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. 2010 Sep 23;51(1):64–75. doi: 10.1093/geront/gnq077

Intergenerational Transmission of Chronic Illness Self-care: Results From the Caring for Hypertension in African American Families Study

Jan Warren-Findlow 1,*, Rachel B Seymour 2, Dena Shenk 3
PMCID: PMC3018870  PMID: 20864590

Abstract

Purpose of the study: African Americans often experience early onset of hypertension that can result in generations of adults managing high blood pressure concurrently. Using a model based on the Theory of Interdependence, this study examined whether intergenerational transmission of hypertension knowledge and self-efficacy would affect hypertension self-care of older parents and their adult children. Design and Methods: We recruited 95 African American older parent–adult child dyads with hypertension. We constructed separate logistic regression models for older parents and adult children with medication adherence as the outcome. Each model included individual demographic and health characteristics, the partner’s knowledge, and self-efficacy to manage hypertension and dyad-related characteristics. Results: Parents were more adherent with medication than adult children (67.4% vs. 49.5%, p < .012). There were no significant factors associated with parent medication adherence. In adjusted models for adult children, medication adherence was associated with child’s gender (odds ratio [OR] = 3.29, 95% confidence interval [CI] = 1.26–8.59), parent beliefs that the child had better hypertension self-care (OR = 4.36, 95% CI = 1.34–14.17), and child reports that the dyad conversed about hypertension (OR = 3.48, 95% CI = 1.18–10.29). Parental knowledge of hypertension and parent’s self-efficacy were weakly associated with adult children’s medication adherence (OR = 1.35, 95% CI = 0.99–1.84 and OR = 2.59, 95% CI = 0.94–7.12, respectively). Implications: Interventions should consider targeting African American older adults to increase self-care knowledge and empower them as a primary influencer of hypertension self-care within the family.

Keywords: Minority issues, Parent–child relationships, Social support, Treatment adherence

Research suggests that family members can be highly influential on chronic disease self-care of older adults (Gallant, Spitze, & Prohaska, 2007; Warren-Findlow & Prohaska, 2008). Most of the studies examining social support and chronic illness self-care focus on diabetes (Gallant, 2003), despite the fact that hypertension is more prevalent and requires similar self-care activities. Social support for chronic illness can take many forms. Family members provide instrumental support such as filling prescriptions or driving an older adult to the physician, behavioral support for diet and exercise regimens, informational support such as reminders to take medications, and emotional support to cope with the uncertainties of chronic illness (Gallant, Spitze, & Grove, 2010). However, not all family support for chronic illness self-care is positive, particularly in relation to diet (Gallant et al., 2007; Warren-Findlow & Prohaska). Studies examining family social support for chronic illness self-care among older adults do not differentiate between support from spouses versus adult children or other family members (Gallant, 2003).

Research with older African Americans who have chronic disease indicates that family members and extended family provide the same types of support for chronic illness self-care as occurs in White families and other ethnic groups (Gallant et al., 2010). However, among African Americans, there may be a greater expectation for older adults to provide reciprocal support of some kind, such as caring for small children (Ruiz, 2000). Having a large family to provide support may entail increased burden on older adults to give support (Sarkisian & Gerstel, 2004). Older African Americans also gain support from their social networks in less direct ways, such as using experiential knowledge gained from family members with shared health conditions as a method of assessing their own chronic disease risk (Warren-Findlow & Issel, 2010). As family members’ health status changes, individuals with a similar condition may reevaluate their own health and health practices. This vicarious experiential learning becomes a form of passive informational support.

In the gerontology literature, provision of social support for health issues is usually viewed within the context of caregiving with the implication that the care recipient is frail or impaired. Support in this situation typically flows from adult children to older adults or from one spouse to another (Litwak, 1985). We have found no studies that have examined how older adults’ health and health knowledge may influence the health self-care of an adult child when the parties are not impaired. Within African American families, the family structure is frequently highly interdependent with multiple generations coresident (Peek, Koropeckyj-Cox, Zsembik, & Coward, 2004). These living arrangements are not necessarily the result of impairment or lack of resources but rather cultural practice and avoidance of institutional living (Gallant et al., 2010; Hays & George, 2002). Intergenerational relationships may be particularly important to study among African Americans as they are less likely to be married than White Americans (hereafter Whites; Dixon, 2009) and therefore may rely more heavily on other family members for social support.

Older adults may have an important influence on adult children when both the older parent and the adult child share a chronic health condition, such as hypertension. African Americans often experience early onset of hypertension causing both younger and older adults to be managing high blood pressure (Stewart, Johnson, & Saunders, 2007). A shared health concern in conjunction with an interdependent family structure may create an opportunity for intergenerational sharing of self-care practices and knowledge. The potential for transmission of health knowledge and health beliefs as a form of informational support from one generation to another is of interest to public health gerontologists who are searching for effective ways to intervene to improve hypertension self-care among African Americans.

This study examines whether African American older parents and adult children who share a common chronic illness provide informational and behavioral support to each other that influences their hypertension self-care. We use a conceptual model based on the Theory of Interdependence (Lewis, DeVellis, & Sleath, 2002; Lewis et al., 2006; Rusbult & Van Lange, 1995) to guide our analyses of the influence of older parents on adult children’s hypertension self-care and, conversely, adult children’s influence on older parents’ self-care. This study extends the literature on dyadic relations between older parents and adult children within a chronic illness context. It also contributes to the research on intergenerational transmission of health knowledge and beliefs among older parents and adult children.

Hypertension Among African Americans

African Americans experience a disproportionately high prevalence of hypertension (42.5%) in comparison with Whites (30.5%) or Mexican Americans (29.5%; Fryar, Hirsch, Eberhardt, Yoon, & Wright, 2010). They also experience early onset of hypertension, with high blood pressure sometimes occurring in adults as young as 20 or 30 years. Early onset will require an individual to manage a chronic illness for several decades. When early onset occurs within families, multiple generations may be attempting to manage high blood pressure concurrently.

Unfortunately, African Americans are less likely than Whites to have their hypertension under control (Howard et al., 2006), although recent analyses of national trends suggest that this gap is improving (Egan, Zhao, & Axon, 2010). Adherence to antihypertensive medication regimens is important to blood pressure control in conjunction with other self-care behaviors related to diet and exercise (U.S. Department of Health and Human Services, 2004). African Americans are less likely than Whites to be adherent to medication protocols for hypertension (Bosworth, Powers, et al., 2008; Ndumele, Shaykevich, Williams, & Hicks, 2010). Determining potential influencers of hypertension self-care and medication adherence would enhance our knowledge and enable public health gerontologists to intervene more effectively with African Americans. Targeted interventions could be designed based on a clearer understanding of who is a possible influence on hypertension self-care.

Predictors of Medication Adherence Among African Americans

Reported medication adherence rates among African Americans with hypertension range from 30% to 72% (Bosworth, Powers, et al., 2008; Braverman & Dedier, 2009; Hekler et al., 2008; Ndumele et al., 2010; Schoenthaler, Ogedegbe, & Allegrante, 2009). These rates are substantially lower than rates reported among Whites, which range from 70% to 80% (Kressin et al., 2007; Ndumele et al., 2010). Lack of insurance can affect medication adherence (Duru, Vargas, Kermah, Pan, & Norris, 2007) but is not sufficient to explain this gap. Low-income African Americans on Medicaid had 55% lower odds of having sufficient hypertension medication on hand than Whites on Medicaid (Shaya et al., 2009). This finding suggests that additional factors other than health insurance may contribute to medication adherence. Research has suggested that many African Americans do not believe that medications are effective in treating high blood pressure (Heurtin-Roberts & Reisin, 1992). African Americans have traditional cultural beliefs about illness that are associated with nonadherence (Becker, Gates, & Newsom, 2004) and inconsistent with biomedical knowledge of hypertension (Schoenberg & Drew, 2002). African Americans with hypertension report more negative side effects with hypertensive drugs, such as diuretics, which can cause increased urination (Bosworth et al., 2006). African Americans are more likely than Whites to have a complex medication regimen requiring them to take more pills (Kressin et al., 2007). Having comorbid conditions is associated with reduced adherence to antihypertensive medication among low-income individuals (Shaya et al., 2009). Older African Americans are more likely to be adherent to antihypertensive drug therapies than younger adults (Dunbar-Jacob & Mortimer-Stephens, 2001; Hekler et al., 2008). Lack of knowledge about hypertension and poor health literacy may also play a role in nonadherence among African Americans (Bosworth, Olsen, et al., 2008).

The literature also suggests that knowledge about one’s health condition and self-efficacy for chronic disease management influence medication adherence. Individuals’ knowledge of hypertension and its treatment are important factors in performing self-care activities including medication adherence. Lack of knowledge about hypertension has been associated with 60% increased odds of not having controlled blood pressure among African Americans (Kressin et al., 2007). Self-efficacy is the confidence to perform a behavior within a situation or context (Bandura, 1977). Self-efficacy for chronic disease management has been associated with better chronic disease self-care for individuals with asthma, diabetes, and arthritis (Bodenheimer, Lorig, & Holman, 2002; Marks, Allegrante, & Lorig, 2005). A specific form of self-efficacy, medication adherence self-efficacy, has been associated with self-reported and objective measures of medication adherence among African Americans with hypertension (Fernandez, Chaplin, Schoenthaler, & Ogedegbe, 2008; Kressin et al., 2007; Schoenthaler, Ogedegbe, et al., 2009). Hypertension management requires individuals to perform a number of self-care activities in addition to taking medication (U.S. Department of Health and Human Services, 2004), thus a more comprehensive measure of self-efficacy may be necessary.

Older Parent–Adult Child Dyad Characteristics

A number of factors have been associated with older parent–adult child relationship dynamics. Physical distance, or proximity, between aging parents and adult children can affect the quality of the older parent–adult child relationship and the level of interaction (Mercier, Paulson, & Morris, 1989; Shapiro, 2004; Spitze & Miner, 1992; Szinovacz & Davey, 2001). The gender content of the dyad can be important to the giving and receiving of help as daughters frequently have more contact with older parents than sons (Gallant et al., 2010; Laditka & Laditka, 2001; Shapiro, 2004). Marital status of children is also associated with parental interactions and provision of help (Laditka & Laditka, 2001; Shapiro, 2004).

Conceptual Framework

We conceptualized a model for intergenerational self-care activities (see Figure 1) based on the Theory of Interdependence (Lewis et al., 2002, 2006; Rusbult & Van Lange, 1995). The Theory of Interdependence suggests that dyad partners have a reciprocal influence on one another if they have shared health goals. Typically, only one partner is targeted for behavior change; thus, the model has primarily been applied in studies with parents and minor children (Jackson, Henriksen, & Foshee, 1998; Simons-Morton & Hartos, 2002) or among spouses (Burman & Margolin, 1992; Lewis et al., 2006). In the situation where both partners have the same health condition, then theoretically both would have a shared goal of better self-care. In the model for this study, the solid lines indicate a relationship between an individual’s demographic and health characteristics and his or her medication adherence (an actor effect see Lewis et al., 2006). In a scenario with intergenerational transmission, a dyad partner can potentially influence the other partner’s hypertension self-care behavior by providing informational support through knowledge, self-efficacy, and experience as indicated by the diagonal dashed lines in the model. When only the partner influence affects the individual’s self-care, there is a partner effect. If characteristics of the individual and the partner predict self-care, there is a joint effect. When joint effects occur among both partners, there is a joint mutual effect. Partners may model self-care behavior for each other, so we included the possible influence of each partner’s medication adherence on the other person’s adherence as seen by the vertical dashed line. We extended the Theory of Interdependence by borrowing the concepts of proximity and frequency of contact from social network theory (Berkman & Glass, 2000) to control for the fact that not all older parents and adult children coreside. We also included dyad communication about chronic illness, partner gender and marital status, and beliefs about who is doing better at hypertension self-care.

Figure 1.

Figure 1.

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Conceptual model for intergenerational transmission of chronic illness self-care among African Americans.

Based on the model, we hypothesized that a two-way or intergenerational effect might occur when both the parent and the adult child share the chronic illness of hypertension. Older African American parents who may have more knowledge and greater self-efficacy managing hypertension would provide informational support and demonstrate a positive influence on their adult child’s medication adherence (a downward intergenerational transmission). Conversely, adult children may be more knowledgeable about hypertension or have greater self-efficacy because of more education or being less traditionally oriented may provide informational support that positively influences their parents’ medication practices (an upward intergenerational transmission).

Methods

Participants were recruited in older parent–adult child pairs as part of the Caring for Hypertension in African American Families (CHAAF) study. CHAAF is a cross-sectional study designed to examine intergenerational transfer of self-care among African Americans. CHAAF assessed self-care practices based on current clinical recommendations for activities to manage blood pressure, including medication adherence.

Eligible participants were African American, at least 21 years old, diagnosed with high blood pressure for at least 6 months, and were prescribed hypertensive medications. Hypertension diagnosis was confirmed through a medication inventory. An individual was not enrolled in the study until his or her partner, either parent or child who met the same criteria, was enrolled. Recruitment efforts were targeted toward older adults as parents, middle-aged adults as parents or adult children, and younger African Americans as adult children. Participants were recruited through partnership with the American Heart Association/American Stroke Association (AHA/ASA), community-based organizations, low-income clinics, Black churches, barber shops, newspaper and radio, word of mouth, and community events. Participants completed an informed consent process approved by the University of North Carolina at Charlotte Institutional Review Board. Data were collected by trained African American interviewers in face-to-face sessions at the participant’s preferred location (92% were in the participant’s or partner’s home). Each participant was interviewed separately. Interviews lasted an average of 58 min.

Measures and Scoring

Medication Adherence.—

The outcome was adherence to antihypertensive medications. Medication adherence was measured with three items that assess the number of days in the last week that an individual (a) takes their blood pressure medication, (b) takes it at the same time every day, and (c) takes the recommended dosage. Participants reporting that they followed these 3 recommendations on 7 of 7 days (score of 21) were considered adherent (1 = yes, 0 = no). Internal consistency for the sample was good (α = .83).

Sociodemographic Factors.—

Individual demographic factors consisted of age (continuous), gender (1 = female, 0 = male), marital status (1 = married, 0 = not married), and education measured as having a 4-year college degree or more (1 = yes, 0 = no).

Cultural beliefs were measured using the African American Acculturation Scale—Revised (Klonoff & Landrine, 2000). This scale contains 47 items to assess how oriented an individual is to traditional African American culture. The scale includes concepts related to religious beliefs, preferences for African American media and entertainment, interracial attitudes, family practices, health beliefs, cultural superstitions, experiences with segregation, and family values. Response options are 1 strongly disagree to 7 strongly agree. The possible range of scores is from 47 to 329. Higher scores indicate a more traditional cultural orientation. Internal consistency was good (α = .88).

Health Factors.—

Knowledge of hypertension was assessed with a nine-item multiple choice quiz “Test Your High Blood Pressure IQ” developed by the AHA/ASA (AHA, 2007). Scores ranged from 1 to 9; higher scores indicated better knowledge of hypertension. Self-efficacy to manage hypertension was measured with five items. This scale was modified from an existing measure that assessed self-efficacy to manage disease in general (Lorig et al., 1996). Each item begins with the phrase “How confident are you that you can … ?” For example, “How confident are you that you can judge when the changes in your illness mean that you should visit a doctor?” We substituted the word “high blood pressure” for “illness.” Response options ranged from 1 (not confident at all) to 10 (totally confident). Internal consistency was good (α = .81). Scores were calculated as the mean of participants’ responses. For these analyses, scores greater than or equal to 9 were dichotomized into good self-efficacy (1 = yes); all others were coded as a 0.

Participants were asked “how long have you been diagnosed with or treated for high blood pressure?” Many older adults did not remember when they were diagnosed or reported that they had hypertension “all my life.” This variable was not included in these analyses due to missing data and data quality. In analyses conducted with a subsample with complete data for all variables, years with hypertension was not associated with medication adherence for either dyad partner.

To assess health status, we asked respondents whether they had any of 18 possible health conditions in addition to their hypertension (Hughes, Edelman, Chang, Singer, & Schuette, 1991). “Yes” responses were summed to determine a total number of chronic conditions. Participants also reported their health insurance status. Individuals without health insurance were coded as a 1; all others were 0.

Dyad Characteristics.—

Dyad characteristics were assessed with five variables. Proximity was measured by whether the partners lived together (1 = yes, 0 = no). Frequency of contact was the larger of either the average number of days that partners reported having face-to-face contact or the average number of days that partners spoke on the telephone. Values range from 0 to 7 days. Communication was assessed with a single item: “Do you and family member ever talk about your high blood pressure?” Responses were coded as 1 = yes and 0 = no. Subjective assessment of hypertension self-care was asked, “In your opinion, who is taking better care of their high blood pressure, you or family member?” Participants who responded that their family member took better care were coded as a 1; all other responses were coded as 0. We also included the dyad partner’s gender (1 = female, 0 = male) and marital status (1 = married, 0 = not married).

Analyses

Descriptive statistics were calculated to assess participants’ individual and dyadic characteristics. Bivariate analyses were conducted using logistic regression to measure associations between demographics and other health-related characteristics and the outcome of medication adherence. Results are reported as odds ratios (ORs) and 95% confidence intervals (CIs).

For multivariate analyses, we constructed separate models for older parents and adult children. For each partner group, Model 1 contains individual demographic characteristics and health factors as predictors of medication adherence. Model 2 includes the Model 1 variables and then adjusts for dyad characteristics and partner health factors. Model 3 is a reduced form model containing variables from Model 2 that met a minimal standard of significance at p < .10.

Results

Characteristics of Parents and Adult Children

Parents and adult children differed on several sociodemographic characteristics as shown in Table 1. There was a wide distribution of ages with considerable overlap in age between the oldest children and the youngest parents. All participants were community dwelling. Parents were more likely to be mothers (χ2 = 10.35, p < .01) and to hold more traditional cultural values than their adult children (t = 2.96, p < .01). Parents had twice as many additional chronic conditions than their children (t = 6.41, p < .001). Parents and children did not differ on their knowledge of hypertension or their self-efficacy to manage the disease. One third of dyads lived together. The frequency of contact among dyads who lived together (mean 6.71 days of 7) versus those who did not (mean 5.88 days) was significant (t = 3.43, p < .001) (data not shown). Mothers and daughters form the majority of the dyads (51.6%). Parents and children reported that they talked about hypertension in roughly equal numbers; however, children were more likely to report that the parent was taking better care of his or her blood pressure than the child. Parents were more likely to be adherent to blood pressure medications (χ2 = 6.26, p < .05).

Table 1.

Sample Characteristics for Total Sample and by Dyad Role

Total sample (n = 190) Older parents (n = 95) Adult children (n = 95)
Sociodemographic characteristics
    Age (years), M (SD) 53.29 (16.12) 65.40 (10.44) 41.18 (10.81)***
    Range 22–88 42–88 22–68
    Gender (% female) 71.60 82.10 61.1***
    Marital status (% married) 35.26 34.74 35.79
    Education (% with 4-year degree or higher) 25.80 22.10 29.50
    Cultural beliefs (range 132.0–303.0), M (SD) 237.70 (33.57) 244.75 (33.35) 230.64 (32.45)**
Health factors
    Hypertension knowledge score, M (SD) 6.60 (1.52) 6.54 (1.55) 6.67 (1.50)
    Good self-efficacy to manage hypertension (% scoring 9 or better) 40.50 42.10 38.90
    Number of chronic conditions (range 0–10), M (SD) 2.33 (1.92) 3.14 (1.83) 1.52 (1.66)***
    Health insurance status (% uninsured) 11.10 4.20 17.90
Dyad characteristics
    Proximity (% of dyads who live together) 32.60
    Contact frequency (range 1–7 days), M (SD) 6.15 (1.42)
    Dyad gender relationship
    Mother–daughter 51.60
    Mother–son 30.50
    Father–daughter 9.50
    Father–son 8.40
    You and partner talk about hypertension (% yes) 74.70 77.90 71.60
    Who takes better care of hypertension (% family member) 61.10 24.20 52.6***
    Medication adherence (% adherent) 58.40 67.40 49.5*
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*p < .05. **p < .01. ***p < .001.

Predictors of Medication Adherence Among Parents and Adult Children

Table 2 presents unadjusted ORs and 95% CIs for the hypothesized model variables and medication adherence among older parents and adult children. There were no significant associations between model variables and parent medication adherence. For adult children, daughters had three times the odds of being adherent to medication (OR = 3.17, 95% CI = 1.33–7.54). Better hypertension knowledge was associated with 42% increased odds of being adherent (95% CI = 1.06–1.92); each additional chronic condition increased odds of being adherent by 32% (95% CI = 1.01–1.73). Being uninsured decreased the odds of medication adherence among adult children by 75% (95% CI = 0.08–0.84). Having a parent who believed that the child was taking better care of their blood pressure increased the odds of being adherent threefold (OR = 3.02, 95% CI = 1.11–8.24). The parent’s hypertension knowledge was associated with a 34% increased odds of being adherent to medication protocols (95% CI = 1.01–1.77).

Table 2.

Unadjusted Results for Sample Characteristics Predicting Medication Adherence among Older Parents and Adult Children

Older parents Adult children
OR (95% CI) OR (95% CI)
Sociodemographic characteristics
    Age (years) 1.02 (0.98–1.06) 1.03 (0.99–1.07)
    Gender (1 = female) 1.16 (0.38–3.48) 3.17 (1.33–7.54)
    Marital status (1 = married) 0.77 (0.32–1.89) 1.49 (0.64–3.47)
    Education (1 = 4-year degree or higher) 1.28 (0.44–3.69) 2.36 (0.95–5.87)
    Cultural beliefs 1.01 (1.00–1.02) 1.00 (0.99–1.02)
Health factors
    Hypertension knowledge score (range 1–9) 1.01 (0.77–1.34) 1.42 (1.06–1.92)
    Good self-efficacy to manage hypertension (1 = scoring 9 or better) 2.30 (0.92–5.75) 1.94 (0.84–4.47)
    Number of chronic conditions 1.08 (0.85–1.38) 1.32 (1.01–1.73)
    Health insurance status (1 = uninsured) 1.48 (0.15–14.79) 0.25 (0.08–0.84)
Dyad characteristics
    Proximity (1 = dyad lives together) 1.03 (0.41–2.56) 0.94 (0.40–2.21)
    Contact frequency (range 1–7 days) 1.00 (0.74–1.36) 1.03 (0.78–1.38)
    You and partner talk about hypertension (1 = yes) 1.37 (0.50–3.74) 1.81 (0.67–4.88)
    Dyad partner gender (1 = female) 0.80 (0.33–1.96) 2.03 (0.68–6.04)
    Partner’s belief about who takes better care of hypertension (1 = family member) 1.56 (0.66–3.70) 3.02 (1.11–8.24)
Partner health factors
    Partner’s hypertension knowledge score (range 1–9) 1.04 (0.78–1.39) 1.34 (1.01–1.77)
    Partner’s good self-efficacy to manage hypertension (1 = scoring 9 or better) 1.53 (0.62–3.78) 1.75 (0.77–3.98)
    Partner’s number of chronic conditions 1.08 (0.82–1.41) 1.25 (0.98–1.59)
    Partner’s medication adherence (1 = yes) 1.29 (0.55–3.06) 1.29 (0.55–3.06)
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Note: CI = confidence interval; OR = odds ratio.

In adjusted models for parents (see Table 3) when controlling for other individual characteristics (Model 1), having good self-efficacy to manage hypertension was associated with 2.5 times better odds of being adherent but not at conventional levels of significance (95% CI = 0.94–6.81). In Model 2, which adjusts for dyad characteristics and the child’s health factors, the magnitude of the association between self-efficacy (OR = 2.71, 95% CI = 0.93–7.95) and medication adherence increased. Having a college degree, being uninsured, and having an adult child who believed that you were taking better care of hypertension doubled the odds of parent medication adherence; however, results did not achieve statistical significance. In a reduced form (Model 3), good self-efficacy was only marginally associated with medication adherence (OR = 2.37, 95% CI = 0.92–6.02).

Table 3.

Adjusted ORs for Predictors of Older Parents’ Antihypertensive Medication Adherence

Model 1 OR (95% CI) Model 2 OR (95% CI) Model 3 OR (95% CI)
Sociodemographic characteristics
    Age (years) 1.03 (0.98–10.08) 1.04 (0.98–1.11)
    Gender (1 = female) 0.93 (0.26–3.31) 1.10 (0.26–4.63)
    Marital status (1 = married) 0.95 (0.34–2.71) 0.92 (0.29–2.86)
    Education (1 = 4-year degree or higher) 2.43 (0.69–8.58) 2.85 (0.71–11.39)
    Cultural beliefs 1.02 (1.00–1.03) 1.02 (1.00–1.04) 1.01 (1.00–1.03)
Health factors
    Hypertension knowledge score (range 1–9) 1.07 (0.78–1.49) 1.00 (0.69–1.46)
    Good self-efficacy to manage hypertension (1 = scoring 9 or better) 2.54 (0.94–6.81) 2.71 (0.93–7.95) 2.37 (0.93–6.02)
    Number of chronic conditions 1.12 (0.85–1.47) 1.17 (0.84–1.64)
    Health insurance status (1 = uninsured) 2.36 (0.16–35.35) 2.00 (0.06–71.84)
Dyad characteristics
    Proximity (1 = dyad lives together) 0.92 (0.30–2.79)
    Contact frequency (range 1–7 days) 0.96 (0.63–1.45)
    You and partner talk about hypertension (1 = yes) 1.45 (0.38–5.62)
    Dyad partner gender (1 = female) 0.39 (0.12–1.25)
    Partner’s marital status (1 = married) 0.49 (0.17–1.47)
    Partner’s belief about who takes better care of hypertension (1 = family member) 2.35 (0.75–7.32)
Partner health factors
    Partner’s hypertension knowledge score (range 1–9) 1.07 (0.75–1.54)
    Partner’s good self-efficacy to manage hypertension (1 = scoring 9 or better) 1.43 (0.45–4.47)
    Partner’s number of chronic conditions 0.98 (0.65–1.48)
    Partners medication adherence (1 = adherent) 1.53 (0.48–4.89)
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Note: CI = confidence interval; OR = odds ratio.

Table 4 shows the adjusted models for adult children. In Model 1, each additional chronic condition was associated with 47% increased odds of medication adherence when adjusting for other individual factors (95% CI = 1.03–2.10). In Model 2 when dyad and partner characteristics are added to the model, communication about hypertension within the dyad increases the child’s odds of medication adherence fourfold (OR = 4.22, 95% CI = 1.12–16.00). Having a parent who believed that the child was taking better care of his or her hypertension increased the odds of adherence 5.73 times (95% CI = 1.24–26.46). The parent’s knowledge of hypertension and having a parent with good self-efficacy to manage hypertension was weakly associated with increased odds of adherence among adult children (OR = 1.45, 95% CI = 0.99–2.11 and OR = 3.07, 95% CI = 0.86–11. 05, respectively). In the final model for adult children (Model 3), being a daughter increased the odds of medication adherence 3.29 times (95% CI = 1.26–8.59). Talking about hypertension within the dyad increased odds of medication adherence by 248% (OR = 3.48, 95% CI = 1.18–10.29). The parent’s hypertension knowledge also affected the child’s medication adherence, increasing the child’s odds by 35% (95% CI = 0.99–1.84). Having a parent who believed that the child was doing a better job of caring for his or her hypertension increased odds of being adherent by four times (OR = 4.36, 95% CI = 1.34–14.17). Having a parent with good self-efficacy to manage hypertension increased the odds of an adult child’s adherence by 2.59 times with a trend toward significance (95% CI = 0.94–7.12).

Table 4.

Adjusted ORs for Predictors of Adult Children’s Antihypertensive Medication Adherence

Model 1 OR (95% CI) Model 2 OR (95% CI) Model 3 OR (95% CI)
Sociodemographic characteristics
    Age (years) 1.00 (0.95–1.05) 1.01 (0.95–1.08)
    Gender (1 = female) 2.25 (0.82–6.18) 2.88 (0.86–9.61) 3.29 (1.26–8.59)
    Marital status (1 = married) 1.74 (0.63–4.86) 1.67 (0.46–6.08)
    Education (1 = 4-year degree or higher) 1.82 (0.57–5.77) 1.40 (0.34–5.74)
    Cultural beliefs 1.00 (0.99–1.02) 1.00 (0.98–1.02)
Health factors
    Hypertension knowledge score (range 1–9) 1.22 (0.86–1.74) 1.17 (0.78–1.76)
    Good self-efficacy to manage hypertension (1 = scoring 9 or better) 2.19 (0.81–5.92) 1.60 (0.51–5.05)
    Number of chronic conditions 1.47 (1.03–2.10) 1.36 (0.89–2.08)
    Health insurance status (1 = uninsured) 0.47 (0.12–1.78) 0.90 (0.18–4.39)
Dyad characteristics
    Proximity (1 = dyad lives together) 1.17 (0.32–4.27)
    Contact frequency (range 1–7 days) 0.96 (0.62–1.49)
    You and partner talk about hypertension (1 = yes) 4.22 (1.12–16.00) 3.48 (1.18–10.29)
    Dyad partner gender (1 = female) 1.86 (0.35–9.99)
    Partner’s marital status (1 = married) 1.08 (0.30–3.89)
Partner’s belief about who takes better care of hypertension (1 = family member) 5.73 (1.24–26.46) 4.36 (1.34–14.17)
Partner health factors
    Partner’s hypertension knowledge score (range 1–9) 1.45 (.99–2.11) 1.35 (0.99–1.84)
    Partner’s good self-efficacy to manage hypertension (1 = scoring 9 or better) 3.07 (0.86–11.05) 2.59 (0.94–7.12)
    Partner’s number of chronic conditions 1.24 (0.90–1.72)
    Partner’s medication adherence (1 = adherent) 1.48 (0.46–4.74)
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Note: CI = confidence interval; OR = odds ratio.

Discussion

This study examined the influence in the form of informational support that parents and adult children have on each other’s medication adherence for hypertension. We found evidence to support our hypothesis for a downward transmission of intergenerational self-care from parents to adult children. Parents’ beliefs in their child’s better ability to manage hypertension and children’s perceptions of communication about hypertension between the dyad partners were associated with adult children’s medication adherence. Parental knowledge and self-efficacy were also modestly associated with medication adherence in adult children. The child’s gender was the only individual characteristic associated with adult children’s medication adherence, suggesting that in this sample, it was primarily a parental influence that affected adult children’s adherence—a partner effect (Lewis et al., 2006). We found no support for the hypothesis of an upward transmission of self-care informational support.

These findings support previous work with older African American women who reported using family members’ health experiences as a form of passive informational support (Warren-Findlow & Issel, 2010). This study suggests that older parents directly influence adult children through conversation and knowledge about hypertension self-care. Other research has found that among African American and White older adults, informational support for chronic illness self-care was associated with friends but not with family (Gallant et al., 2007). Becker and colleagues (2004) report that self-care advice was shared between parents and adult children, although both parties did not necessarily have a shared health condition. Reliance on informal sources of information rather than physicians may occur among African Americans because of continued distrust of health care providers (Musa, Schulz, Harris, Silverman, & Thomas, 2009) or poor provider communication (Schoenthaler, Chaplin, et al., 2009).

Contrary to previous research, we did not find strong support for the role of hypertension self-efficacy in predicting individual medication adherence (Fernandez et al., 2008; Kressin et al., 2007; Schoenthaler, Ogedegbe, et al., 2009). There was a consistent association between parent self-efficacy and parent medication adherence in all three models; however, conventional levels of significance were not achieved. We may not have seen an association because our measure of self-efficacy, while specific to managing hypertension, was not specific to medication adherence as in previous studies. We wanted a broader measure of hypertension self-efficacy because we were assessing multiple hypertension self-care activities in addition to medication adherence.

Surprisingly, the dyad partner’s actual medication adherence behavior was not a factor in an individual’s medication adherence, which has been suggested in previous research with African Americans (Ogedegbe, Harrison, Robbins, Mancuso, & Allegrante, 2004). In this study, daughters with hypertension were influenced by their parents but parents were not influenced by their daughters, contrary to previous studies (Gallant et al., 2010; Laditka & Laditka, 2001; Shapiro, 2004). Our findings did not indicate that proximity or frequency of contact were associated with self-care among the dyad partners (Shapiro, 2004; Szinovacz & Davey, 2001). Our results indicated a high level of contact between parents and adult children with over 70% of dyads talking or meeting on 6 of 7 days.

Strengths and Limitations

A major strength of this study is the use of theory to guide the research and analyses. The study also extended the Theory of Interdependence by incorporating concepts from social network theory to help operationalize some important aspects of the theory. The study used a validated scale to measure medication adherence with a much more conservative criterion for what constitutes adherence. Further we focused on a specific relationship within the family, older parent–adult child. Many studies on social support examine support received from any family member or focus exclusively on spousal support. Also unique to this sample, both partners shared the same chronic condition, which has not been previously reported in the literature.

This study was exploratory and lacks a sufficient sample size that would facilitate more sophisticated statistical analyses, such as hierarchical linear modeling. Similarly within each partner group, we had relatively small numbers that may affect our results. The sample was overwhelmingly female and so results related to men must be interpreted with caution. The study sample was diverse in terms of age and socioeconomic status. However, participants were primarily from an urban Southern city, and these findings may not be generalizable to African Americans from other geographic regions or rural areas. Because enrollment in the study required one partner to recruit the other partner, the older parent–adult child dyads in this sample may be more actively involved with each other; this unique quality of the sample limits the possibilities for generalization. We did not have systematic data on participants’ other family members with hypertension. These individuals may also exert influence on medication adherence. We were unable to fully test the conceptual model because of inconsistent data on the length of time members of the dyads knew about their hypertension. Consequently, nothing can be reported on how relative length of personal history with hypertension affected the influence on the other member of the dyad. Furthermore, nothing is known about whether one member of the dyad influenced the other in having the hypertension diagnosed. Future studies would be stronger if they incorporated the history of disease among dyad members and members’ interactions over time with respect to the disease and its treatment. This study used a cross-sectional design that prevents us from making any conclusions about causality.

Conclusions

This study advances the research on the Theory of Interdependence by including additional dyadic characteristics and assessing a two-way relationship. These findings also contribute to the literature on intergenerational transmission of chronic illness self-care. The influence of African American older adults on adult children’s self-care suggests new opportunities for health promotion interventions targeted to hypertension self-care. Interventions with older parents will improve their individual knowledge and self-efficacy and can empower them as a catalyst for good self-care within the family. For clinicians, these results suggest the importance of obtaining a complete family history of living African American family members who are also managing hypertension as they may be important actors in supporting patients’ self-care. The ability to intervene with one family member and potentially have a positive effect on other family members could double the reach of self-care interventions and possibly their cost-effectiveness.

Funding

This work was supported by the National Institute on Aging (R03 AG030523).

Acknowledgments

The authors would like to thank Drs Sarah Laditka and Ahmed Arif for their comments on this manuscript.

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