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. , Ｎｏ２. , ２０１０<Original Article>

A Cross Cultural Comparison of Knowledge of Hypertension,
Health Promoting Lifestyle, and Spirituality in Residents
with Hypertension from Iwate Japan and Southeastern
North Carolina USA
1)

Jeanne Kemppainen

1)

4)

Yuriko Kanematsu

Kazuko Kikuchi
4)Michiko Tsuboyama

Kyoko Noguchi
1)2)Perri Bomar)

5)

Iwate Seiwa Hospital

4)

Akiko Ando

5)

6)

Sumiko Chiba

University of North Carolina Wilmington
3)3)

Hiroaki Ambo

2)

Iwate Prefectural University

Former Iwate Prefectural University

Kobe Continuing Education Center, Japanese Nursing Association
6)

Takizawa Village Office, Iwate

Abstract
Objectives: The aim of this study was to identify and compare knowledge about hypertension, healthpromoting lifestyle, and level of spirituality/religiosity in persons with hypertension from Iwate, Japanand Southeastern North Carolina, USA.
Methods:

A cross-sectional design was used to explore differences and similarities between rural

residents receiving care through a health clinic and a prefectural hospital in Iwate and through primarycare clinics in southeastern North Carolina.
Results:The convenience sample included 212 Japanese（67%）and 105 North Carolina residents（33%）. Compared with North Carolina, rural residents in Iwate had an increased systolic blood pressure（147.0 vs. 130.4）and increased total cholesterol（204 in Iwate vs. 191in North Carolina）. North Carolina
participants had increased BMI rates（31.5 in North Carolina vs. 25.5 in Iwate）with an average waist
circumference of 102 cm. While Iwate participants had a higher correct answer rate on the Knowledgeof Hypertension Survey（77.9% vs. 61.2%）, North Carolina participants scored higher on the Belief ina Higher Being in Healing Scale（16.3 vs. 4.3）. In Iwate, behaviors involving health responsibility（p<.000）, nutrition（p<.000）, interpersonal relationships（p<.000）, and stress management（p<.000）,
were higher than those of residents in North Carolina. No differences were found on the HPLP II between
participants of both countries on physical activity and spiritual growth.
Conclusions: The major challenge in caring for persons with hypertension is improving health literacy
for this chronic disease and the benefits of lifestyle modification. Study findings also emphasize thecritical need for developing and testing interventions aimed at hypertension, weight control, andcholesterol. Relevant spiritual practices are important internationally and also need to be assessed.
Keywords: Hypertension, Health Promotion, Cross-cultural, Spirituality, Pender

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岩手看護学会誌/Ｊｏｕｒｎａ
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. , Ｎｏ２. , ２０１０

Introduction

Methodology

Hypertension is a continuing chronic health problem for

A cross-sectional design was used to explore differences

residents in both rural northern Japan and the Southeasternand similarities between participants in northern Japan and1) -3)

Despite recent advances in the prevention

southeastern North Carolina. In Iwate, data was collected

and treatment of hypertension, rural residents in both Iwate

from a convenience sample of rural residents receiving care

Prefecture and Southeastern North Carolina have a continuing

through a health clinic of a community health center and an

high incidence of hypertension, with limited explanations of

outpatient clinic of a prefectural hospital. In North Carolina,

United States.

4)-5)subjects were recruited through primary care clinics locatedthe contributing factors to hypertension.

With the continued rising rates of hypertension,in rural southeastern North Carolina. Both subjects were theincreasing attention is being focused on health-promoting

visitors to the clinics on data collection days and were given

lifestyles as a contributor in reversing this trend.Whilequestionnaire surveys and blood pressure, height and weight

beginning studies report associations between demographic

measurements by researches.

variables and health-promoting lifestyle, the relationship

The study was approved by Institutional Review Boards

between cognitive, behavioral, and other contributing factors

at the University of North Carolina Wilmington, Iwate

which impact hypertension has not been widely researched.

Prefectural University and the Takizawa Health Center in

A collaborative international research study was developed

Takizawa, Iwate. All subjects were informed orally with ain response to this continuing health care challenge

written document which included anonymity, respect forexperienced jointly by health professionals in northern Japan

individual intent, and the use of the data to be limited toand Southeastern North Carolina. The conceptual framework,

research purpose, and gave consent. In preparation for thedesign, and study protocols were developed by the study teamstudy, faculty from the Iwate Prefectural University researchmembers at joint meetings in North Carolina and Iwate andteam translated study measures to Japanese and back-also via the Internet. This research project examinedtranslated the surveys.

commonalities and differences in cognitive, behavioral, andcultural variables related to health promoting lifestyles andFigure 1physiologic variables among residents with hypertension

Individual Characteristics，
Behavioral Specific Cognitions＆Socio-cultural Factors

from each country.

Behavioral
Outcomes

The specific aims of this study were to identify and compare
1)

INDIVIDUAL CHARACTERISTICS

2)

knowledge about hypertension, levels of spirituality/religiosity,

Demographics（age，ethnicity，gender，education，marital status，
religious affiliation，and income）

3)

and health promoting lifestyles in persons with hypertension
living in Iwate and Southeastern North Carolina.

HEALTHPROMOTINGLIFESTYLE

BEHAVIORAL

Theoretical Framework

・Cognition
・Medication Adherence
・Knowledge of Hypertension

The theoretical framework for this study was a6)，
modification of Pender s revised Health Promotion Model.
The concepts used for this model include individual

Socio-Cultural
Spirituality/Religiosity

characteristics（age, ethnicity, gender, education, marital
status, religious affiliation, and income）, cognition（knowledge of hypertension）, behavioral（medication
adherence）, and socio-cultural（spirituality or religiosity）
factors. The model consists of two interrelating categories
containing variables that influence, either directly or
indirectly; the health-promoting lifestyles that affect thephysiologic factors of hypertension（see Figure 1）.

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Physiologic Factors

・Systolic BP・Diastolic BP・Body Mass Index
・Waist Measurement
・Cholesterol岩手看護学会誌/Ｊｏｕｒｎａ
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Instrumentson the American Heart Association Human Blood Pressure

The Health Promoting Lifestyle II Survey（HPLP II）was

Determination by Sphygmomanometry, with the use of adesigned to investigate patterns and determinants of health-consistent aneroid manometer. Cholesterol levels, including

promoting lifestyles, as well as the effects of interventions toalter lifestyles. The HPLP II is a 52 item likert-type scale

total cholesterol, LDL, and HDL were obtained from study，
participants charts. Body Mass Index（BMI）calculations

consisting of 6 subscales: spiritual growth, healthwere based on a standardized formula using weight in

responsibility, physical activity, nutrition, interpersonal

kilograms and height in meters. Waist Measurement was

7)

relations, and stress-management. The Japanese language

calculated in centimeters in North Carolina participants.

version of the HPLP Ⅱ was provided by Wei and colleagues
8)，with sufficient reliability and validity. Cronbach s alphaData Analysis

coefficients in this study were .90 in total score in Iwate anddemographic and physiologic characteristics of respondents.97 in NC, and in subscales,.60-.80 in Iwate, .72-.91 in NC.

in both groups. Independent t tests and Chi-Squared tests were

Commonly used interchangeably religion and spirituality are
different concepts and the meanings vary by culture. For thisused to compare group means and percent distribution on，
study measures and Pearson s correlation co-efficients werestudy, spirituality was defined as an individual process ofused to examine relationships between physiologic

searching for purpose and meaning of life and often associatedcharacteristics, the HPLP II, the Morisky Medication

with meditation, connecting with others, choosing values, andAdherence Scale, The Knowledge of Hypertension Survey,

reflection.

9)

Descriptive statistics were calculated to assess theand the Belief in a Higher Being in Healing. SPSS 16.0j for

Spirituality was measured using the HPLP II

Windows was used for analysis.

subscale for spiritual growth. Religiosity is defined as
personal relationship with a supernatural or divine force that
includes worship and obedience. Belief in a supreme being

Results

was measured by using a 7 item subscale from the Belief in

Demographics
A total of 317 persons with hypertension participated in thea Higher Being in Healing scale with reported validity andreliability.

10)

study, including 212 Iwate（67%）and 105 North Carolinians

The seven items were translated/back-translated，
and used in this study. Cronbach s alpha in this study were（33%）. One hundred percent of the participants from Iwate.84 in Iwate and .89 in NC.

Prefecture were Japanese, while 62% of North Carolina

The Morisky Medication Adherence Scale, a scale withparticipants were African American, 30% were Caucasian,

widely reported reliability and validity, was used to measureand 8% Native American. Ninety-one percent（n = 193）of

11)

This four

the participants from Iwate were over the age of 50 years,

item self-report measure was based on the knowledge thatcompared with 70%（n = 74）for North Carolina participants.

medication omission can occur in several ways such as

A higher percentage of Iwate participants were married（77%

forgetting, carelessness, stopping the medication whenin Iwate vs. 50% in North Carolina）, and a higher percentage

feeling better, or stopping the medication when feeling worse.

were living with family and friends（90% in Iwate vs. 80%

The Knowledge of Hypertension Survey, developed byin North Carolina）. Both groups had a similar distribution

adherence with antihypertensive medications.

12)

consists of 12 true/false items with widelyof female participants, with 62%（n = 131）in Iwate and 57%

reported reliability and validity. These two surveys were（n = 60）in North Carolina.（Table 1）. Compared with Iwate,translated/back-translated and used in this study. The results

North Carolina participants had increased BMI rates（31.5 inwere analyzed on each item. The Demographic Data Survey

North Carolina vs. 25.2 in Iwate）and an average waist

included information about age, gender, marital status, level

circumference was 102 cm in North Carolina.

Knopp & Razlaffof education, occupation, and antihypertensive medications.
Physiologic measures included systolic and diastolic bloodpressures, cholesterol levels, waist measurement, and Body
Mass Index（BMI）. Researchers in both countries followed
standardized protocols for measuring blood pressure, based

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. , Ｎｏ２. , ２０１０Compared with participants from North Carolina, persons

residents indicated that they were receiving antihypertensive

in Iwate had an increased systolic blood pressure（147.0 in

medicines. Fifty seven percent of the Iwate rural residents

Iwate vs. 130.4 in North Carolina）and increased totalreported taking antihypertensive medications more than 5cholesterol（204 in Iwate vs. 191 in North Carolina）. While

years compared to 45% of the North Carolina participants.

91% of the North Carolina participants were currently taking

Japanese participants reported greater adherence tomedications to control blood pressure, only 76% of the Iwate

antihypertensive medication regimens（p<.019）.

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Differences in Spirituality and Religiosity

Differences in Knowledge of Hypertension
Number of participants of correct answeres and % in theParticipants living in North Carolina had higher scores on

total participants are shown in Table2. The only item

the Belief in a Higher Being in Healing Scale, with a mean

regarding stroke was answered correctly by more than 90%score of 16.3（SD 4.3）, compared with Iwate participants atof the participants in both countries. Three items regarding

4.34（SD 4.3）. No significant differences were found,body weight, heart attack, headaches and blurred vision were

however, between the countries on the Spiritual Growth

responded correctly by over 90% in North Carolina, but those

subscale of the HPLP II. In Iwate, the score of the Belief inin Iwate remained low. There were three items responded

Higher Being Scale significantly correlated with healthcorrectly by about 10% and less in NC. The correct answer

responsibility（p<.01）, physical activity（p<.01）, spiritual

rate varied 34.4-92% in Iwate.

growth (p<.01）, interpersonal relationship（p<.01）, and stress

North Carolina participants had a lower average correct

management（p<.05）of the HPLPⅡ.In North Carolina, theanswer rate than Iwate participants（61.2% in North Carolina

score of this scale was significantly correlated withvs.77.9% in Japan）. In Iwate, increased knowledge ofspiritual growth（p<.01）and stresshypertension was significantly associated with higher scoresof the HPLPⅡ.（Table 3-1, 3-2）

on the HPLP II physical activity subscale.（Table 3-1）In
North Carolina, increased knowledge was significantly
associated with physical activity and nutrition in HPLPⅡ.
（Table 3-2）

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management（p<.01）岩手看護学会誌/Ｊｏｕｒｎａ
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between study participants in both countries.

Differences in Health Promoting Behavior between Iwate

Iwate participants had an increased systolic blood pressure

and North Carolina
Table ４ lists the differences in health promoting behaviors

and increased total cholesterol. Higher blood pressure rates

between rural residents in both countries. In Iwate, behaviors

in Iwate participants may be due to the increased age of theinvolving health responsibility（p<.000）, nutrition（p<.000）,

study participants and also to lower rates of prescribedinterpersonal relationships（p<.000）, and stress management

antihypertensive medications. North Carolina participants（p<.000）, were higher than those of North Carolina

had higher BMI rates and larger waist circumferences. Thisparticipants. No differences were found between participants

finding reflects the high prevalence of obesity among ruralof both countries on spiritual growth and physical activity.

North Carolina residents.

5)

North Carolina participants also

The six subscales of health promoting behavior on the

had lower levels of knowledge about hypertension. Study

HPLP II were correlated with physiologic variables forfindings suggest a higher need for culturally tailored patientparticipants in both countries. In Iwate, total cholesterol

education on hypertension regimens.

correlated with the HPLP II nutrition subscale(p<.05）. In

Although hypertension knowledge level was higher inNorth Carolina, systolic blood pressure correlated withJapanese participants, the range of correct answers varied

physical activity（p<.05）, nutrition（p<05）, spiritual growth

widely and they did not correlate with blood pressure（p<.05）, and interpersonal relationship（ p<.05）.Diastolicreadings. Murata and others found that knowledge about

blood pressure correlated with physical activity（p<.05）,

hypertension and salt intake in hypertensive patients was low,

nutrition（p<.01）, spiritual growth（p<.01）, interpersonal

but persons monitoring blood pressures at home had increased

relationship（p<.01）.（Table 3-1, 3-2）

interest and better adherence to hypertensive medications.

13)

Saito and colleagues
Discussion

14)

found that untreated hypertensive

patients had lower knowledge of hypertension complications

This study provides important information about theassociations between health promoting behaviors, knowledge

and daily self-management activities compared to those withtreatments. Physician，s standards for starting antihypertensiveof hypertension, and spirituality/religiosity in persons living

medicines was 148/92 mmHg, while patient，s expectations

with hypertension in rural northern Japan and southeasternfor initiating medication was 162/95 mmHg.

rural North Carolina. Significant differences were found

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countries.

The HPLP II mean scores for both countries indicate thatparticipants were less than often engaged routinely in health

Conclusion

promoting behaviors related to hypertension. Study findings
are consistent with other research that demonstrates that

Significant differences in knowledge of hypertension,

adherence to lifestyles changes and modification is typicallyspirituality, religiosity, and health promoting lifestyle were

low. In Iwate, HPLPⅡtotal score and 4 subscale scores were

found between rural residents with hypertension in Iwate andhigher than those in NC, but they did not correlate with blood

North Carolina.
Although rural residents in NC tended to practice morepressures. More effective health behaviors which
hypertension in

health related behavior to influence blood pressure comparedNorthern Japan should be identified, and their educational

to Iwate residents, both groups lagged substantially behindprogram must be developed. More useful hypertension

in the practice of heart health lifestyles.

influence blood pressureof people withMore health related behaviors to influence blood pressureknowledge in daily life should be identified and taught
effectively in both countries.

and more useful health knowledge related to hypertension

The mean spirituality and religiosity scores were comparedfor each country and to each other. Iwate participant，s scoresshould be identified and taught effectively in both countries.

on the Belief in Higher Being Scale were much lower thanhypertension is improving health literacy for this chronic

those of North Carolina participants. The mean religiosity

disease and the benefits of lifestyle modification. Studyscores were positively correlated with the HPLP II subscalefindings emphasize the critical need for developing andscores of health responsibility, physical activity, spiritual

testing culturally tailored interventions aimed at

growth, interpersonal relationship and stress management

hypertension, weight control, and cholesterol. Relevant（Tables 3-1, 3-2, 4）. These findings suggest the importancespiritual beliefs and practices that influence health outcomesof spirituality in maintaining and improving health promoting

are important internationally and also need to be assessed.

The major challenge in caring for persons withbehavior and emotional wellbeing for both Japanese and theNorth Carolina group.

15) 6)

References

Religion has little impact on

Japanese people today however there is more interest in1）Ong K, Cheung B, Man Y, Lau C, Lam K. Prevalence,spirituality. Japanese people seek healing through books,

awareness, treatment, and control of hypertension amongmusic, pictures and other methods. Theologians,

United States adults 1999-2004. Hypertension.

psychologists, folklorists, and health professionals in Japan

2007;49:69-75.

16)also show higher interests in spirituality and spiritual care.

2）Journal of Health and Welfare Statistics. 2009;56（9）:82.

The high scores on the HPLP II spiritual growth subscale in3）Ministry of Health and Welfare, 2001, Accessed

North Carolina reflect the important emphasis placed on

November 14, 2009 at

spiritual practices and beliefs related to health and medical

http://www.mhlw.go.jp/toukei/saikin/hw/kenkou/jyunkan/care among persons living in the rural south of the U.S.

10)jyukan00/gaiyou2.html）
4）Ohsawa M, Itai K, Tanno K, Onoda T, Ogawa A,

Because of varying demographic characteristics between
the two countries, a cross-cultural comparison can be

Nakamura M, et al. Cardiovascular risk

factors in thechallenging. Japan is one of the few countries providing

Japanese northeast ruralnational health insurance, whereas health care in the U.S. is2008 Aug 14

provided by many separate entities. In the United［Epub ahead of print］.

States, health care facilities are largely owned and operated

5）Huston S. The burden of cardiovascular disease in Northby private sectors and health insurance is also provided by

Carolina: August 2008 update. North Carolina Department

private companies. Many of the North Carolina participantsof Health and Humanin this study were uninsured. Despite the differences, theServices. Accessed October 10, 2009 at

study fills an important gap in the literature and offers

www.startwithyourheart.com

population. Intl J Cardiology.

6）Pender,N.J,Health promotion in nursing practice.

important indications for health care providers in both

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. , Ｎｏ２. , ２０１０

education（HIPE）.University of Kansas School of

3rd ed. stamford CT：Appleton＆Lange;1996.

Medicine. 2000.

7）M i t c h e l l J , M a t t h e w s H F , Y e s a v a g e J A . A

13）Murata K, Nagaoka C, Kunimitsu K, Nagaoka K. 血圧

multidimensional examination of depression among theに関するアンケート調査.Community Medicine.

elderly. Research on Aging. 1993; 152:198-219.

2007;21（4）:280-288

8）Wei C, Yonemitsu H, Harada K, Miyakita T, Omori S,，14）Saito I. Gap between untreated, treated patients and，physicians attitudes and awareness toward hypertension

Miyabayashi T, Ueda A. A Japanese language version of
the health-promoting lifestyle profile. Nippon Eiseigaku

and its complications, cardiovascular diseases.

Zasshi.2000; 54(4):597-606.
9）Carson V, Koenig H.（Editors）Spiritual dimensions ofProgress in Medicine. 2008;21(4):280-288.
15）Noguchi W, Ohno T, Morita S, Aihara O, Tsujii H and etnursing practice. Revised Edition. West Conshohocken,

al. Reliability and validity of the Functional Assessment

PA:Templeton Press;2008.

，
10）Mansfield C, Mitchell J, King D. The doctor as God sof Chronic Illnes Therapy-Spiritual（FACIT-Sp）for

mechanic? Beliefs in the southeastern United States. Social

Japanese patients with cancer. Support Care Cancer.

Science and Medicine 2002;54（3）:399-409.

2004;12:240-245.

11）Morisky DE, Green LW, Devine DM. Concurrent and16）Kubodera T. 魂の痛みへのケア―スピリチュアリテ

predictive validity of a self-reported measure ofィとは．Environment and Health.2008;21（ 2）: 148-154.
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medication adherence.Medical Care. 1986;241:67-74.
12）Knopp R, Rattzlaff K. Hypertension: improvising patient

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岩手県とノースカロライナ州南東部に居住する高血圧
者の高血圧についての知識、
健康増進ライフスタイル、
スピリチュアリティの比較
ジーン

1)

ケンペイネンペリ
4)

坪山美智子

ボマー

1)

菊池和子

5)

野口恭子

安藤明子

2)

安保寛明

3)

2)

千葉澄子

4)

兼松百合子

6)

1)

ノースカロライナ大学ウィルミントン校看護学部

2)

岩手県立大学看護学部

3)

岩手晴和病院

4)

元岩手県立大学看護学部

5)

日本看護協会神戸研修センター

6)

滝沢村役場

要旨
岩手県とノースカロライナ州に居住する高血圧者の高血圧についての知識、健康増進ライ
フスタイル、スピリチュアリティのレベルを明らかにし、比較することを目的とした。岩手
県の１保健センターと１県立病院の外来と、ノースカロライナ州南東部のプライマリーケア
クリニックにおいて、研究参加を承諾した岩手住民212人と、ノースカロライナ住民105人を対象として質問紙調査と血圧測定、身長・体重測定を行なった。
岩手住民（I）はノースカロライナ住民（NC）と比べて、収縮期血圧値と総コレステロー
ル値が有意に高かった。NCのBMIはIに比べて有意に高かった。高血圧の知識の正答率はIがNCより有意に高かった。宗教性スケールでは、NCの方が有意に高かった。健康増進ライフ
スタイル（HPLPⅡ）では、Iは健康意識（p＜.000）、栄養（p＜.000）、人間関係（p＜.000）、
ストレス管理（p＜.000）、総点（p＜.000）において、NCより有意に高かったが、血圧値との相関は見られなかった。NCでは、運動、栄養、スピリチュアリティ、人間関係において、収縮期血圧並びに拡張期血圧との有意な相関がみられた。
本研究の結果は、文化の特徴に基づく、高血圧、体重、コレステロールのコントロールを目指した健康増進介入方法の開発と検証の必要性、スピリチュアルな実践の国際的重要性を示唆するものであった。
キーワード

高血圧

健康増進

異文化間

スピリチュアリティ

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