Access to Care, Treatment Ambivalence, Medication Nonadherence, and Long-Term Mortality Among Severely Hypertensive African Americans: A Prospective Cohort Study.
African Americans living in poor neighborhoods bear a high burden of illness and early mortality. Nonadherence may contribute to this burden. In a prospective cohort study of urban African Americans with poorly controlled hypertension, mortality was 47.6% over a median follow-up of 6.1 years. Patients with pill-taking nonadherence were more likely to die (hazard ratio, 1.80; 95% confidence interval [CI], 1.18-2.76) after adjustment for potential confounders. With regard to factors related to nonadherence, poor access to care such as difficulty paying for medications was associated with prescription refill nonadherence (odds ratio [OR], 4.12; 95% CI, 1.88-9.03). Pill-taking nonadherence was not associated with poor access to care; however, it was associated with factors related to treatment ambivalence including lower hypertension knowledge (OR, 2.97; 95% CI, 1.39-6.32), side effects (OR, 3.44; 95% CI, 1.47-8.03), forgetfulness (OR, 3.62; 95% CI, 1.78-7.34), and feeling that the medications do not help (OR, 2.78; 95% CI, 1.09-7.09). These data suggest that greater access to care is a necessary but insufficient remedy to the disparities experienced by urban African Americans with hypertension. To achieve its full promise, health reform must also address treatment ambivalence.
Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD.|Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
J Hunter
JH
Young
Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
Derek
D
Ng
Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
Chidinma
C
Ibe
Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, MD.
Kristina
K
Weeks
Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD.
Daniel J
DJ
Brotman
Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
Sydney Morss
SM
Dy
Frederick L
FL
Brancati
Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD.|Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
David M
DM
Levine
Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD.|Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.|Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
Michael J
MJ
Klag
D000328:Adult; D001741:Black or African American / Q000523:psychology / Q000706:statistics & numerical data*; D000959:Antihypertensive Agents / Q000008:administration & dosage*; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D006973:Hypertension / Q000188:drug therapy / Q000208:ethnology* / Q000401:mortality*; D008297:Male; D055118:Medication Adherence / Q000208:ethnology*; D008875:Middle Aged; D011446:Prospective Studies; D012307:Risk Factors; D014481:United States / Q000453:epidemiology; D016903:Drug Monitoring
D000959:Antihypertensive Agents