There has been a tendency in the medical and nursing literature to oversimplify the problems of hypertension management and of health education interventions and evaluation in this kind of setting. Some investigators have assumed that physicians' instructions were followed. Others presumed too much about the transferability to hypertension of educational technology, behavior modification, and cognitive theories from other health problems and populations in which they had successfully employed them. Many expect too much of blood pressure readings, clinic records, the possibility of pill counts, and even of survey methodologies to yield hard outcome data. Some have attempted or proposed to use the same dependent variables as the earlier Veterans Administration studies, which were not primarily concerned with patient compliance. The realities of inner-city clinic management of the typical hypertensive patient do not allow investigators simply to import educational or behavior modification strategies and prevail upon existing clinical staff to implement them. Neither the strategies nor the instrumentation to measure their effects have been sufficiently developed and field tested to justify their immediate, large-scale application in clinical trials that disrupt clinic routines, impose on the time of staff and patients, and are of unknown efficacy. Our approach to these issues has been to presume as little as possible and to build on a series of exploratory, methodological, and feasibility studies before imposing new procedures on overburdened clinics.
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