Betancourt JR, Carrillo JE, Green AR.
Hypertension in multicultural and minority populations: linking communication to compliance.
Curr Hypertens Rep 1999;1(6):482-8.

This paper reviews the importance for minority and low-income populations of physician-patient communication in encouraging patient compliance with medical advice on treating hypertension. The cardiovascular disease burden is particularly high in African American communities, and the recent decreases in mortality due to cardiovascular disease are much lower in Hispanics than in other populations. Hypertension is one of the major modifiable risk factors for cardiovascular disease; therefore, identifying means to help African American and Hispanic patients control hypertension is of crucial importance. Nonetheless, rates of hypertension control in the United States have decreased over the past few years. Sub-optimal blood pressure control may be more marked in socially disadvantaged populations and racial and ethnic minority groups because of a variety of issues that relate directly to medical care compliance.

The authors categorize factors associated with compliance as being either "systemic" (e.g., lack of health insurance and difficulty maneuvering the health care delivery system) or within the medical encounter (e.g., socio-cultural variation in health beliefs, values, and behaviors). They argue that members of racial and ethnic minority groups might be at greater risk for noncompliance because of systemic and medical encounter factors, which can be overcome if they are identified and appropriate interventions are put in place. The authors warn against categorizing all members of a particular social, racial, or ethnic group as non-compliant because this practice is not conducive to developing and implementing successful interventions to improve compliance.

Provider-patient communication is linked to patient satisfaction, compliance, and health outcomes. Barriers to good communication are linguistic (discordance between the primary languages of patient and provider) and contextual (poor understanding of context and meaning between patient and provider despite concordance in language). Of particular importance for good provider-patient communication is the patient's "explanatory model" (lay cognitive model of disease or conceptualization of the illness) and level of acculturation.

The authors propose a 4-part model for communication and compliance called the ESFT Model. The four domains are: determining the explanatory model, determining social and financial risk for non-compliance, determining fears and concerns about medication and side effects, and determining understanding of the suggested treatment regime. This model is designed to "allow for screening for barriers to compliance and outline strategies for intervention that might improve outcomes for all hypertensive patients."