne.
Also, Teledyne incurred hidden costs by
allowing employees to leave their worksites to have
their blood pressures checked.
This included travel
time to and from the screening area, sometimes
waiting in line, and going through the screening
maybe more than once.
Therefore, demands made upon
Teledyne had to be minimized.
Because Teledyne's Northridge facility functions
under a very strict security system, internal communication, or advertising the screening, had to be
accomplished from within the Teledyne system.
One
week before the program began, announcements were
posted on all bulletin boards.
Standard posters designed
by the National High Blood Pressure Education Program,
and provided by the High Blood Pressure Council, were
used throughout the facility to announce date, time and
64
location of the screening.
Three days before the program,
an article appeared in the employee newsletter (Appendix
A).
In the article hypertension was defined, morbidity
and mortality were discussed, and the actual announcement
was made.
The article also stated that screening was
optional to each employee.
The morning of the screening,
department heads were asked to remind their people of
the screening.
The Office of Safety warned that this particular
population was not very responsive to such activities
and that a response of 400 out of 1100 employees would
be a probable expectation; especially considering that
it was August and many were on vacation.
By five
o'clock the day of the screening, 820 employees had
been screened.
TABLE 6
Employee Participation
Participated
Number
Per Cent
Didn't Participate
Total
820
280
1100
74.55
25.45
100.00
One week prior to the screening, program personnel received informal written protocols describing
the purpose of the program, Teledyne, the flow of the
program, and the functions of each position, with
65
instructions as they applied to each of the positions.
The
nine people staffing the program were assigned to one of
four functions:
one worked as a receptionist, guiding peo-
ple through the holding area; two coordinated traffic
through the electronic sphygmomanometers; five counseled;
one coordinated the above.
The screening sit was physi-
cally segregated by the above functions.
des~ribes
Figure
the following in flow-chart format.
Reception and Holding
People first arriving for screening were
asked to sit and rest for five minutes.
It
was explained that even the physical exertion
of walking to the screening site could cause
elevation of blood pressure and that as normal a reading as possible was necessary.
As
the electronic sphygmomanometers were vacated,
those waiting in the holding area were directed
to a sphygmomanometer if they had already
waited five minutes.
Those with readings
greater than 139/89 mm Hg, systolic and/or
diastolic, were directed back to the holding
area.
Here they were again asked to rest,
this time ten to twenty minutes, depending
upon the individual's patience with the
process (and most were willing).
Question-
FIGURE 4
Flow Chart of Teledyne Hypertension Screening Program
First BP
Less Than
1.
140/90
Employee
Newsletter
Article
First BP
mm Hg
First BP
Greater Than
139/89
mm Hg
Return to
Complete
cQues tionnaire.
(see 2
below)
2nd BP
Less Than
2.
140/90
From rest
area to 2nd
BP Measurement
mm Hg
2nd BP
Group
Assignment
by Coin
Toss
Control
Group - No
Counseling
N==28
Phone
Call to
Determine
omplianc:e
...
.J
(J)
(J)
67.
naires were completed during this time (Appendix C).
The receptionist helped with prob-
lem areas on the questionnaire when needed.
These people were then asked if they were currently on any medication, since some medications cause blood pressure to rise.
Responses
were recorded on the back of the questionnaire.
Next, these people were again directed to one
of the sphygmomanometers for a second reading.
Screening
The two people working this function
assisted people in and out of the machines,
monitored readings, and answered questions
about the equipment.
If the reading was
less than 140/90 mm Hg, systolic and/or
diastolic, the screenee was advised to have
a re-check every six months, invited to take
any literature from the literature table
located exactly at the entrance/exit to the
screening area, and returned to work.
If the first reading was 140/90 mm Hg,
systolic and/or diastolic, or higher, this
reading was written on the first line of the
cover letter to the questionnaire (Appendix B),
and handed to the screenee to carry back to
the ho-lding area.
If the second reading was
68
140/90 mm Hg, systolic and/or diastolic, or
higher, both readings were recorded on a blood
pressure record card (to be retained by the
screenee) and the second reading was also
written at the bottom of the cover letter
to the questionnaire.
At this point the program coordinator
assigned this screenee, by coin toss, to the
control or experimental group.
The coin
toss was done in an area adjacent to the
screening site.
A person became member of
the control group, the questionnaire was
retained at the screening site, the screenee
was handed a copy of the referral sheet,
directed to have his/her blood pressure taken
again not later than the following Thursday,
and referred to the literature table.•
If a member of the experimental group, the
screenee was handed a blood pressure record
card and questionnaire and escorted to a
counselor.
This person could also be referred
back to holding if all counselors were
* Screening guidelines set by the Joint National
Committee on Detection, Evaluation, and Treatment
of High Blood Pressure recommend primary screening
and secondary screening on different occasions.
(4:37)
69
momentarily busy.
After a counseling session
of approximately ten minutes, this experimental group member was handed the same
referral sheet, the same reminder to have
a blood pressure taken again, and then
returned to work.
Any screenee with a second diastolic
pressure greater than 119 mm Hg was immediately eliminated from the study and
referred directly for medical attention
(hypertensive episode imminent). (20:964)
There was one such person.
Also, any
screenee with an arm too small or too large
for the electronic sphygmomanometer received a manual blood pressure check by one
of the counselors certified in blood
pressure measurement by the High Blood
Pressure Council of Los Angeles.
Counseling
Counselors first reviewed the screenee's
questionnaire to check for omissions, and for
blood pressures recorded on the questionnaire's
cover letter and on the blood pressure record
card.
Indication of medication was also
verified.
During the counseling session the
~
70
following key points were discussed with the
individual:
1.
that the current elevation of
blood pressure does not mean
hypertension is present;
2.
a simple definition of the
figures in the person's blood
pressure reading (i.e. systolic and diastolic); (39:70;
35:84)
3.
that the cause of high blood
pressure is still unknown;
(58:32)
4.
that usually there are no
symptoms; (48:23; 63:662;
39:70; 35:84)
5.
the sequelae consequences of
sustained, untreated high
blood pressure; (63:662;
39:70; 35:84)
6.
that high blood pressure and
hypertension are synonomous;
(35:83-84)
7.
that although there is no cure
for high blood pressure (primary)
71
it can be controlled in most
cases; (62:A-267)
8.
that people with lower blood
pressures live longer lives
(3:2)
9.
and that there are hereditary
factors associated with high
blood pressure. (62:A-267;
23:56-5 7)
After these key points were covered
counselors were free to use the remainder of
the session to answer questions and to address
any issues pertinent to the screenee.
For
example, when talking to a smoker, the relationship between hypertension and smoking
might be discussed.
Next, the follow-up
blood pressure measurement and the referral
sheet were discussed.
In concluding, the
counselor would hand the individual materials
pertinent to this person (e.g. Black?
menopausal?) and/or bring the person's
attention to the literature table.
A
reminder was also given in both groups
about the follow-up phone call that would be
received.
72
Follow-up
Each member of both the control and experimental groups was asked to seek his own
fol.low-up screening within one week of the
initial program. (23:56)
Within one to
three weeks following the program each of
the 64 persons in the study was telephoned
either at home or at work.
Only one per-
son could not be contacted (moved out of
the state), which brought the study population from an original 65 to 64 persons.
The screening occurred on August 3, 1978
(a Thursday).
During the follow-up
phone call each participant was asked:
(1) if he/she had had a follow-up blood
pressure taken; (2) if yes, when; (3) if
yes,
wher~.
If this blood pressure had
been taken prior to Friday, August 11, 1978,
subject was considered to have complied.
If no follow-up blood pressure was taken,
or if one was taken on Friday, August 11,
1978, or later, subject was considered not to
have complied.
Remember that one aspect
of compliance was defined as having the second
screening within one week of the initial
screening.
73
Funding
A grant of $1,000.00 was awarded by the Student
Projects Committee at California State University,
Northridge.
The grant specified that funds were to be
used solely for the duplication and printing of program
materials and for renting equipment used in the
screening (electronic sphygmomanometers).
Of the
$1,000.00, $41 •. 00 was used for printing and duplicating,
$642 •. 00 for equipment rental (including four
technicians to operate the equipment), and $317.00 t-Jas
returned to the funding source unused.
Statistics
T-tests, and z-tests for differences between
proportions were performed to determine differences in
demographic characteristics between the control and
experimental groups.
at
.os.
The level of significance was set
To test the hypothesis that compliers were no
population~
different from non-compliers in this
discriminant model was utilized.
a
This method identifies
those factors which can best predict who will fall into
one or the other of these categories.
For this
analysis, the subjects were divided into two groups,
compliers and non-compliers, regardless of whether
they were control or experimental.
This division was
based on the assumption that the compliers differed
74
in some respects from the non-compliers.
The predic-
tors used included smoking, age, weight, height, sex,
race, type of job, marital status, education, perceived
stress level, medical history of self and blood family,
current diagnostic status of high blood pressure,
perception of physical/mental health, income, and
stated value of health.
CHAPTER IV
RESULTS
The statistical results of the study are presented
in this chapter.
steps:
This analysis is presented in three
1) testing the comparability of the control and
experimental groups on several independent variables;
2) testing for differences in compliance between the
control and experimental groups; and 3) compiling a
profile of compliant and non-compliant persons.
It was first necessary to test for differences
between the control and experimental groups in relation
to responses given on the questionnaire.
As is to be
expected of randomization, there were no significant
differences between the two groups in the variables
. considered.
All statistical analyses given in this
chapter were computed at the .05 level of significance.
Smoking
It is shown in Table 7 that 27.78% of the
control group smoked as contrasted with 35.71% in the
experimental group.
There was no difference in the
proportion of smokers between the two groups.
Note that the original responses were solicited
in terms of no smoking,
s~oking
less than one pack
per day, and smoking one or more packs per day --
75
76
three choices.
The latter two were combined into the
"yes" category to prevent distortion in data analysis.
TABLE 7
DISTRIBUTION OF SMOKERS - in Per Cent
= 36
Control
N = 28
Experimental
N = 64
Both Groups
YES
27.78
35.71
31.25
NO
72.22
64.29
68.75
N
Age, Weight, Height and Education
Some of the more standard demographics included
age, weight, height, and last grade completed in school.
These data are shown in Table 8.
The mean age of the
control and experimental groups was 45.72 years and
46.00 years respectively.
was 45.84 years.
The mean age for both groups
The two groups were similar in age
as well as other demographics.
For weight, the control
group weighed 169.14 lbs. and the experimental group
174.29 lbs..
For height, the control mean was measured
at 68.32" and the experimental mean at 69 •.34".
The
last school grade completed was also measured in terms
of means and standard deviations.
The mean number of
school years completed for the control group was 14.00,
and 13.46 for the experimental group.
performed on the data given in Table 8.
A t-test was
At a significance
TABLE 8
DISTRIBUTION OF AGE, WEIGHT, HEIGHT AND EDUCATION
(Mean and Standard Deviation)
N
=
36
N - 28
Control
Mean
St.Dev.
Age in Years
Weight in Pounds
Height in Inches
Last Grade
Completed in Years
N • 6-4
---~xi?_e£j_m~_rli;_al
_____ Both G_f'oups
St.Dev.
Mean
St.Dev.
Mean
45.72 +-
11.77
46.00
169.14 +...
29.69
174.29
68.32 +-
3.98
69.34
14.00 +
-
2.56
13.46
+
-
9.81
45.84 !.
10.88
!. 30.57
171.44 !.
29.96
4.24
68.80 !.
4.11
2.44
13.73 !.
2.46
+
-+
...J
....J
7S
level of •. 05 with 62 degrees of freedom no significant
differences between the control and experimental groups
were found.
Race
Because prevalence of high blood pressure among
Blacks is almost twice as high as among Whites, it was
necessary to test for racial distribution between the
groups.
The racial distribution of the Teledyne study
group is given in Table 9.
z-tests for differences in
proportion showed no differences in racial distribution
between the control and experimental groups.
TABLE 9
RACIAL DISTRIBUTION - in Per Cent
N = 36
Control
N = 28
Experimental
N = 64
Both Groups
Black
8.33
3.57
6.25
Hispanic
2.78
7.14
4.69
White
83.33
82.14
82.82
Other
5.56
7.14
6.24
Sex
As shown in Table 10, males and females were also
evenly distributed between the control and experimental
groups.
A z-test for differences in proportions showed
that none existed.
The control group contained 86.11%
79
men and 13.,89% women; the experimental group had 78.57%
men and 17.19% women.
TABLE 10
DISTRIBUTION OF SEXES - in Per Cent
N = 36
Control
N = 28
Experimental
N = 64
Both Groups
Male
86.11
78.57
82.81
Female
13.89
21.43
17.19
Job Categories
Twenty-six different job titles were listed by
the study's subjects.
Such a large cluster rendered
the data unwieldly if all categories were to be used,
so job titles were condensed into three categories:
1) salaried, exempt; 2) salaried, non-exempt; and
3) hourly.
Table 11 shows this distribution.
Seventy-
five per cent of the control group were salaried, exempt
TABLE 11
DISTRIBUTION OF JOB CATEGORIES - in Per Cent
Salaried
Exempt
Salaried,
Non-Exempt
Hourly
N = 36
Control
N = 28
Experimental
N = 64
Both Groups
75.00
57.14
67.19
8.33
21.43
14.06
16.67
21.43
18.75
80
employees contrasted with 57.14% in the experimental
group.
The control group also had 8.33% salaried, non-
exempt and 16.67% hourly employees.
The experimental
group had 21.43% of its members belonging to these
two groups.
Of the total screenees, 67.19% were
salaried, exempt; 14.06% were salaried, non-exempt,
and 18.75% were hourly.
A z-test for proportions
showed no significant differences between the groups.
Perhaps these figures would have more significance
to the reader if these terms were defined for those
who are unfamiliar with labor laws.
According to these
laws, enforced by the Fair Employment Practices
~ommission
(Federal) and the Department of Industrial
Relations (California), an employee's position must
meet certain criteria established by the statutes
these agencies enforce.
If the criteria are satisfied,
the individual is not entitled to overtime pay when
more than forty hours are worked within one calendar
week.
In this case, the person is considered "exempt."
Although these criteria can have different interpretations in different situations, there are three general
guidelines:
1) monthly income; 2) number of employees
directly supervised; and 3) percent of time consumed by
management functions.
Specifically, one must currently
be salaried in excess of $900.00 per month, supervise
at least two full-time employees, and spend not less
8,1
than 80% of one's time performing management level
functions.
Some professions are automatically excluded
from overtime statutes.
The other two categories,
"salaried, non-exempt," and "hourly" refer to positions
which do not meet the above criteria and which are
compensated on either a salary or wage basis.
The
choice is the employer's.
Marital Status
Because supportive relationships play a role in
motivating the hypertensive patient to comply, would
the same also apply to this sample of screenees'?
For this
reason it was important to determine marital status.
The
marital status for the study group is presented in Table
TABLE 12
DISTRIBUTION OF MARITAL STATUS - in Per Cent
N = 36
Control
N = 28
Experimental
N = 64
Both Groups
Single
19.44
3.57
12.50
Married
66.67
71.43
68.75
Divorced
5.56
17.86
10.94
Separated
5.56
3.57
4.69
Widowed
2.78
3.57
3.13
The control group consisted of 19.44% single, 66.67%
married, 5.56% each for both divorced and separated, and
1~
82
2.78% widowed.
Of the experimental group, 3.57% were
single, 71.43% married, 17.86% divorced, and 3.57%
each for both separated and widowed.
Here, too, a
z-test for differences in proportions showed no
significant differences in marital status between the
two groups.
Perception or Stress
If a person is experiencing stress at the time
of screening, regardless of the source of that stress,
blood pressure may be affected.
This information is
later useful to the evaluating physician should the
person be referred for diagnosis.
Here, again, the
response given is determined by the individual's own
evaluation of his stress level at the time of the
screening.
As Table 13 indicates, the control group's
report of stress was split exactly in half at the time
of screening:
50% responded in the affirmative and
TABLE 13
RESPONDENT'S PERCEPTION OF STRESS - in Per Cent
N = 36
Control
N = 28
Experimental
N = 64
Both Groups
YES
so.oo
35.71
43.75
NO
50.00
64.29
56.25
83
50% in the negative.
In the experimental group 35.71%
reported feeling stress at the time of the screening
while 64.29% of this same group did not feel stress.
A z-test for differences in proportions between the
control and experimental groups revealed no significant
differences.
Medical Correlates of Hypertension in Blood Family
The second section of the questionnaire attempted
to elicit information about medical correlates of
hypertension for both the respondent and his blood
relatives.
Here, too, an even distribution of variables
between the groups was important if the statistical
integrity of the study was to be maintained and if the
results were to be valid.
Note that the questionnaire
(Appendix C) asked for the relationship of any blood
relatives having one of these diseases.
Because this
quantity of information made the data too unwieldly
during data analysis it was eventually excluded ·
(i.e. which relative had which disease.)
Heredity
is crucial in hypertension but it was not a significant
finding in this study.
Tables 14 and 15 show the
distribution of this information.
Of the entire study,
these data provide the most prolific information.
z-tests for differences in proportion were performed on
all variables in both tables and again no significant
TABLE 14
DISTRIBUTION OF HYPERTENSIVE SEQUELAE AMONG
RESPONDENTS AND THEIR BLOOD FAMILIES - in Per Cent
Have you ever had these illnesses?
NO
c
E
High Blood ]?resst1re
77_. 78
6 7. 86
Heart Problems
88.89
Diabetes
97.22
Stroke
_KA_d_n_ey
100
~-i~eas~
__ _ _
100
100
96.43
100
92.86
YES
c
E
7}~_44
22.22
:32_!_14
92.19
11.11
96.88
BG
100
96.88
BG
26.56
0
7.81
2.78
3.57
3.13
0
0
0
0
7.14
3.13
co
~
"'
TABLE 15
DISTRIBUTION OF HYPERTENSIVE SEQUELAE AMONG
RESPONDENTS AND THEIR BLOOD FAMILIES - in Per Cent
Has anyone in your blood family ever had these illnesses?
YES
NO
c
E
BG
c
E
DON'T KNOW
BG
C
E
BG
High Blood Pressure 38.89
50.00
43.75
47.22
32.14
40.63
13.89 17.86
15.63
Heart Problems
63.89
50.00
57.81
27.78
39.29
32.81
8.33 10.71
9.38
Diabetes
69.44
53.57
62.50
16.67
35.71
25.00
13.89 10.71
12.50
Stroke
63.89
64.29
64.06
25.00
28.57
26.56
11.11
Kidney Disease
86.11
75.00
82.81
0
0
0
7.14
9.38
13.89 25.00
17.19
CX>
U1
86
differences were found between the control and experimental
groups.
All medical correlates elicited on the ques-
tionnaire, for both the individual respondent and his
blood family, were evenly distributed between the two
groups.
Oral Contraceptives
During the initial design of the questionnaire
it was recognized that some members of the population
to be screened would be women, that some of these
women might be on birth control pills and that,
because oral contraceptives tend to elevate blood
pressure, this information would be appropriate for
this study.
Of the sixty-four member study group only
eleven were women, and seven reported being on oral
contraceptives.
Although this information was crucial
during the on-site program, it was not significant as a
variable, was not considered in the data analysis, and
was not given consideration beyond that point.
Health Status
The next item on the questionnaire, nAre you
currently being treated for high blood pressure? .. ,
served to help define the parameters of the research.
Those answering in the affirmative were excluded from
the study group since new hypertensives were the focus.
Table 16 shows what the study group considered its own
8.7
health to be.
As can be expected with an odd-numbered
choice of responses, most of the group's answers fell
into the middle response.
Perhaps this question was
weakened by its poor formulation.
In the control group,
TABLE 16
DISTRIBUTION OF HEALTH STATUS - in Per Cent
N = 36
Control
N· = 28
Experimental
Poor
11.11
3.57
7.81
Good
61.11
57.14
59.38
Excellent
27.78
39.29
32.81
N = 64
Both Groups
11.11% described their health as poor, 61.11% as good,
and 27.78% as excellent.
In the experimental group,
2.57% described their health as poor, 57.14% as good,
and 39.29% as excellent.
Again z-tests for differences
in proportion were performed and again no differences
were observed.
Income
Income is a standard demographic and, therefore,
it was not excluded from this study.
For purposes of
this research information about income was solicited in
terms of household income.
Later it was realized that
this tended to obscure income data specific to members
88
of the research group.
That is, it sometimes contained
data about income earned by a spouse or other member of the
household.
This served to weaken the significance of
these data in their application to this study.
In future
research it is recommended that only the income of the
individual be considered for tighter control over this
variable.
As seen in Table 17, income for this population
was skewed toward hi·;Jher income levels.
This group
was a highly paid group and/or two-income figures were
being reported..
given above.
Again, this uncertainty is due to reasons
Those with a household income of less
than $10,000.00 were 11.12% of the control group; none
in the experimental group.
of both groups.
This represented 6.62%
In the control and experimental groups,
13.89% and 14.29%, respectively, fell into the $10,000.00
to $14,999.00 household income range.
Of the entire
group, 14 •. 06% had household incomes in this range.
In
the control and experimental groups, 8.33% and 28.57%
fell into the $15,000.00 to $19,999.00 range with 17.19%
of the entire group having household incomes in this
range.
It was stated above that the income of these
two groups was skewed toward higher income levels.
Note
that the cumulative total of the first four of the seven
89
income ranges is 37.51% for both grou;:-Js.
This leaves
62.49% of the participants falling into the highest three
TABLE 17
DISTRIBUTION OF INCOME RANGES - in Per Cent
Inclusive figures
N = 36
Control
Less than $10,000
11.12
None
$10,000 - $14,999
13.89
14.29
14.06
$15,000 - $19,999
8.33
28.57
17.19
$20,000 - $24,999
25.00
32.14
28.13
$25,000 - $29,999
22.22
14.29
18.75
$30,000 +
19.44
10.71
15.63
N = 28
Experimental
N = 64
Both Groups
6.26
household income ranges, or earning $20,000.00 per year
or more.,
This observation confirms the skewed nature
of these income data when compared to the more normal
distribution of the bell curve.
two reasons:
This could be due to
1) the highly technological, scientific
nature of this population would push it into higher
income levels; 2) the salary ranges used on the questionnaire were skewed toward lower incomes relative to
the actual income distribution within the Teledyne
population.
This was not known at the time the ques-
tionnaire was designed.
Again, it is important to
remember that we are talking in terms of annual household
90
income, not annual income of the individual respondent.
To continue, 25% of the control group and 32.14%
of the experimental group reported annual household
incomes in the $20,000.00 to $24,999.00 group with
28.13% of the two groups (the highest) earning in this
income range..
Of those indicating incomes in the
$25,000.00 to $29,999.00, 22.22% were from the control
group and 14.29% were from the experimental group.
Annual household incomes of $30,000.00 or more were
reported by 19.44% of the control group and by 10.71% of
the experimental group.
z-tests for differences in·
proportion showed no significant differences between
the two groups.
Health Attitude
The last item on the questionnaire to be presented
prior to the discussion of compliance concerns the
respondent's stated attitude toward health.
The intent
behind this item was to determine the relationship, if
any, between the screenee's attitude toward health and
compliant behavior.
The distribution of stated health
attitudes appears in Table 18.
Not one person of the
entire study group stated that health was ttnot important
at all."
Only 2.78% of the control group and 7.14%
of the experimental group felt that their health·was
91,
TABLE 18
DISTRIBUTION OF STATED ATTITUDE TOWARD HEALTH - in Per Cent
N = 36
Control
Not important at all
N = 28
N = 64
Experimental Both Groups
None
None
None
2.78
7.14
4.69
Very important
47.22
so.oo
48.44
Of greatest importance
so.oo
42.86
46.88
Somewhat important
"somewhat important."
Those responding that health was
"very important" to them were 47.22% from the control
group, 50.00% from the experimental group, and 48.44%
from both groups.
Fifty percent of the control group,
42.86% of the experimental group, and 46e88% of the
entire study group responded that their stated attitude
toward health was "of the greatest importance."
z-tests
for differences in proportion showed no differences
between the two groups.
Health Value
The last item on the questionnaire attempted to
obtain a statement of the respondent's value of health
by equating this stated value with monetary expenditure.
The purpose was to test for consistency between attitude
(expressed verbally) and value (expressed behaviorally).
This attempt failed for two reasons:
1) the question
9~
was poorly stated and twenty-nine screenees failed to
respond at all; 2) a written response used to determine
a value is still not a reliable indication of what the
actual behavior might be.
An attitude is more specific
to the moment and, therefore, is subject to change.
A value, however, being more deep-seated, requires a
much more sophisticated change process to be influenced.
Compliance
The focus of the study was to increase compliance.
As seen in Table 19, there was no significant difference
between the two groups.
In fact, not only were the
compliance rates of the control and experimental
groups similar, the entire study group experienced
unexpectedly high compliance.
In the control group, 63.89%
compared with the experimental groups 64.29%, complied.
TABLE 19
DISTRIBUTION OF COMPLIANCE - in Per Cent
N = 36
Control
Complied
Did not
comply
N = 28
Experimental
N = 64
Both Groups
63.89
64.29
64.06
36.11
35.71
35.94
Those who did not comply represented 36.11% of the control
group and 35.71% of the experimental group.
Of the
93
entire study group, 64.08% complied and 35.94% did not
comply.
Recall that compliance was defined as having
another blood pressure measurement taken within one
week of the initial screening.
These data support the
null hypothesis that there would be no significant
difference in compliance between the two groups.
There
was no significant difference.
Blood Pressure
As an adjunct to the above, two additional relationships were examined:
(1) blood pressures between
the control and experimental groups; (2) blood pressures
between compliers and non-compliers.
These data are
summarized in Tables 20 and 21 respectively.
T-tests
performed on the data given in these two tables failed
to show any significant differences in blood pressures
between control and experimental and between compliers
and non-compliers.
TABLE 20
DISTRIBUTION OF "BEFOREu BLOOD PRESSURES IN MM HG
Control, Experimental - Mean and Standard Deviation
N = 36
Control
Mean Systolic
Mean Diastolic
N = 28
Exoerimental
I
+
+
143.74-14.3
151.46-15.2
+
91.56-11.1
+
89.47-11.3
N = 64
Both Groups
+
147.11-15.1
+
90.64-11.2
94
TABLE 21
DISTRIBUTION OF "BEFORE'' BLOOD PRESSURES IN MM HG
Compliers, Non-Compliers - Mean and Standard Deviation
N = 28
Experimental
N = 64
Both Groups
146.01:.15.0
+
149.09-15.5
+
147.11-15.1
+
90.40-10.6
+
91.07-12.4
+
90.64-11.2
N = 36
Control
Mean
S~stolic
Mean Diastolic
Profile of Compliance
An attempt was made to develop a profile of the
compliant screenee in terms of all the foregoing variables
when correlated against compliance.
Stepwise discriminant
analysis was used in an attempt to identify the most
significant predictor variables.
These analyses showed
that there were no differences in any characteristics
tested between compliers and non-compliers and between
control and experimental subjects.
For this reason no
profile of screenee compliance emerged from the_study
and all null hypotheses were accepted.
CHAPTER V
DISCUSSION
The purpose of this study was twofold:
(1) to
determine if hypertension education, when interjected
into a screening program, would significantly increase
the number of people following up with a second blood
pressure measurement; (2} to develop a profile
o~
the
compliant screenee in terms of those criteria distinguishing compliance from non-compliance as elicited
by the data collection instrument (Appendix C).
As presented in the previous chapter, all null
hypotheses were accepted as stated.
Not only was
there no significant difference in compliance between
the control and experimental groups, compliance of
both groups was independent of the variables examined.
This resulted in no profile development.
Ironically,
although self selection is a factor in every voluntary
screening, compliance was high (64.06%} in both groups.
This is contrary to studies reviewed in the literature.
The following discussion will explore this
phenomenon and, with the help of some conjectures, will
focus on the successful aspects of the program before
offering recommendations for future research.
95
96
Conclusions
Response.
First, let's consider why there was
such a high response rate.
One fact given earlier,
though with little visibility, was that 72.7% of the
entire teledyne population participated in the screening.
Of 1100 employees, Teledyne thought 400 1.vould be a good
turnout (or 36.4%).
A similar screening program con-
ducted for the employees of Western Electric in New
York City (1976) had only 35% of the employees
participate in a voluntary screening program, although
all employees were invited.
Other industrial screening
programs in New England attempted to deal with this
problem of non-response by inviting each employee with
a letter.
Here response rose to 55%. (4:37)
The following discussion offers only conjecture
on Teledyne's high (72.7%) response rate.
1.
The screening program was announced in the
company newsletter one week prior to the screening.
Hypertension, including its prevalence and sequelae,
was discussed in the article (Appendix A).
Confiden-
tiality of results was assured.
2.
Teledyne endorsed a program sponsored by
the High Blood Pressure Council of Los Angeles.
The
article stated that all employees were invited to
participate in a study and to test the new electronic
sphygmomanometers.
Wouldn't this arouse the curiosity
97
of a scientific, research-oriented population?
was the orientation of the article.
3.
Such
Did it work?
Bulletin board announcements were also used
to advertise the screening, giving date, times, and
locations.
The morning of the screening each department
head was asked to remind his personnel of the screening.
To succeed, a health information campaign must employ
communication media which are used and trusted by the
population.
4.
Was trust a factor here?
If your population cannot or will not come to
you, then you must go to them.
Teledyne's employee
population was divided among three buildings:
and two auxiliary.
one main
We were told that those working
in the auxiliary buildings seldom came into the main
building.
Therefore, it was decided to mobilize part
of the program during an anticipated slow period.
was announced on the bulletin boards.
This
Was it effective?
Although cause and effect cannot be proved in any
of the above considerations, the highly successful
response of the Teledyne employees cannot be disregarded.
Compliance.
groups so high?
Why was the compliance rate in both
Again, the following considerations
are merely conjectural.
Table 14 (page 84) shows that 26.56% of both
groups reported having had high blood pressure at one
time.
(Remember that because these respondents reported
98
not being on hypertensive medication at the time of the
screening, they were not defined as hypertensives and,
therefore, not excluded from the study.)
Table 15 shows
that 40.63%, 32.81%, 25.00% and 26.56% of both groups
reported familial occurrences of hypertension, heart
problems, diabetes and stroke, respectively.
Certainly
this would sensitize any group to hypertensive awareness.
Would this not motivate one to comply?
Does this not
become a nfelt needtt of the individual?
For an
individual to respond to a health threat he must
~
that threat.
Rosenberg et. al.
(1971) observed that patients
who understood the why, what, and when of a prescribed
regimen were more cooperative with, and more participatory in, their own care than those patients who merely
received a prescription. (41:3)
Wouldn't this same
dynamic pertain to the Teledyne population?
Here we
had a group of people who were told the why, what and
when of hypertension in the newspaper article released
one week prior to the study.
Perhaps this constituted
enough education to raise compliance in both groups,
eliminating the need for counseling.
Counseling, as
the isolated variable, does not seem to have been the
determinant.
What about the other demographic variables?
role did they play in compliance?
As discussed in
What
99
Chapter IV, none of the variables entertained in this
study had a significant affect on compliance.
This
includes compliers tested against non-compliers.
According to Podell et. al. (1975), this is not unusual.
In their literature review they found inconsistent and
often contradictory associations between specific raciodemographic variables and observed compliance.
While
some studies showed that income was positively correlated
with compliance, other studies showed inverse relationships.
Most showed no correlations at all.
They did
find some consistency in the relationship between
economic standing and the propensity to seek medical
care.
No strong correlations were found between compli-
ance per se and any of the sociodemographic variables.
(39:17)
There are two significant aspects to Podel's
findings:
(1) both compliance and non-compliance were
noted among persons of all social and demographic
types; (2) ..... they argue against the implicit assumption
of the socio-demographic method, i.e., that there are
inherent patient characteristics sufficient in themselves to determine compliance." (39:17)
Bloom (1978) ascertained one significant factor
in screenee compliance.
The task of getting first-time
screenees to return for a second screening is facilitated
if the screening occurs within the person's usual routine,
100
such as place of employment. (4:37)
Most of those com-
plying in the Teledyne study did so at Teledyne.
The
place of the second screening may be a sleeping variable
of some significance.
The Hawthorne effect is another consideration here.
This says that motivation is enhanced merely by paying
attention to someone.
If there were a significant
difference in compliance between the two groups, then
it would be fairly safe to conclude that the dynamics
of the Hawthorne effect were created by the counselor's
attention to the screenee; however, there was no
significant difference.
Is it possible that the
dynamics of the Hawthorne effect can be triggered by even
the smallest amount of attention?
If this were true,
then these dynamics were significant in both the control
and experimental groups.
Its presence in the experimental
group is readily visible when the influence of the
counseling is considered.
What is easily overlooked,
because i t is not so visible, is that members of the
control group were asked to have their blood pressures
checked again within one week.
urged to do so.
Actually, they were
It is possible that even this slight
interaction was enough to put the dynamics of the
Hawthorne effect into play.
In fact, Teledyne's having
the blood pressure screening program for its employees,
in itself, could have created and/or contributed to the
101
Hawthorne phenomenon.
is overlooked.
Generally, the Hawthorne phenomenon
Why not capitalize on it?
Why not give
attention in all programs if it is effective?
The entire premise of the first hypothesis (that
there would be no significant difference in compliance
between the two groups based on the affect of the
counseling) assumes a cause-and-effect relationship
between compliance and screenee knowledge.
Podell (1975)
found no consistency on this issue in approximately
three dozen studies reviewed. (39:20)
It is the author's
opinion that the efficacy of education is group specific;
that it will be effective in some groups while ineffective
in others.
Additionally, ineffectiveness in some groups
may indicate that awareness levels are already developed.
The last consideration entertained is that of
fear.
"Vigilance is accompanied by a sense of emotional
distress and the need for reassurance to alleviate it.
Along with the need for reassurance comes a state of
hypersuggestibility and increased dependence upon
authorities who. seem to offer a way out of danger."
(39:58)
Not only was compliance a way out of danger,
but doubly so when the entire group's familial medical
history, and subsequent potential sensitivities, are
recollected.
The foregoing discussion reviewed some of the
more visible determinants of the study's outcome.
What
102
resulted in a rejection of the null hypotheses could
have been caused by any one of the foregoing considerations, by any synergistic combination of same, or by
none of the above.
In fact, it is possible that
variables not even considered in this discussion were
the cause of accepting the hypotheses as stated.
Transferring information does not assume behavior
change, although behavior change must occur if health
is to be achieved.
Failure to identify and utilize
the myriad steps required to alter an attitudinalbehavioral system surely causes the failure of many
health education campaigns.
The ultimate measure of
success in any health education issue is the integration
of those behaviors with which health is achieved.
Considering the h·igh compliance rate of both the control
and experimental groups, is it not possible that the
program was more effective in its application of these
principles than what is readily apparent to the casual
observer?
This is difficult to determine.
What happens to the individual presumably
depends on many factors, including the individual's
knowledge, the family and social influences about
him, and his personal experience with the disease,
with drugs, and with physicians. It depends on
his current life stresses, and on his particular
hopes and half-buried fears. It depends on the
individual style of coping and characteristic
defenses. (39:55)
Additional influences on an individual's behavior,
as it relates to a health issue, are strongly distorted
103
by his perceptions.
His perceptions of his own vulner-
ability to the disease, of the severity of the disease,
and of the efficiency of the proposed treatment as
it reduces the threat of that disease all contribute
to the attitude with which the problem is approached.
His health behavior may also be influenced by his perception of the barriers and obstacles of a proposed
plan of treatment.
These barriers may be internal
(e.g. a defensive posture) or external (e.g. cost of
treatment).
Recommendations
An experimental study is supposed to produce
new information or validate old information.
information should be useful.
practical purpose.
This
It should serve some
When one considers the cost-
effectiveness of research, new information per dollar
becomes one criterion for success.
Another function of experimental research is
the identification of variables and new ideas to
trigger further research.
On the issue of future
research on education intervention in hypertension
screening, the author offers four recommendations for
future testing.
These are dis·cussed presently, and
stem from the observation that compliance in the control
and experimental groups was nearly identical.
This
104
indicates that
in both groups.
t~o
many of the same forces were present
The objective of the following recommen-
dations is to create greater differences between the
two research groups.
Employee newsletter article.
It was identified
earlier that the article published in the employee's
newsletter might have contained enough information to
educate both groups sufficiently to raise compliance
to nearly identical levels in both groups.
This could
be the most significant finding of the entire study; if
so, further research in this area is required.
Suggested
research would consist of the same research design
utilized in this study with exposure to the newspaper
article (or, possibly, some other form of mass communication) being the tested variable.
Positive results would
indicate a less expensive, perhaps more effective method
of raising compliance than one-to-one counseling.
Did
this newsletter article provide sufficient information
to motivate for the high turnout and/or the high
compliance (Appendix A)?
Matched-pair sampling.
The advantage here is to
eliminate word-of-mouth reinforcement between the two
groups.
Again, the focus is still on counseling.
This
sampling technique would control the word-of-mouth
dynamic that was not controlled in the current study.
The problem here is matching each of the demographic
105
variables in addition to an elevated blood pressure.
This would be eliminated by reducing the number of
variables used.
Eliminate "previous" hypertensives.
In this
study any screenee who was currently undergoing treatment for hypertension was excluded from the study.
Those who had been treated at one time, but who were
not currently undergoing some kind of treatment, were
allowed to remain in the study.
Considering that these
people constituted 26.56% of the entire study group, this
variable could distort the data.
By eliminating those
with any history of hypertension, this bias is controlled.
Question non-compliers.
pliers is also recommended.
A follow-up on non-corn-
This could produce useful
information for later research into the compliance
phenomenon.
Pertinent variables that are currently
unknown, as well as those already considered in earlier
research, could serve as key aspects of future research.
Summary
This paper focused on the use of one-to-one
counseling intervention, used at the primary screening
site in hypertension screening, to increase the number
of screenees following up with a suggested second blood
pressure measurement.
The screenee was considered
compliant when the follow-up screening occurred within
106,
one calendar week of the initial screening.
Additionally,
development of a profile of the compliant screenee was
attempted.
In an industrial setting with approximately
1100 employees, a hypertension screening program was
scheduled to run from 7:00 A.M. to 5:00 P.M. that
same day.
One week prior to the screening an article
in the employee's newsletter announced the screening
and discussed prevalence, incidence, and sequelae of
hypertension (Appendix A).
Ancillary prompts were also
used to increase employee participation in this voluntary program.
Upon arrival at the screening site, employees were
guided through electronic sphygmomanometer consoles.
Any employee with a blood pressure less than 140 mm Hg
systolic and/or less than 90 mm Hg diastolic simply
returned to his work station.
Any employee with a blood
pressure greater than 139 mm Hg systolic and/or greater
than 89 mm Hg diastolic was asked to sit and rest for
five minutes before having another measurement taken.
During this rest period a questionnaire was completed by
the screenee.
If the second reading was greater than
the above criteria, the screenee was assigned (by coin
toss) to the control or experimental group.
Control
group members were asked to have another blood pressure
measurement within the following week and asked to return
107
to work,
Experimental group members were individually
counseled for approximately ten minutes and then asked
to return to work.
Members of both groups were invited
to take literature on hypertension, given referral
sheets for ·the follow-up blood pressure measurement,
and told they would be phoned so that compliance could
be determined.
Of an approximate 1100 employees, 820 (74.55%)
participated in the screening.
Of the 820 participants,
64 had elevated blood pressures after two readings.
These 64 people comprised the study population (no
sample was used).
By coin toss, 36 people were assigned
to the control group and 28 people were assigned to the
experimental group.
Using z-tests for differences between proportions,
t-tests, and stepwise multiple discriminant analysis,
it was determined that no significant differences of any
kind existed between the control and experimental groups.
For this reason, a profile of the compliant screenee
did not emerge from the discriminant analysis.
Null
hypotheses were accepted as stated.
The most significant finding of the study, although
conjectural, is that the article appearing in the company newsletter one week prior to the screening had
enough of an impact to motivate both groups to high
108
compliance.
The reason for the high employee partici-
pation rate might also be linked to this article
(Appendix A).
Although the source of these phenomena
remain obscure, suggestions for future research are
offered.
Specific sociodemographic and personality
characteristics may influence compliance
in certain individuals and under different circumstances, but they are not the
sole determinants. Instead of seeking
and describing such associations, we
should look more carefully for interactions among the many causal mechanisms.
While strong associations are suggestive
as to where to look for causal mechanisms,
associations, no matter how strong, do not
necessarily imply causation, nor does the
failure to find association between two
variables mean that there is no causal
link between them.(39:14)
109
REFERENCES
1.
Alderman, M.D .. , Michael H. and Ellie E. Schoenbaum,
B.A., "Detection and Treatment of Hypertension
at the Work Site." New England Journal ofMedicine, Vol. 293, No. 2, pp. 65-68.
2.
Alkhateeb, Waleed Ahmed. Broken Appointments, Masters
Thesis, Cal State University Northridge, June
1972.
3.
Blockley, W.V.. "Blood Pressure Screening as a
Device for Initiating Life Style Modification
in Large Groups," Presented at the 6th Congress
of the International Ergonomics Association,
Washington D.c., July, 1976.
4.
Bloom, Ph.D., Joan R.. "Hypertension Control Through
the Design of Targeted Delivery Models." Public
Health Reports, Vol. 93, No. 1, January-February
1978, pp. 35-40.
5.
Caldwell, John R., and Sidney Cobb, Monroe Dowling,
and Dasja De Jongh. 11 The Dropout Problem in
Antihypertensive Treatment." Journal of Chronic
Diseases, February 1970, Vol. 22, pp. 579-592.
6.
Charman, Robert c., M.D •• ttHypertension Management
Program in an Industrial Community.u Journal of
the American Medical Association, January 21.,
1974, Vol. 227, No. 3, pp. 287-291.
7.
Chei tl in, I"l.D. , Melvin D. • "The Physician and Hypertension.n Journal of the American Medical
Association, June 3, 1974, Vol. 228, No. 10,
pp. 1249-1250.
8.
Chwalow, A. Judith, Lawrence w. Green, David M.
Levine, Sigrid G. Deeds. "Clarification and
Repetition of Hypertension Regimens As a First
State in Patient Education to Improve Compliance:
Preliminary Experimental Results." For Presentation at the American Public Health Association.
Chicago, Illinois. November 19, 1975. National
Heart and Lung Institute Grant No. 1 R25 HL
17016-01.
110
9.
Dahl, M.D., Lewis K•• "Salt and Hypertension."
The American Journal of Clinical Nutrition,
February 1972, pp. 231-244.
D.~v.,
"Letters to the Editor
Screening for
Hypertension.u The Lancet, March 13, 1976,
Vol. I, No. 7959, p. 591.
10.
Dau,
11.
Daubs, O.D., M.P.H., J •• "The Influence of Prevalence on Screening Test Validity." Opt. J. Rev.
Optom, Vol. 110, No. 24, December 15, 1973,
pp. 15-17.
12.
Dustan, Harriet P.. "Clinical Approaches to Hypertension.u Modern Medicine, November 26, 1973,
pp. 34-41.
13.
Finnerty, Jr., M.D., Frank A•• ttThe Hypertension
Problem: What We Can Do About It." Circulation,
Volume Xlviii, October 1973, pp. 681-683.
14.
Freedman, J.L. and S.C. Fraser. ucompliance without
Pressure: The Foot in the Door Technique."
Journal of Personality and Social Psychology,
Vol. 4, pp. 195-202.
15.
Galton, Lawrence. The Silent Disease:
New York: Signet Books, 1973.
16.
Glogow, Ph.D., Eli. nEffects of Health Education
Methods on Appointment Breaking." Public Health
Reports, Vol. 85, No. 5, May, 1970, pp. 441-450.
17 .,
Griffith, Elizabeth V.Jelk and Blanche Madero. "Primary Hypertension: Patients' Learning Needs."
American Journal of Nursing, Vol. 73, No. 4,
April 1973, pp. 624-627.
18.
Holder, Ph.D., Lee. •'Effects of Source, Message,
Audience Characteristics on Health Behavior
Compliance... Health Services Reports, Vol. 87,
No. 4, April 1972, pp. 343-350.
19.
ttHypertension Programs: Screening's Not Enough."
Medical World News, October 25, 1974 (only one
page long, no page no. given).
20.
"Hypertension Screening: Defining the Problem,
Setting Priorities." Journal of the American
Medical Association, February 26, 1973, Vol. 223,
No. 9, pp. 961-962.
Hypertension.
111
21.
"The Infomemo." National High Blood Pressure Education Program, National Heart, Lung, and Blood
Institute, u.s. Department of Health, Education,
and Welfare, Public Health Service National
Institutes of Health, No. 10, July 1977.
22.
Insel, Ph.D., Paul M., et. al.. "Blood Pressure
Education in An Industrial Setting." Grant
Proposal of the Stanford Research Institute
Submitted to the Department of Health, Education, and Welfare, Public Health Service,
December 13, 1974.
23.
Inter-Society Commission for Heart Disease Resources.
Hypertension Study Group. Guidelines for the
Detection, Diagnosis and Management of Hypertensive Populations. Circulation, 44, A263,
1971.
24.
Kerlinger, Fred N.. Foundations of Behavioral
Research • . 2nd ed. San Francisco: Holt, Rinehart, Winston, 1964.
25.
Khoury, M.D., M.P.H., Sami A.. "A Screening for
Hypertension in Y.lashington, D. C., 19 71." Health
Services Reports, 88, pp. 824-826.
26.
Kochar, M.D., Mahendra s.. uHypertension Screening.u
Journal of American Medical Association,
November 29, 1976, Vol. 236, No. 22, p. 2551.
27.
Kurlander, A.B., E.H. Hill and P.E. Enterline. "An
Evaluation of Some Commonly Used Screening Tests
for Heart Disease and Hypertension. 11 Journal
of Chronic Diseases, Vol. 2, 1955, pp. 427-439.
28.
Levanthal, Ph.D., Howard. 11 Changing Attitudes and
Habits to Reduce Risk Factors in Chronic Disease."
The American Journal of Cardiology, Vol. 31,
May, 1973, pp. 571-580.
29.
Lquria, Donald B., Allyn P. Kidwell, Marvin A.
Lavenhar, Inderjit s. Thind, and Reza G. Najem.
nprimary and Secondary Prevention Among Adults:
An Analysis with Comments on Screening and
Health Education." Preventive Hedicine, Vol. 5 7
No. 4, December 1976, pp. 549-572.
112
30.
Malmon, Arnold H., Mahendra s. Kochar and Norman E.
Kosloske. "Counseling at Blood Pressure
Screenings: The First Step Towards Compliance.n
An unpublished article from The Milwaukee Blood
Pressure Program, Medical College of Wisconsin,
Milwaukee, Wisconsin, 1976.
31.
Miller, Ph.D., r1.P.H., George D•• "An Epidemiclogical View of Hypertension." Urban Health
(year and issue unknown).
32.·
Mroczek, M.D., ~lilliam J. and Margene Martin, RN.
11
Letters to the Editor -- Hypertension Screening.u Annals of Internal Medicine, Vol. 82,
No. 3, March 1975, pp. 384-5.
33.
, "Letters
---:":"-Hypertension."
to the Editor
Screening for
The Lancet. January 18, 1975,
page 166.
34.
"National High Blood Pressure Education Program
Report to the Hypertension Information and
Education Advisory Committee." Task Force I.
Data Base. September 1, 1973. DHEW Publication
No. (NIH) 75-593.
35.
"National High Blood Pressure Education Program
Report to the Hypertension Information and
Education Advisory Committee.n Task Force II.
Professional Education. September 1, 1973.
DHEW Publication No. (NIH) 75-593.
36.
Nie, Norman H., et. al.. Statistical Package for the
Social Sciences.--San Francisco: McGraw-Hill
Book Company, 2nd ed., 1975, pp. 434-441.
37.
Page, M.D., Irvine H.. "Egregious Errors in the
Management of Hypertension.n Journal of American
Medical Association, Vol. 236, No. 23, December
6, 1976, pp. 2621-2.
38.
Perez-Stable, M.D., Eliseo c., and Barry J. Materson,
M.D.. "vlorkup of the Newly Discovered Hypertensive Patient." Postgraduate Medicine, Vol. 57,
No. 3, March 1975, pp. 109-113.
39.
Podell, M.D., M.P.H., Richard N•• Physician's Guide
to Compliance in Hypertension. Merck & Co., Inc.,
1975.
113
40.c
"The Public and High Blood Pressure. n A Survey
Conducted for The National Heart and Lung
Institute, June 1973, by Louis Harris and
Associates, Inc.. DHEW Publication No. (NIH)
74-356 •.
41.
Rosenberg, M.A., M.P.H., Stanley G•• "A Case for
Patient Education." Hospital Formulary
Management, Vol. 6, No. 6, June 1971, pp. 1-4.
(Also HEW Publication No. (HSM) 73-4030).
42.
Schoenberger, M.D., James A., et. al •• "Current
Status of Hypertension Control in an Industrial
Population." Journal of the American Medical
Association, Vol. 222, No. 5, October 30, 1972,
PP• 559-562.
43.
Selltiz, Claire, Lawrence s. Wrightsman, and Stuart
w. Cook. Research Methods in Social Relations.
San Francisco: Holt, Rinehart, and Winston,
3rd. ed. 1976.
44.
"The Spotlight is on Hypertension at Safety Conference." The International Journal of Occupational Health and Safety. January/February
1974, pp. 29 et passum.
45.
Stamber, M.D., Jeremiah. "High Blood Pressure in
the United States -- An Overview of the Problem
and the Challenge." National Conference on High
Blood Pressure Education, Report of Proceedings,
January 15, 1973, DHEW Publication No. (NIH)
73-486, pp. 11-66.
46.
, Rose Stamber, M.A., Wallace F. Riedlinger,
MS, George Aogera, and Richard H. Roberts, M.D ••
uHypertension Screening of 1 Million Americans. 11
Journal of American Medical Association, Vol.
235, No. 21, May 24, 1976, pp. 2299-2306.
47.
"Target of the Year: Hypertension: After Mass
Screening , TJ'lha t. tt Medical World News, August 24,
1973, pp. 69-76.
48.
Thomson, M.D., Gerald E •• uApproaches to the
Management of Hypertension." Urban Health,
Vol. 2, 1974, pp. 22 et passum (22-23, 40).
49.
, "Hypertension: Guidelines for Management.u
Urban Health, Vol. 3, No.3, June 1974, pp. 17
et passum.
114
50.
Tobian, Jr., M.D., Louis. "A Viewpoint Concerning
the Enigma of Hypertension." American Journal
of Medicine, Vol. 52, May 1972, pp. 595-609.
51.
"To Screen or Not to Screen for Hypertension.u
Medical Ooinion, April 1973, pp. 19-24.
52.
The Underwriting Significance of Hypertension for
the Life Insurance Industry. Prepared for the
National High Blood Pressure Education Program
by the National Heart and Lung Institute,
Bethesda, Maryland, 20014. DHEW Publication
No. (NIH) 75-426, 1974.
53.
"Update: Some New Figures on High Blood Pressure.n
Leaflet published by the NHBPEP, un-dated.
54.
Verdesca, M.D., A.S., 11 Hypertension Screening and
Follow-up." Journal of Occuoational Medicine,
Vol. 16, No. 6, June 1974, pp. 395-401.
55.
Veterans Administration Cooperative Study Group
on Antihypertensive Agents: Effects of Treatment on Morbidity in Hypertension. Results
in patients with diastolic blood pressures
averaging 90 through 114 mm Hg. Journal of
the American Medical Association, 213:1143,
August 17, 1970.
56.
Veterans Administration Cooperative Study Group on
Antihypertensive Agents: Effects of Treatment
on r-1orbidi ty in Hypertension. Results in
patients with diastolic blood pressures
averaging 115 through 129 mm Hg. Journal of the
American Medical Association, 202:116, February
11, 1967.
57.
Warren, M.D., James v.. "Sphygmomanometers at the
Shopping Center." Medical Opinion, April 1973,
pp. 41-42.
58.
~verdegar,
59.
"~·lhat
M.D., David. "Hypertension: Insight into
Health Care Needs of the Community." Urban
Health, Vol. 2, No. 2, April 1973, pp. 32
et passum.
Every Woman Should Know About High Blood
Pressure." National High Blood Pressure Program,
National Heart, Lung, and Blood Institute,
115
National Institutes of Health, Bethesda,
Maryland, 1977.
60.
Wilber, M.D., Joseph A.. 11 The Problem of Undetected and Untreated Hypertension in the
Community." Bulletin of the New York Academy
of Medicine, Vol. 49, No. 6, June 1973, pp.
510-520.
61.
, and J. Gordon Barrow, M.D •• "Hyper---:t-e-n-sion -- A Community Problem." American
Journal of Medicine, Vol. 52, May 1972, pp.
653-663.
62.
Wood, M.D., J.E., Chairman. "Report of InterSociety Commission for Heart Disease Resources:
Guidelines for the Detection, Diagnosis, and
Management of Hypertensive Populations. 11
Circulation, Vol. XLIV, November 1971.
63.
, J .G. Barrow, and E.D. Freis, et. al ••
"Guidelines for the Detection, Diagnosis, and
Management of Hypertensive Populations.u
Circulation, 1971, 44:A263-A272.
116
Appendix A
High Blood Pressure Devastates Americans
The National High Blood Pressure Education Program
was recently required to update the estimate of the number of Americans who have high blood pressure. In 1974
the Heart and Lung Institute, of the National Institutes
of Health, estimated that approximately 23,000,000
Americans had high blood pressure. Today, because of
the inclusion of populations not previously considered,
and because of lowering the cut-off point from 160/95 mm
Hg (milimeters of mercury) to 140/90 mm Hg, it is estimated that 60,000,000 Americans have high blood pressure. This means that one out of every five adult Americans, including young adults, has a greater chance of
experiencing a stroke, or a heart attack, or kidney failure, and sometimes even blindness, than the remainder of
the American populace. Among Black populations it ranges
twice to four times as prevalent as among Whites.
Although 140/90 mm Hg is considered the borderline
between high and normal blood pressure (also known as
hypertension), there is still some danger even with only
a moderate elevation. A 35-year-old man, for example,
with a blood pressure of 120/80 mm Hg is expected to have
a normal life span. When that blood pressure increases
to a constant 130/90 mm Hg, he will live four years less.
At a constant 140/90 mm Hg nine years are lost, and seventeen fewer years will be lived if this typical 35-yearold man has a constant blood pressure of 150/100 mm Hg.
Although primary high blood pressure cannot be cured, in
most cases it can be controlled, and often without medication.
(An elevated blood pressure does not necessarily
mean that high blood pressure is present.)
Because of the alarming change in the status of
high blood pressure in this country, Teledyne has arranged
for the High Blood Pressure Council of Los Angeles to
conduct a high blood pressure screening program as a service to its employees. The screening is scheduled for
next Thursday, August 3, 1978, from 7:00 A.M. to 5:00 P.M.
in the cafeteria. There will also be screening services
in the annexes on this same date. The hours for screening
in the annexes will be announced on the day of the screening.
Blood pressures will be taken with a new digital
automatic blood pressure computer and results will be
117
confidential between employees and the High Blood
Pressure Council.
Everyone is urged to have their blood pressure
checked. Remember: your welfare is your responsibility.
No one else can do it for you.
118
Appendix B
High Blood Pressure Council of Los Angeles
2603 West Magnolia Boulevard, Burbank, CA. 91505 • (213) 843-2614
You have just had your blood pressure taken. It was _____/
mm Hg
(millimeters of mercury). This does not mean that you have highblOOd
pressure. There are many things which can cause blood pressure to go up:
stress at work and/or away from work; a full bladder; food consumed or
cigarettes smoked within the last hour; and medications you might be taking.
Your mood can also affect your blood pressure. Even the physical exertion
of walking here to the screening site can cause your blood pressure to go
up. Because of this, we're asking you to sit quietly for about five minutes
before we take a second reading. Three or four readings are sometimes
necessary for an accurate blood pressure measurement.
If your next blood p~essure reading is below 140/90 mm Hg you are within the normal range but should have it checked again within the next six
months. If yoUr next blood pressure reading is greater than 140/90 mm Hg
you are above the normal range and should have your blood pressure checked
again by next Friday (August 11, 1978). We will give you a list of places
where you can go to have this done for free or for a minimal charge. If
your blood pressure continues to remain above 140/90 mm Hg you should then
refer yourself :for medical attention. Again, your blood pressure ~Y be
okay ••• we just W8nt someone to take a closer look at you. If you need to
have your blood pressure checked again by next Friday, we'll call you after
next Friday to see if you had any trouble doing this.
While you're waiting, relax and fill out the attached questionnaire.
This information will help us to determine: (1) any physical/mental
conditions affecting today's blood pressure; and (2) any difficulties you
might have getting your blood pressure taken again. This information is
confidential between you and the High Blood Pressure Council and will be
seen by no one else--not even by Teledyne personnel.
If you have any questions about high blood pressure after leaving the
screening site today, please call us at the above number. Also, we have
materials here which tell you about high blood pressure. Help yourself and
take them home with you. We are concerned about your health, and we want
you to be too.
Thankyou for participating in our survey.
119
Appendix C
High Blood Pressure Council of Los Angeles
Teledyne High Blood Pressure .Screening Survey
This information is confidential to this survey and will
not be released to any other parties without prior consent.
Please Print
Do you smoke cigarettes?
CJNo
G I First Name Only
CJYes
If yes:
en
Work
t::J less than 1 pack per day?
~ f Home
Phone
c:::J 1 or more packs 1>er dav?
e o Phone
lr
Height
c::IAsian CJ Black C]Hispanic
Age r·leight
Sex c:J Male
c::::J Female
CJWhite CJ Other
~
Job Title
1
C!Single c:J Married CJ Separated
c::JDivorced CJ Widowed
Do you feel that you are
What was the last grade
you finished in school?
currently under any stress? CJ No DYes
I
nswer for the
resent & past.
Have you ever had
these illnesses?
No
Yes
Illness
MH High Blood
I
Has anyone in your blood family
ever had these illnesses?
No
Yes
Don't
If yes, relationship?
Know
e
i Pressure?
d s Heart
li t Problems?
Diabetes?
~ 0
a r
ly Stroke?
Kidney
Disease?
Are you currently taking birth control pills?
CJNo c::l Yes
Are you currently being treated for high blood pressure? c:J No CJYes
Do you feel that your current
~hYsical/mental health status is:
C!Poor? CJ Good?
c:::J Excellent?
What is the annual
income in your
household (before
taxes)?
c:Jless than 55,000 per year
CJ55,0C)l - 59,999
c:J510,000 - 514,999
c:J515,000 - 519,999
Do you feel that your health 1s:
~please
'
CJ520,000 - 524,999
CJ$25,000 - S29,999
c:J530,000 or more
check oneJ
c=Jnot important at all?
c::::J
somewhat important?
t:Jvery important?
c::::J
of the greatest importance?
Please fill in the blank.
If I had no medical insurance, or any other kind of group medical plan, my
priority would be to spend money on __________________before I could spend money on
health care