Using Complementary and Integrative Medicine to Treat High Blood Pressure in African Americans in the United States: Impact of Knowledge,Beliefs,Attitudes,and Behaviors

Abstract

Background:

African Americans have the highest prevalence of high blood pressure (HBP) in the United States, but the lowest blood pressure control rates among all major racial/ethnic groups. This study examined the extent to which African Americans use home remedies to treat HBP and assessed their knowledge, beliefs, attitudes, and behaviors regarding such use.

Materials and Methods:

This study utilized a descriptive, exploratory, cross-sectional, and correlational research design. We determined the association between knowledge, beliefs, attitudes, and behaviors and use of home remedies among participants using a principal investigator-developed online questionnaire entitled the Beliefs about Hypertension Survey (BHS).

Results:

Reliability for the BHS representing all four dependent variables was good (Cronbach's α = 0.848). The study sample was 254 African Americans with and without HBP (79.9% females; 83% aged 30–59). Participants were more willing to use home remedies to treat rather than to prevent HBP, with 58% of participants with HBP reporting current use of home remedies as treatment. Results of the Multivariate Analysis of Variance test indicated statistical significance (P = 0.000) only for the behavior variable (α = 0.05), with no significant differences found between participants with and without HBP with respect to knowledge, beliefs, and attitudes.

Conclusion:

The results suggest that diagnosis of HBP increases African Americans' willingness to use home remedies, but this group needs more education about the effects and risk factors of HBP. Further evidence-based studies will help to increase knowledge and acceptance of home remedies as a viable treatment option for HBP.

Introduction

African Americans have the highest prevalence of high blood pressure (HBP) in the United States,^1

–5 but only 45% of those who use prescription medicine attain blood pressure (BP) control.⁴ The risk of death due to stroke is twice as great for African Americans compared to Whites, primarily due to the lack of BP control in African Americans.⁶ Previous studies suggest that African Americans are using complementary and integrative medicine (CIM) more often to treat health problems, especially chronic illnesses such as HBP.^7,8 This is especially true for home remedies,⁷ hence the focus of this type of CIM in this study. African Americans are more likely to use home remedies as a complement to prescription medicine,^7,8 with an estimated CIM use of 67.6%–71.3%.⁸ Previous studies also indicate that the use of CIM by African Americans is greatly affected by their health beliefs, current geographic location, culture, income, family size, country of origin, education level, and socio-economic status.^5,7,8

CIM are medical and health care systems, practices, and products that can replace or be used with traditional allopathic approaches and are not currently part of conventional medicine.⁹ HBP is defined as consistent BP readings of 130 mm Hg systolic pressure or higher or 80 mm Hg diastolic pressure or higher.^10
–12

A home remedy, also called a folk or natural remedy, is a traditional therapy that uses natural products, nutritional supplements, or physical measures.¹³ These remedies can be divided into food products and readily available non-food products and include herbs, animal byproducts, spiritual practices/religious conviction, and naturopathic therapy.¹⁴ African Americans typically use the term to describe the food items (e.g., garlic, ginger and leafy green vegetables), herbal medicines (e.g., herbal or green tea) and lifestyle habits (e.g., eating healthy foods and praying) that they utilize to treat chronic diseases and other ailments.

The most common home remedies used by African Americans in general are garlic, honey, herbs, green tea, spices, prayer, meditation, music, exercise, fruits and leafy green vegetables.¹⁵ Fruits and leafy green vegetables, such as spinach and collards, are high in potassium, a mineral known to lower BP.¹⁶ Clinical evidence also indicate that garlic,^17,18 green tea,¹⁹ and regular physical activity are also effective ways to lower BP.²⁰ A diet rich in fresh fruits and vegetables can also help reduce the risk of HBP and other health problems, as previous studies have shown.^21,22 These remedies are also cheaper, more accessible, and have fewer side effects than prescription medications.

The primary purpose of this study was to determine the impact of knowledge, beliefs, attitudes, and behaviors on African Americans' use of home remedies to treat HBP using a novel survey instrument.

Materials and Methods

This study was approved by the Institutional Review Board at Seton Hall University. A descriptive, exploratory, cross-sectional, and correlational research design was utilized, and a principal investigator-developed online questionnaire entitled the Beliefs About Hypertension Survey (BHS) was used for data collection. The tool was created and validated through several rounds of the Delphi Technique by a panel of experts.²³ Data were collected from July to September 2020. Demographic data collected included age, race/ethnicity, gender, education level, marital status, and country or U.S. state of origin. It was hypothesized that the knowledge, beliefs, attitudes, and behaviors of African Americans would affect their use of home remedies to some extent, regardless of BP status.

Eligible participants were Black/African American, 18 years or older, current U.S. residents, and were able to read and understand English. Individuals who did not meet these criteria were excluded from participating in the study. An a priori G*Power Analysis for F-test Multivariate Analysis of Variance (MANOVA) Global Effects²⁴ was used to calculate the required sample size of 204 participants, while 15% was added to account for attrition, which resulted in a total required sample size of 235 participants. Significance was determined at α = 0.05. The independent variables of this study were African Americans with HBP and African Americans without HBP, while the dependent variables were knowledge, beliefs, attitudes, and behaviors.

Participants completed all 47 questions of the BHS via SurveyMonkey. Data analysis was conducted using Microsoft SPSS software version 26.^25,26 Validity and reliability of the BHS were established using the Delphi Technique, Cronbach's Alpha, and Exploratory Factor Analysis (EFA).^25,27 Participants were recruited via social media outlets (Facebook^® and WhatsApp^®) and snowball sampling. The results were analyzed using MANOVA, follow-up univariate analyses of variance (ANOVAs), Pearson's and Spearman's rank correlation, scatter plots, and the inductive approach to create themes for the qualitative data.²⁶

Results

The Cronbach's alpha score for all the variables (with a total of 50 items) is 0.848, which is considered a good reliability score for a survey instrument.²⁶ A total of 254 African Americans participated in the study; 203 females and 51 males. One hundred thirty-five participants reported that they had HBP, while 119 participants reported that they did not have HBP. Most participants were between 30 and 59 years old (83%), and 72% reported having a graduate or doctoral degree. Study participants were well dispersed across the United States, representing a total of 35 states.

Thirty-six percent of participants reported using home remedies to treat their HBP, while 48% said they used prescription medicine as treatment, which suggests that African Americans are more likely to take prescription medicine than CIM to treat HBP (Table 1). The results also indicated that 91% of participants were somewhat knowledgeable about HBP, however, over 71% believed that HBP can not only be treated, but can also be cured.

Table 1.

Participants' Reported Use of Home Remedies and Prescription Medicine to Treat High Blood Pressure

	No. of participants who reported use of home remedies to treat HBP	No. of participants who reported use of prescription medicine to treat HBP
Answer choices
Yes	92	122
No/unsure	84	52
Not Applicable	78	80

Participants who selected “not applicable” are those who reported that they do not have high blood pressure.

HBP, high blood pressure.

While 91% of participants reported having at least one blood relative who has HBP, 94% also reported knowing others with HBP who they are not related to, which further indicates how prevalent this chronic disease is in this population. The most common ways in which participants manage their HBP are shown below (Table 2). A list of the most common types of CIM that are generally used to treat HBP is also shown (Table 3).

Table 2.

How Study Participants Manage Their High Blood Pressure

Answer choices	Responses (no. of participants)	Responses (percentage of participants)
Category
I take home remedies^a	71	27.95
I take prescription medicine^b	95	37.40
I eat healthy foods^c	96	37.80
I exercise regularly^d	74	29.13
All of the above apply to me	32	12.60
I do not take any medication^e	19	7.48
I have not changed my lifestyle habits^f	12	4.72
I do not have HBP^g	116	46.67
Other (please specify)^h	12	4.72

Study participants were asked: “How do you manage your high blood pressure?” Participants had the option to select more than one answer choice, hence the total responses exceed the total number of study participants.

Categorized as medications or tonics that are administered without prescription or professional supervision and have no proof of effectiveness.

Categorized as any conventional or mainstream medicine that was prescribed by a medical doctor or other qualified health care professional.

It was left up to participants' perception and discretion to determine what they considered healthy foods.

It was left up to participants' perception and discretion to determine what they considered to be regular exercise.

Medication in this context is defined as any conventional medicine that was prescribed by a clinician.

Categorized as any habitual behaviors that affect one's health either immediately or gradually.

Defined as consistent blood pressure readings of 130 mm Hg systolic pressure or higher, or 80 mm Hg diastolic pressure or higher.

Participants were given the option to indicate other ways in which they manage their HBP. Those indicated included “irregular exercise and diet,” “…I was diagnosed once but I took the medications and some home remedies, and it has been normal since,” and “I do what is generally required for good health with eating, exercise and controlling environment. Nothing specifically to reduce blood pressure.”

Table 3.

Complementary and Integrative Medicine Techniques Used to Treat High Blood Pressure

Item	Which of the following techniques/food items used to treat HBP? (no. of participants who selected each item) (N = 252)	Which of the following techniques/food items do you use to treat your HBP? (no. of participants who selected each item) (N = 248)
Technique
Lifestyle and Nutritional Counseling^a	167	48
Garlic and herbs	154	51
Herbal tea	127	45
Leafy green Vegetables	133	58
Prayer	115	55
Meditation	132	51
Yoga	117	23
Oatmeal	56	23
Ginger	97	31
Massage	69	33
Music	64	33
Bananas	37	26
Cucumbers	45	20
Berries	39	19
Red beets	42	11

Participants had the option to select more than one response item for both questions. Less common techniques included the use of onions, dried seeds, skim milk and/or yogurt, pomegranates, cannabis, dark chocolate, olive oil, cinnamon, alcohol, scallions, seafood, and pistachios. For the second question, 125 participants (of the 248) reported that they do not have HBP.

Categorized as focusing on one's nutrition, behavior, and fitness with the support of a health coach, dietician, or other member of a medical team to help the individual make better choices to prevent or manage a chronic disease.

A small positive linear relationship (r = 0.150) was found between the behaviors of study participants regarding HBP and their use of home remedies as treatment in the last 12 months.²⁶ The results also indicate a small positive linear relationship (r = 0.225) between participants' beliefs and attitudes toward the use of home remedies as treatment for HBP.¹⁹ A small positive linear association was also found between the other variables. However, a significant relationship was found between current use of home remedies to treat HBP and the use of home remedies to treat the condition in the last 12 months (r = 0.916). No significant relationship was found between current or recent use of home remedies to treat HBP and the variables knowledge, beliefs, and attitudes.

The results of the Pearson's and Spearman's Correlation Coefficients indicated very small correlations between the variables, so to ensure accuracy of these results, scatter plots were also graphed, and these confirmed the results of the correlation coefficients. The lines of best fit indicated that behavior was the only variable that has a moderate positive linear relationship with current use of home remedies and use of home remedies in the past 12 months to treat HBP. Behavior was also the only variable with either a moderate positive linear relationship or a trend toward a positive linear relationship with all the other variables. The scatter plots with lines of best fit further indicated a moderate positive relationship between behaviors and knowledge, and between beliefs and attitudes, and a trend toward a positive linear relationship between behaviors and attitudes, and between beliefs and behaviors.

Based on the MANOVA values for the dependent variables, a significant difference, where P = 0.000 (95% confidence interval), was found for only one variable, behaviors (Table 4). The univariate ANOVA follow-up test also confirmed that a significant difference between the groups (P = 0.000; 95% confidence interval) was evident only for the behaviors variable. There were no significant differences found between participants with HBP and those without HBP with respect to the knowledge, beliefs, and attitudes variables regarding the use of home remedies as treatment. The post-hoc analysis was also calculated using MANOVA Global Effects and the power of the sample size obtained was 1.000, which indicates that this study was highly powered.^28,29

Table 4.

Multivariate Analysis of Variance for All Four Dependent Variables

Tests of between subjects effects
Source	Dependent variable	Type III sum of squares	Degree of freedom	Mean square	F	Significance	Partial eta squared	Noncentrality parameter	Observed power^e
Groups
	Knowledge_v	4.635	1	4.635	1.370	0.243	0.005	1.370	0.215
	Attitudes_v	52.167	1	52.167	1.367	0.243	0.005	1.367	0.214
	Beliefs_v	322.265	1	322.265	3.242	0.073	0.013	3.242	0.434
	Behaviors_v	40150.546	1	40150.546	1990.569	0.000	0.888	1990.569	1.000

F-value is an indication of the significance of the difference between the means of two groups.

Discussion

We expected that all four dependent variables would affect African Americans' use of home remedies to treat HBP, but the results indicate that behavior was the only variable that has a significant impact on such use. A significant difference was found between the behaviors of African Americans with HBP and those without the condition. Participants with HBP were more likely to use home remedies than those without the condition, indicating that home remedies are more popular as a treatment for HBP rather than as a preventive measure against the condition.

The results indicate that the most popular home remedies used by African Americans to treat HBP are garlic, herbs, leafy green vegetables, prayer, meditation and support from professionals (e.g., a dietitian) to maintain healthy lifestyle habits (Table 3). The use of these remedies is usually encouraged by stories or rituals told within families, locally, or that are culturally accepted.¹⁴ The use of home remedies from generation to generation within families contributes to their popularity among this population.

Even though participants were found to be quite knowledgeable about HBP, 71% indicated that they believe HBP can be cured, indicating that this population needs additional education about this condition and other chronic diseases, since chronic diseases can be treated, but they cannot be cured. Participants also commented that it would be beneficial for the African American community to receive education on the use of home remedies as treatment for HBP. Educating African Americans about HBP and home remedies that they can use to effectively treat the condition may help change their attitude and behavior toward HBP and reduce some of the mistrust many African Americans have in the health care system.⁴ This mistrust often results in some African Americans not taking their HBP medications as prescribed due to fear of the possible side effects of these medications.⁴ Finding more effective ways to educate this population about HBP and different treatment options, such as home remedies, may lead to a mindset shift, which would enable them to start taking proactive steps to significantly reduce their risk of diagnosis.

Physicians and other health care professionals may benefit from formal training on home remedies and the efficacy of their use to treat different health conditions during their initial medical training or during refresher courses throughout their medical careers. This would likely help health care providers feel more comfortable and confident talking to their patients about these treatment options. A previous study found that 86.6% of non-physician practitioners, such as nurse practitioners, were more favorable toward the use of CIM as treatment for patients in comparison to physicians.³⁰ Additionally, the authors also found that physicians and other health care professionals may benefit from traditional allopathic curricula that incorporate teachings in holistic medicine.³⁰ This may also help African American patients feel more comfortable with their providers which, in turn, may result in them talking to those providers about any home remedies that they may already be taking, thereby giving the providers the opportunity to provide relevant guidance to those patients. Currently, 48% of practitioners in large U.S. hospitals do not know if CIM is being discussed with or recommended to their patients.³¹

The results also indicate that the more favorable participants' beliefs were regarding the benefits of using home remedies to treat HBP, the more favorable were their attitudes toward such use. Furthermore, the more knowledgeable participants were about HBP, the more likely they were to change their behaviors to reduce their risk of diagnosis and the more likely those already diagnosed with the condition were to use home remedies as treatment. In fact, 78% of study participants who do not have HBP stated that they would be willing to take home remedies to reduce their risk of diagnosis. African Americans who have chronic conditions are much more likely to use CIM than not.⁸ The results indicate that African Americans are more willing to adopt healthy lifestyle habits after HBP diagnosis than they are to taking preventive action. This suggests that HBP diagnosis is a gamechanger for African Americans in terms of lifestyle habits.

The results also indicate that African Americans are more likely to use home remedies together with prescription medicine rather than as an alternative to the same, which supports previous literature on this topic.^2
–4,8 No significant relationship was found between the knowledge, beliefs and attitudes of African Americans regarding HBP and their use of home remedies as treatment. The insignificance found between these variables may have been because most of the participants had a similar educational background. Furthermore, previous studies indicate that many African Americans do not consider HBP to be a serious condition and so may think it is unnecessary to take preventive measures to lower their risk of HBP diagnosis, especially if they do not consider themselves to be susceptible to the condition.^3,4,7,8,32

The belief that HBP is not a serious condition and that it can be cured are the likely reasons why home remedies are more popular as a treatment for HBP rather than as a preventive measure against the condition, since this viewpoint may have resulted in African Americans not being motivated to take action to prevent a HBP diagnosis. However, if these individuals are eventually diagnosed with the condition and start suffering from its effects, it is likely that they would then realize its severity, which would motivate them to change their behaviors to limit the effects they experience from the condition.

There was also a gender gap between study participants, with 203 females and 51 males. This result supports the findings of Smith³³ who explored the reasons why more females than males tend to participate in research studies that are conducted online, regardless of the topic of the study. After examining the relationship between online survey non-response and various demographic factors, including gender, it was found that females are much more likely to respond to online surveys than males and it was inferred that this is because females spend more time online than their male counterparts.³⁴ The results of such studies may therefore include gender bias.³⁵

Seventy-two percent (72%) of study participants self-reported that they had a master's or doctoral degree.³⁵ In 2008, only 19.6% of African Americans over the age of 25 years old in the United States held any type of college degree, with 58% of those being African American women.³⁵ There was, therefore, an education gap between most of the African Americans who participated in this study and the general African American population in the United States. This may also account for why most participants were quite knowledgeable about HBP. The literature review also indicated that individuals with a high level of education are more likely to use home remedies than individuals who are less educated and have a low socio-economic status,^2,35
–37 which may further explain why most study participants indicated their willingness to start using home remedies either as a treatment or as a preventive measure against HBP diagnosis.

There were several limitations of this study, including the fact that the results are not generalizable to all African Americans because this was just one cross-sectional study in time and the education levels of participants were not representative of the general African American population in the United States. The results of some of the dependent variables may also have been affected by confounding variables, such as religion, age, socio-economic status, gender, and marital status.

Conclusion

An estimated 55% of African American adults in the United States have HBP. This chronic disease develops in this group of people at a younger age, and its effects are more severe in African Americans than in any other major racial/ethnic group in the country.¹ Previous studies suggest that the inadequate BP control in African Americans may be the result of the excessive and disproportionate prevalence of HBP and the high frequency of conditions that may occur and/or re-occur at the same time, such as diabetes and chronic kidney disease.^2
–4,37 Other possible factors affecting BP control in African Americans include the lack of effective conventional medicine as treatment, not taking the condition seriously, and non-adherence to prescription medication.^{3,4,32,35
–37}

Future research could examine knowledge, beliefs, attitudes, and behaviors in a larger sample size of African Americans with more educational diversity as well as in an international population. A comparative study can also be conducted between African American males and females to determine any differences between both genders regarding the four domains that were addressed in this study. We also recommend that a similar study be conducted on other racial and/or ethnic groups to determine how HBP is treated and controlled among other racial or ethnic groups in comparison to the African American community. The African American community would likely benefit from these studies because they would shed light on the many disadvantages that exist in this population and the inequity of care, which is a factor that affects the treatment and control of HBP in this group. It is our hope that future studies of this nature will bring about policy changes that will make it easier for African Americans to get the care and treatment they need to lower the incidence and prevalence of HBP and other chronic diseases in their communities.

Understanding more about the knowledge, beliefs, attitudes, and behaviors of African Americans regarding HBP and their use of home remedies as treatment provides more insight into effective preventive measures that can be used to reduce the incidence and prevalence of this condition in this population. The results of this study further suggest that home remedies may be an effective complementary/integrative treatment option for HBP in African Americans and, as such, if these remedies are made known on a wide scale to the general public and are promoted for use by Federal, State and local government agencies, as well as by clinicians and other health care professionals, we may very well see a decrease in the morbidity and mortality rates caused by HBP in this population.

Footnotes

Acknowledgments

The novel survey instrument that was created for this research project was done with the support of Denese Lewis, Dr. Siddian Brady-Brown, Dr. Odler Jeanlouie, and Dr. Terrence Cahill who served on the Delphi Panel and who significantly contributed to the success of this project.

Disclaimer

The content is solely the responsibility of the authors and does not necessarily represent the views of the affiliated institutions. No copyrighted materials were adapted or reused in this article.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.▪

References

American Heart Association. High Blood Pressure Among Black People. Online document at: https://www.heart.org/en/health-topics/high-blood-pressure/why-high-blood-pressure-is-a-silent-killer/high-blood-pressure-and-african-americans Accessed July 13, 2022 .

, Lynch

, Claas

, et al. The effects of genes implicated in cardiovascular disease on blood-pressure response to treatment among treatment-naïve hypertensive African Americans in the GenHAT study. J Hum Hypertens, 2016; 30:549–554.

Flack

, Sica

, Bakris

, et al. ISHIB consensus statement—Management of high blood pressure in Blacks. Hypertension, 2010; 56:780–800.

Flack

, Nasser

, Levy

. Therapy of hypertension in African Americans. Am J Cardiovasc Drugs, 2011; 11:83–92.

Maraboto

, Ferdinand

. Update on hypertension in African Americans. Progr Cardiovasc Dis, 2020; 63:33–39.

Schober

, Tate

, Rodriguez

, et al. High blood pressure medication adherence among urban, African Americans in the Midwest United States. J Racial Ethn Health Disparities, 2021; 8:607–617.

Ernst

, Cassileth

. The prevalence of complementary/alternative medicine in cancer: A systematic review. Cancer, 1998; 83:777–782.

Barner

, Bohman

, Brown

, Richards

. Use of complementary and alternative medicine (CAM) for treatment among African Americans: A multivariate analysis. Res Soc Admin Pharm, 2010; 6:196–208.

Fouladbakhsh

, Stommel

. Using the behavioral model for complementary and alternative medicine: The CAM healthcare model. J Complement Altern Med, 2007; 4(1):1–18.

10.

Ferdinand

, Nedunchezhian

, Ferdinand

. Hypertension in African Americans: Advances in community outreach and public health approaches. Prog Cardiovasc Dis, 2020; 63:40–45.

11.

American Heart Association. The Facts About High Blood Pressure. Online document at: https://www.heart.org/en/health-topics/high-blood-pressure/the-facts-about-high-blood-pressure Accessed July 13, 2022 .

12.

Centers for Disease Control and Prevention. Facts About Hypertension. Online document at: https://www.cdc.gov/bloodpressure/facts.htm Accessed July 15, 2022 .

13.

National Institutes of Health. High Blood Pressure. National Heart, Lung, and Blood Institute. Online document at: https://www.nhlbi.nih.gov/health-topics/high-blood-pressure Accessed July 25, 2022 .

14.

Medical Dictionary. Home Remedy. Online document at: https://medical-dictionary.thefreedictionary.com/Home+remedies Accessed May 7, 2023 .

15.

Arcury

, Bell

, Snively

, et al. Complementary and alternative medicine use as health self-management: Rural older adults with diabetes. J Gerontol B Psychol Sci Soc Sci, 2006; 61:S62–S70.

16.

Harley

. Indigenous healing practices among rural elderly African Americans. Int J Disabil Dev Educ, 2006; 53:433–452.

17.

Davis

. The Health Risks of a High Sodium, Low Potassium Diet. 2023. Online document at: https://www.parentgiving.com/blogs/patient-daily-living/health-risks-high-sodium-low-potassium-diet Accessed May 8, 2023 .

18.

Ried

. Garlic lowers blood pressure in hypertensive subjects, improves arterial stiffness and gut microbiota: A review and meta-analysis. Exp Ther Med, 2020; 19:1472–1478.

19.

Cleveland Clinic. Does Garlic Lower Blood Pressure. Online document at: https://health.clevelandclinic.org/garlic-for-blood-pressure/ Accessed May 8, 2023 .

20.

Peng

, Zhou

, Wang

, et al. Effect of green tea consumption on blood pressure: A meta-analysis of 13 randomized controlled trials. Sci Rep, 2014; 4:6251.

21.

American Heart Association. Getting Active to Control High Blood Pressure. Online document at: https://www.heart.org/en/health-topics/high-blood-pressure/changes-you-can-make-to-manage-high-blood-pressure/getting-active-to-control-high-blood-pressure Accessed May 7, 2023 .

22.

Borgi

, Muraki

, Satija

, et al. Fruit and vegetable consumption and the incidence of hypertension in three prospective cohort studies. Hypertension, 2016; 67:288–293.

23.

Blood Pressure UK. Fruits and Vegetables and Your Blood Pressure. 2021. Online document at: https://www.bloodpressureuk.org/your-blood-pressure/how-to-lower-your-blood-pressure/healthy-eating/fruit-and-vegetables-and-your-blood-pressure/#:∼:text=Fruit%20and%20vegetables%20help%20to,which%20keep%20your%20body%20healthy Accessed May 7, 2023 .

24.

Hasson

, Keeney

, McKenna

. Research guidelines for the Delphi survey technique. J Adv Nurs, 2000; 32:1008–1015.

25.

Field

. Discovering Statistics Using IBM SPSS Statistics, 4th ed. Los Angeles, CA: Sage Publications, 2015.

26.

George

, Mallery

. SPSS for Windows Step by Step: A Simple Guide and Reference. 18.0 Update, 11th ed. Boston, MA: Allyn & Bacon, 2011.

27.

Cohen

. Statistical power analysis. Curr Dir Psychol Sci, 1992; 1:98–101.

28.

Ellis

. The Essential Guide to Effect Sizes. London, United Kingdom: Cambridge University Press, 2010.

29.

Faul

, Erdfelder

, Buchner

, Lang

. Statistical power analyses using G*Power 3.1: Tests for correlation and regression analyses. Behav Res Methods, 2009; 41:1149–1160.

30.

Franco

, DeLuca

, Cahill

, Cabell

. Why practitioners should care about music therapy: Understanding its clinical relevance and practical implications through an evidence-based study. Altern Complement Ther, 2018; 24:63–77.

31.

Franco

, DeLuca

. Practitioners' awareness of complementary and alternative medicine practices within Interprofessional Healthcare Teams in Institutions. Health Interprof Pract Educ, 2020; 4:eP2107.

32.

Marshall

, Wolfe

CDA

, McKevitt

. Lay perspectives on hypertension and drug adherence: A systematic review of qualitative research. BMJ, 2012; 34:39–53.

33.

Smith

African Americans and Technology Use: A Demographic Portrait. Pew Center Research. Online document at: https://www.pewresearch.org/internet/2014/01/06/African-americans-and-technology-use/ Accessed January 14, 2021 .

34.

Saunders

, Johnson

. Contemporary Diagnosis and Management of Hypertension in African Americans, 3rd ed. Newton, PA: Associates in Medical marketing Co., Inc., 2009.

35.

Journal of Blacks in Higher Education. News and Views. Online document at: https://www.jbhe.com/news_views/64_degrees.html Accessed December 29, 2020 .

36.

O'Brien

, Parati

, Stergiou

, et al. European society of hypertension position on paper ambulatory blood pressure monitoring. J Hypertens, 2013; 31:1731–1768.

37.

Pickett

, Allen

, Franklin

, Peters

. Illness beliefs in African Americans with hypertension. West J Nurs Res, 2014; 36:152–170.