needs assessment strategies in working with compliance issues and blood pressure control

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NEEDS ASSESSMENT STRATEGIES IN WORKING WITH COMPLIANCE ISSUES AND BLOOD PRESSURE CONTROL

MICHAEL H. BOWLER, Ph.D., DONALD E. MORISKY, M.S.P.H., Sc.M., and SIGRID G. DEEDS, Dr.P.H.

Health Services Research and Development Center and Division of Heaith Education, Johns Hopkins Medical Institutions, Baltimore, Maryland

ABSTRACT

This paper addresses the development and effect of health education interventions on compliance behavior and blood pressure control of hypertensive patients. The focus is on two main tactics: 1) the use of a baseline questionnaire to determine the patients' needs in the area of medical regimen management and the translation of that information into education intervention; 2) the development of a group method as a form of internality training providing a ne6ds assessment and simultaneously responding to the assessment. The results supported the study's hypotheses with respect to blood pressure control. Both the theoretical and practical aspects of internality training as a needs assessment process and a skill training process are discussed.

INTRODUCTION

Hypertension is a life-threatening disease in which the side effects of medication and the sacrifice in- volved in reducing risk factors may exceed' the ap- parent benefits of therapy. Thus there is a need to develop ways of helping patients comply more effec- tively with the medical regimen and so enhance control of their blood pressure, x

One factor affecting compliance is the failure to involve the patient as a responsible agent in his treatment. z Educational efforts have been made by teach- ing patients management skills and principles of pre- vention? The approach in the study and use of

educational methods must be tailored to include both the patient and the provider.'

Prescriptive concerns require that a logical con- sistency exist between the educational diagnosis and the educational intervention. A needs assessment in- ventory will help identify the active educational and therapeutic goals to be achieved by intervention. This paper will focus on two tactics of a research effort to improve compliance in controlling blood pressure: 1) the formulation of three educational interventions based on findings from a needs assessment baseline survey, and 2) the incremental process of needs assessment through small-group methods within the third intervention.

THE NEEDS ASSESSMENT BASELINE SURVEY

Theoretical Background and Survey

The diagnostic baseline survey was constructed to obtain an educational diagnosis and assessment of compliance problems and needs of 305 ambulatory hypertensive patients attending the general medical and hypertension clinics at the Johns Hopkins Hos- pital. The needs assessment framework that influenced the questionnaire construction and the development of a successful program of patient education is discussed in detail elsewhere. 5~ Two conceptual models influenced the design of the questionnaire. The first model, developed by Green, 7 examines health- related behavior within an interacting set of predisposing factors (patient's knowledge, beliefs, attitudes, values, and perceptions), enabling factors (availability of services, referral, and support), and reinforcing factors (relevant attitudes and behaviors of the staff, relatives, friends, employers, and others toward the patient). The second model, the Health Belief Model, is a value expectancy model expanded by Marshall Becker s to encompass the cost/benefit decision-mak- ing process of the patient engaged in managing chronic illness. This model assumes that a person is more

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likely to follow medical advice if he or she believes: 1) in the accuracy of the diagnosis, 2) that the condi- tion could have serious consequence, and 3) that certain actions not only would be beneficial but also would outweigh the possible inconveniences.

Problems identified by patients surveyed included confusion about their specific therapy and difficulty incorporating it into their daily schedule, the lack of family reinforcement and support, and discourage- ment about the management of their regimen? Based on these indications of need and influenced by .the Green Model and the Health Belief Model, an educational program was designed. The program com- prised three aspects: Phase 1, an educational review session with a health educator, following the practitioner encounter, to clarify ambiguities and to rein- force the management plan; Phase 2, a family education session in the patient's home to enlist the family's suppprt; and Phase 3, a series of small-group needs assessment sessions to help patients deal with personal and adaptive problems associated with their hypertension. ~

Research Design

It was hypothesized that the three interventions would complement each other, producing a cumulative effect. The sequence was based on the concept of moving from the least disruptive and least complex, most easily introduced, to the most complex and be- haviorally powerful educational process. Introduc- tion of these interventions in a sequential, randomized, factorial design, as shown in Figure 1, allowed us to evaluate the main effect of each as well as the combined effects of multiple interventions. The design reflects a number of the basic principles of health education, particularly the need for a combination of methods, media, and messages?

After the educational program was completed, a home interview was conducted, consisting of items similar to those on the .baseline survey. Additional follow-up data, including blood pressure readings, weight, and appointment keeping, were obtained from patients' records. The results of the main study are detailed in a paper by Levine. 6 A summary of the findings are presented elsewhere in this paper.

N E E D S ASSESSMENT---SMALL GROUP

Conceptual Framework

Clinical judgment applied to the survey results and to notes taken during the educational review sessions (Phase 1) provided prescriptive directions for tailoring Phase 3. A recurring theme that appeared through-

Phase l Phase 2 Phase 3

n = 200 (E,)---100 (E=)~,x50 (E3)

/ \ ,0 o,

n = 200 (C, Y--.-100 (E~ .)7--50 (Es)

"X'SO (c,) t00( c,)x~x,0 (E~)

"50(C0

Figure 1. Sequential randomized assignment of patients to educational interventions.

E: Experimental group E,----first intervention (exit interview) E2 =second intervention (family support) Ea--third iniervention (small groups)

C: Control C, = control for intervention 1 C2 = control for intervention 2 Ca = control for intervention 3

Experimental combinations

All three (E,E..E=)

1 and 2 only (E,E:C~)

1 and 3 only (EtC:~)

1 o n l y (E~C:C~) 2 and 3 only (C,E_-E~)

2 o n l y (C~E:C~) 3 o n l y (C,C:.E~)

N o n e (C,C:.C~)

out the educational review sessions was 'the patients' feeling of powerlessness in dealing with the medical regimen and the contingencies surrounding it. The research team interpreted this as a need of patients to learn to control their immediate environment.

The locus of control concept introduced by Julian Rotter, 1~ suggests that behavior results both from the value of an outcome to an individual and from the individual's expectation that a given action will result in that outcome. Individuals who believe that they can control outcomes are said to have an internal locus of control, whereas those who believe that their destinies are controlled by chance or by other people are said to have an external locus of control. Evi- dence indicates that the educational/rehabilitation process may be greatly improved if patients develop internal control? 1, 12 The possible application of this concept to health education has been described under the rubric of training patient internality, la

Organizational Framework

The relative effectiveness of the group problem-solving method modeled after primary and reference groups over more didactic methods of education and behavior influence is well known to educators. 3. 14 Internal- ity training methods within a group context were organized with relation to the socioeconomic homoge- neity of the study sample. The patients in the study shared many of the characteristics of lower and working class patient groups. Goldstein 1~ has criticized

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the lack of useful educational/treatment approaches for this group of patients. He advocated a brief, authoritatively administered approach that uses con- crete examples, provides role-taking training, has a behavioral emphasis, and stresses training in social skills.

Our approach used Becker's Health Belief Model variables, Green's predisposing, thus enabling and reinforcing constructs as substantive focal points and having the locus of control concept as a main process focal point. This group approach provided an example of a high-impact technique with a time limitation-- three weekly two-hour sessions for each set--imposed to ensure its incorporation into the routine of the clinic.

Participant Selection Process

Patients selected to participate were members of the randomized sample of 200 assigned to receive the thi~'d intervention. They were sent a letter i.nviting them to become members of the small-group sessions and were later telephoned, at which time the purposes of the group sessions were explained in more detail. Attempts were made to fit the prospective members into a meeting schedule that would accommodate their outside interests. The profile of the group members reflected the profile of the larger study group. Ninety-one percent of the patients were black and 70% were female. They had a median age of 54 years, a median income of $3,250, and a median of seven years of formal schooling. All had been under medical care for at least six months and for an average of six years. Twenty-five patients attended one session only, 38 attended two sessions, and 39 attended all three sessions.

Process

The educational component .focused on medication management issues, appointment keeping, the patient- provider encounter, and blood pressure control. This choice was influenced both by what seemed appropriate given the time limitations and by what was appropriate for the settings, the nature of the medical problem, regimen, and purpose of the investigation. Medication-taking behavior was selected because of the proven efficacy of antihypertensive drugs in controlling blood pressure. Appointment-keeping behavior was selected because continued contact with the health practitioner seemed essential for trying out new behaviors. The appointment-keeping variables were chosen with the anticipation that the experimental group patients might bring more developed, inter- nalized, self-reinforcement systems to the patient- health practitioner encounter.

The prescriptive use of assessment data, as men-

tioned, provided the building blocks for the intervention. Internality training as an educational modeling process by definition cannot place the full responsi- bility for prescription building upon the group leader. The process must allow for a more individualized needs assessment arrangement--a therapeutic alli- ance - tha t engages both the leader and the group member. During the initial session the leaders and the group members established together a contract of expectations based on a review of expressed needs. The process focus on the external-internal locus of control continuum was directed to two main areas: problem-solving activity and problem-solving performance. People who have problems in the first area need assistance in sorting out the major components that make up a problem. Patients who have defects in the second area may be able to solve problems symbolically but may not be able to carry out the necessary responses because of certain performance or environmental deficits. An organizational outline, based on work by D'Zurilla and Goldfried? ~ was followed throughout the sessions, providing more detailed opportunity for needs assessment within the two areas.

After a general orientation, a member of the group was asked to choose one of the needs stated in the contract of expectations. As most members describe their needs in relatively abstract terms, efforts were made to help the patient state the need specifically and concretely. Working within a well-defined and formulated situation, the entire group joined in brain- storming. When it appeared that most strategies had been identified, each member was asked to consider the likely consequences of each strategy and assign values to them in terms of the best strategy. Behavior alternatives were then examined, and skill training was provided through role playing enactments and behavioral rehearsals. The role plays and rehearsals were videotaped and played back to the group. Kagan's lr observations on recall by means of video- tape assisted by a person serving as a facilitator sug- gested that this process could enable people to recog- nize both their impact on others and the impact of others on them.

Every opportunity was taken to enhance and rein- force examples of responsible behavior concerning the medical regimen. The members monitored each other's blood pressure and participated in interpreting the findings and processing that information, in terms of its implication in the patient's life, with other members. Summary segments directed by the patients were held at the end of each session, and agenda items were defined for the next session.

The second and third sessions followed the same format with more effort directed toward helping the

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patient practice different ways of behaving in identified problem situations. An attempt was made to shift responsibilities in the group, with the role of the leaders changing from active in the initial session to that of resource persons by the third session.

Two health educators, unfamiliar with the internality prescriptive base influencing the group design, conducted a content analysis on the process after viewing videotapes of the sessions. Their reports corroborate the process as described in this paper.

Findings

The effect of the internality training with small-group intervention, as measured at the final field follow-up, was analyzed in relation to three dependent variables: self-reported medication compliance, record-reported appointment keeping, and blood pressure control status after the intervention. The blood pressure control cri- teria were as follows: age 20 to 39 years, greater than 140/90 mmHg was considered elevated; age 40 to 59 years, greater: than 150/95 mmHg was considered elevated; and 60 years or older, greater than 160/100 mmHg was considered elevated. If either the systolic or diastolic reading exceeded the limit set for controlled blood pressure, the blood pressure was considered elevated. A full delineation of the measures can be found in a paper by Levine. ~ The small-group intervention produced the most measurable impact on blood pressure control.

Post-Phase 3 blood pressure control status was assessed for patients who were randomized into control and experimental groups for that phase of the study (Table I). Participants in the experimental group were subdivided according to the number of sessions attended.

The number of sessions attended had a clear impact on control of blood pressure. Among members who attended only one session, 36% were in control, while 70% of those who attended all three ses-

Table I. Percentage of patients in control of blood pressure correlated with differential participation in Phase 3 in. ternality training groups.

Percent in Groups control (n)

Control 46% (172) Experimental

No sessions 55% (82) 1 session 36% (22) 2 sessions 54% (37) 3 sessions 70% (37)

chi square----9.4 P<0.05

sions were in control. Among members who were assigned to the intervention but did not attend any sessions, 55% were in control. Since the intervention was not attended by the entire sample invited, the percentages may reflect a tailoring and selection effect. Examination of antecedent variables, such as age, sex, social support, and history of prior hos- pitalization, failed to differentiate between attenders and nonattenders or between the control group and the experimental group.

Pre-Phase 3 blood presure control status was then assumed to determine the proportion in control by participation status in Phase 3 intervention. Findings revealed no significant difference in the proportion in control of blood pressure pre-Phase 3 according to participation status (• NS). Phase 3 produced minuscule changes on the two behavioral measures: medication compliance and appointment keeping. Of the three interventions in the study, the small-group sessions produced the greatest impact on blood pressure control.

Table II reflects an evaluation of the entire educational program rather than of completed interventions. Individuals who were randomly assigned to the interventions but not reached by them are included along with those actually reached. The results thus underestimate the effect of the interventions on those patients who actually received them.

The educational program (all interventions together) had a positive impact on blood pressure control (12% increase) as compared with the control group (1% increase). When considering the specific intervention groups, it is evident that the group assigned all three interventions achieved the greatest improvement in blood pressure control (28% increase). Combinations of any two interventions alone had a modest effect: 10%, 13%, and 13% increases. The family support intervention alone had a similar positive impact on increasing blood pressure control (11% increase), and the small-group approach alone had a slightly greater impact (18% increase). The effect of the exit interview was indistinguishable from the control group, with neither demonstrating any change in blood pressure control.

IMPLICATIONS

Despite limitations and constraints on experimental application of the small-group intervention, the results supported the study hypotheses with respect to blood pressure control: 1) small-group sessions achieve greater blood pressure control than that achieved by patients not receiving this intervention; 2) it is the most powerful of the three main interventions; and 3) improvement in blood pressure control increases with the number of sessions attended.

FIRST QUARTEl~1980

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Table II. Proportion of patients with blood pressures under control by study status.

Study status Prcprogram Postprogram Change * n

Control (CtC2Ca)

Exit interview only (EtCoC3)

Family support only (C1E=C3)

Small group only (CxC2Ea)

Exit interview and small group (E~C2E3)

Family support and small group (CxEzE,)

Exit interivew and family support (EtE2C3)

Exit interview and family support and small group (EtEzEa)

41% 42% +1 40

4O% 41% +1 46

37% 48% +11 42

34% 52% +18 4 4

40% 53% +13 47

41% 54% + 13 43

45% 55% + 10 44

38% 66% +28 44

* Change: postprogram--preprogram

It is not clear why the interventions had such a positive effect on blood pressure control and so little effect on compliance and appointment-keeping measures. Results from another study support no delay factor ( t ime) or selection factor. Possibly this result was ll accomplished through processes we had not measured.

The internality training intervention is an incremental prescriptive s t ra tegy. The general boundaries were established through needs assessment data obtained in the baseline questionnaire and refined through clinical judgment applied to exit interview information. The direction of activity within the boundaries was guided by a continuation of the needs assessment process that occurred within the group. Attention was immediately given to helping the group members establish personal boundaries to their definition of the problem and to developing techniques for working with the problem as defined. Research findings suggest that stressful events in the emotional life

of patients influence the lability of blood pressure and affect the progress, and occasionally the primary pathogenesis, of hypertension. 18 A reduction in anxi- ety based on a more personalized and emotionally supportive discussion of hypertension and management issues and on some boundary management work around the issues of attribution and control might have occurred within the group. Further studies of this type of educational approach and program with a larger number of patients are indicated.

A C K N O W L E D G M E N T S

This work was supported by N H L B I grant numbers 1R25 H1 17016-10, and T32 HL07180. Lawrence W. Green and David M. Levine were principal in- vestigators. We are also indebted to Carol Johns, Patterson Russell, Joan Wolle, Judy Chwalow, Chris- tine Lewis, Lorraine Midanick, Sam Shapiro, and Marion Field Fass.

REFERENCES

1. Barofsky, I. (1977): Sociological and psychological aspects of medication compliance. In: Medication Com- plia, ce, pp. 29-44. Editor: I. Barofsky. Charles Slack, New Jersey.

2. Podell, R. (1976): Physician's guide to compliance in hypertension. In: Preventive Medich~e USA, 15p. 45-59. Prodist, New York.

3. Green, L., Werline, S., Schaeffer, H., and Avery, C. (August, 1977): Research and Demonstration Issues in Self Care: Measuring in Decline of Mediocentrism. In: Consumer Sel[-Care in Health, 20-36. DHEW Publication No. (HRA), 77-3181.

4. Goldstein, A. and Stein, N. (1976): Prescriptive Psycho. therapy. Pergamon Press, New York.

5. Green, L. W., Levine, D. M., Lewis, F. M., Deeds, S., Chwalow, l., Fass, M., Wolle J., and Bowler, M. (1978): The supplementation of statistical profiles with clinical

judgement and behavioral therapy in the diagnosis of patient education needs. Presented at the Second Annual Needs Assessment Conference, Louisville, Kentucky, March 1978.

6. Levine, D. M., Green, L. W., Deeds, S., Chwalow, J., Russell, R. P., Finlay, J., and Morisky, D. (1979): Health education for hypertensive patients. J. Am. Med. Assoc. 241, 16.

7. Green, L. W. (1974): Toward cost benefit evaluations of health education: some concepts, methods, and examples. Health Education 3Ionograph 2: 34.

8. Becker, M. (1976): Sociobehavioral determinants of compliance. In: Compliance with Medical Reghnens, pp. 40-50. Editors: D. Sackett and B. ttaynes. Johns Hopkins Press, Baltimore.

9. Green, L. W., Levine, D. M., Deeds, S. G. (1975): Clinical trials of health education for hypertensive out- patients: design and baseline data. Prey. Med. 4, 417.

PATIENT COUN$~-L~G AND HEALTH EDUCATION

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10. Rotter, J. B. (1966): Generalization expectancies for internal versus external control of reinforcement. P~'cho- logical Monographs 80, (whole no. 609).

I1. MacDonald, A. P., Jr. (1972): Internal-external locus of control change techniques. Rehabil. Lit. 33, 44.

12. Dua, P. S. (1970): Comparison of the effects of be- haviorally oriented action and psychotherapy reeducation on introversion-extroversion, emotionality, and internal- external control. I. Co!msel. Psychol. 17, 567.

13. Wallston, B. S. and Wallston, K. A. (1973): Health care education programs: training patient internality. Pre- sented at the Annual Meeting of the American Public Health Associa!ion, San Francisco, California, November 1973.

14. Varenhorst, B. (1969): Behavioral group counseling. In:

Theories and Methods o/ Group Counseling in the Schools. Editor: G. Gazda. Charles C Thomas, Spring- field, Illinois.

15. Goldstein, A. (1973): Structured Learning Therapy. Academic Press, New'York.

16. D'Zurilla, T. and Goldfried, M. R. (1971): Problem solving and behavior modification. 1. Abnorm. Pa3"chol., 78, 107.

17. Kagan, N. (1975): Interpersonal Process Recall: A Method o[ lnflttencing Httman Interaction, p. 4. Michigan State University.

18. Shapiro, A., Schwartz, G., Ferguson, D., Redmond, D., and Weise, S. (1977): Behavioral methods in the treatment of hypertension. Ann. Intern. Med. 86, 626.

BUREAU OF HEALTIt EDUCATION ANNOUNCES NEW ItEALTII EDUCATION RESOURCE

The Bureau of Health Education, Center for Disease Control, has initiated a project to provide current literature and program description information to health education providers. A basic purpose of this service will be to gather and disseminate information on the nature of current and past health education programs and methodology and their effectiveness in attaining the goals for which they were established. The Bureau is now soliciting germane literature and descriptions of programs from persons and organizations for inclusion in this data base. Topics of interest include: community health education; health education methods; regulation, legislation, and administration; professional education and training; health education in occupa- tional settings; risk reduction (nutrition, smoking); patient education; health education research and evaluation; school health education; self-care; and sex education. Program information should include the title of the program, the name of the director, the sponsoring or administering organization, the address of the program, the source(s) of funding, and the beginning and, where known, ending dates. In addition, information about programs should include the purpose and objectives, services offered, methods employed (mass media, group discussion, classes, etc.), size and type of target audience, coordination with other programs, evaluation mechanisms, and results of evaluation (impact of program, etc.). One of the ways this information will be disseminated is through a monthly abstract- ing and indexing publication entitled Current Awareness in Health Education (CAHE). Recipients are encouraged to share the information with others engaged in health education.

Literature references, copies of publications, and program descriptions (including descriptive literature) should be sent to:

Center for Disease Control Bureau of Health Education Attention: Current Awareness in Health Education Building 14 Atlanta, Georgia 30333

FIRST QUARTEPJ1980

needs assessment strategies in working with compliance issues and blood pressure control

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