Date of Award

January 2013

Document Type


Degree Name

Medical Doctor (MD)



First Advisor

Christopher Ruser

Subject Area(s)

Medicine, Education



Essential hypertension is the most common primary diagnosis in the US, with myriad and

serious sequelae inflicting significant morbidity upon individuals and economic losses

upon society. Estimates of adherence to prescribed medication regimens range from 20%

to 60%. Because hypertension is largely asymptomatic, patients may underestimate both

the benefits of adherence and the costs of nonadherence. This novel educational

intervention seeks to encourage adherent behavior by providing patients with a conscious

manifestation of their disease severity through manipulation of pressurized balls.


Randomized controlled pilot trial of patients under treatment for hypertension with SBP

≥140mmHg or DBP ≥90mmHg at index visit, selected by convenience sample at a VA

Primary Care Clinic. Baseline clinical, demographic, medication taking habits and

motivation data obtained by surveys and chart abstraction. All subjects received a short

talk on the dangers of hypertension. Intervention Group subjects simultaneously

squeezed rubber balls in each hand filled to air pressures differing by the same amount

that their current SBP exceeded 120mmHg. Followup medication taking habits,

motivation, medication possession ratios and blood pressure measurements were

determined by telephone survey, pharmacy and clinical records over 90-, 180-, 270- and

360-day time periods. Feasibility of a larger study was determined by structured

interviews with a physician and nurse who employed the intervention in clinical practice.


Thirty subjects were enrolled into Intervention and Control Groups of equal size.

Immediate motivational impact by 7-point scale significantly favored the Intervention

(6.3, p < 0.001 vs 4.3, p = 0.164). Change in self-reported adherence on an 8-point scale

at 90-days favored the Intervention but was not significant (0.5, p = 0.372 vs -0.1, p =

0.798). Change in 360-day medication possession ratio favored the Intervention and

approached significance (11.3%, p = 0.088 vs 0.7%, p = 0.934). Both Groups

demonstrated clinically relevant improvements in MAP with greater magnitude, duration

and significance for the Intervention Group through 360 days (-12.2mmHg, p = 0.008 vs

-6.0mmHg, p = 0.164). Larger improvements in adherence were significantly associated

with greater baseline motivation and immediate motivational impact from the

intervention while longer disease experiences were associated with less improvement.

Clinicians reported favorable reception from their patients and felt that the intervention

represented a simple and helpful tool that they would use in everyday practice.


The results of this pilot trial suggest that a novel, brief educational intervention designed

to provide a somatosensory manifestation of an otherwise asymptomatic disease process

may show promise in promoting adherent behavior and clinically useful reductions in

blood pressure in patients with poorly controlled hypertension. A larger study appears

feasible and is required to confirm and investigate the statistical significance of these