PLACE IN RETURN BOX to remove this checkout from your record.
TO AVOID FINES return on or before date due.
MAY BE RECALLED with earlier due date if requested.

 

 

. E E | DATE DUE DATE DUE
failing 5 [1) EOEWEIMQBM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6/01 c:/C|RC/DaleDue.p65-p. 15

A SCREENING PROTOCOL AND EDUCATIONAL PAMPHLET TO AID
IN THE IDENTIFICATION AND TEACHING OF RISK FACTORS
ASSOCIATED WITH HYPERTENSION IN AFRICAN
AMERICAN PERI-MENOPAUSAL WOMEN

BY

Julia Allen Hartman
Louise Ann Osbourn

A SCHOLARLY PROJECT
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of
MASTER OF SCIENCE IN NURSING

College of Nursing

1999

ABSTRACT
A SCREENING PROTOCOL AND EDUCATIONAL PAMPHLET TO AID IN THE

IDENTIFICATION AND TEACHING OF RISK FACTORS ASSOCIATED WITH
HYPERTENSION IN AFRICAN AMERICAN PERI-MENOPAUSAL WOMEN

BY

Julia Allen Hartman
Louise Ann Osbourn

Hypertension is a significant health concern because it
can lead to other diseases such as coronary heart disease,
stroke, and_congestive heart failure to name a few.
Although hypertension is a common condition, there are a
disproportionate number of African-American women who
develop this disorder. At any decade of life African
American women are more likely to develop hypertension than
their white counterparts. This scholarly project is based
on a review of the literature that supports the need for
early intervention in the prevention of hypertension.

The Health Belief Model provides the theoretical
framework for this project. This model is relevant because
it takes into consideration the specific demographics of
this unique population. Through the identification of risk
factors for hypertension, the Health Belief Model promotes
self-efficacy through the perceived threat of illness. The
acronym BP HELPED is screening tool used by the APN in the
screening process based on the model. The educational
pamphlet provides the client with relevant information to

improve understanding of how to prevent hypertension.

ACKNOWLEDGMENTS

We would first like to thank Dr. Louise Selanders for
her guidance in this project and for her sense of humor in
London. Her encouragement made the completion of this
project possible. We would also like to thank the other
members of our committee, Dr. Sue Wheeler and Dr. Georgia
Padonu. All of their input in the project as well as their
experience and knowledge made this project a valuable

learning experience.

I would like to thank my husband Jim and children, Ben,
Theresa and Mary for their understanding and patience.
Without their love and support I could not have completed
this degree. And finally, to Julia, who has been with me
for some of the most interesting experiences I have had in
the last three years, thank you for being there and getting

me through the project. - Louise Osbourn

I would first like to thank my mom for her editing
abilities and her willingness to read this project several
times. I would also like to thank my family and friends for
all of their support during the past three years. I would
also like to thank Louise for not only the interesting
experiences but also her patience with me while working with

me on this project. - Julia Hartman

iii

TABLE OF CONTENTS

LIST OF TABLES . O C O O O C O O O C O O O 0
LIST OF FIGURES . . . . . . . . . . . . . . .

CHAPTER 1
I NTRODUfl I ON C O O O O O O O O C O C O O O I

Purpose . . . . . . . . . . . . . . . .

CHAPTER 2
CON C EPTUAL WORK 0 O O O O O O O O O O 0
Definition of Concepts . . . . . . . . .

CHAPTER 3

REVIEW OF LITERATURE . . . . . .
Pathophysiology . . . . . .
Comorbidities . . . . . . .
Coronary Heart Disease . . .
COronary Heart Disease and Women
Hypertension and Women . . ‘. .
The difference between Afr
with hypertension . . . .
Hypertension Awareness . .

Obesity and Hypertension . . . . .
Epidemiology of Hypertension . . . .
Signs and Symptoms of Hypertension .

CHAPTER 4

PROJECT DEVELOPMENT . . . . . . . . . . . . .
Tools . . . . . . . . . . . . . . . . .
Target Population . . . . . . . . . . .

CHAPTER 5

IMPLICATIONS FOR THE ADVANCED PRACTICE NURSE
Implications for Practice . . . . . . .
Implications for Research . . . . . . .

CHAPTER 6
CONCLUSION . . . . . . . . . . . . . . . . .

LIST OF REFERENCES 0 O O O O O O O O O O O O

APPENDICES
Appendix A: BP HELPED . . . . . . .
Appendix B: DIRECTIONS FOR GENOGRAM
Appendix C: EXAMPLE OF GENOGRAM . .
Appendix D: PAMPHLET . . . . . . .

iv

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vi

11
11
13
17
18
20

23
28
29
30
31

33
35
39

49
49
54

59
61
66
67

68
69

LIST OF TABLES

TABLE 1: Classification of Blood Pressure for Adults
18 Years and Older . . . . . . . . . . . . . . 12

LI ST OF FIGURES

FIGURE 1: Health Belief Hodel . . . . . . . . . . . . . .

FIGURE 2: Adapted Health Belief Model for the
Peri-Menopausal African American Female . . .

vi

CHAPTER 1

INTRODUCTION

African American women in the United States have one of
the highest rates of mortality and morbidity related to
cardiovascular disease in the developed world (Gillum,
1996). One of the attributing factors for the higher rate
of disease continues to be the prevalence of essential .
hypertension (HTN) in this population. African Americans
and white Americans are likely to differ on those aspects of
hypertension because of their daily experiences and their
management (Brown & Segal, 1996). The disease develops
earlier in African Americans than in whites and is generally
more severe (American Heart Association, 1990). The longer
hypertension is left untreated the more severe are the
complications and risks for serious disease. When compared
to whites, African Americans have 1 8 times the incidence of
strokes, 10-18 times more kidney failure and 3-5 times more
heart failure related to high blood pressure (American Heart
Association, 1990).

Women in general tend to develop coronary heart disease
(CHD) and HTN later in life because of the protective
mechanism of estrogen in the peri-menopausal period. After

‘menopause the risk for the development of CHD and HTN

1

increases dramatically. However, peri-menopausal African
American women still tend to be at an increased risk for
HTN. When comparing every age group of African American and
white women, African American women have a higher systolic
blood pressure (SBP) (Gillum, 1996). Early intervention for
African American women is found to be effective in
controlling or delaying onset of HTN (Gillum, 1996).

Coronary Heart Disease is the leading cause of death
and disability among adult women killing nearly 500,000 each
year in the United States (Haan, 1997; Wenger, 1997). While
CHD prevalence is similar in African American and white men,
African American women generally have a higher incidence
than white women. African American women have a higher
occurrence of risk factors with a higher death rate at a
younger age than their white counterparts (Haan, 1996;
Stamler, 1989; U.S. Dept of Health and Human Services,
1996). The literature does not give specific numbers on the
mortality of African American women. Strong family history
coupled with early onset of disease, increasing age and race
are unalterable factors that raise the risk (Haan, 1997).
In 1995, the death rates due to CHD were 35% higher for
African American females than for white females (American
Heart Association, 1995).

Hypertension with a prevalence of 20-40% of the
population, is one of the most powerful predictors of CHD.
The higher proportion is found in African American females

(Carlson, Eisenstat, Frigoletto, & Schiff, 1995).

2

Hypertension is an independent risk factor for the
development of CHD. The more severe the HTN the higher the
risk of developing CHD. If HTN is coupled with other risk
factors such as elevated cholesterol, smoking, or obesity
the risk of CHD increases substantially (Carlson et a1.,
1995). The research shows that nonpharmacologic
interventions play a part in the prevention of early onset
of the disease. Hypertension requires vigilant and
continual treatment of a disease that may have few or no
symptoms.
ENIDQEB

The purpose of this project is to develop a screening
tool that will consider the unique characteristics of the 40
to 50 year old peri-menopausal African American females in
the identification and management of hypertension. This is
a time when screening, education, and teaching will be most
important due to the progression of the disease in this
population. The protocol will emphasize the unique way that
African Americans approach health care as well as the
socioeconomic situations that African American women face.
The literature will support the fact that while not all-
ethnic groups are homogeneous some generalities can be made
regarding this unique population. The Health Belief Model
(HBM) will further guide the screening protocol as it
relates to the effect of treatment.

Advanced Practice Nurses (APN) can use this tool to

guide the care of this particular population. It will make

3

the APNs aware of the increased risk for HTN for the peri-
menopausal African American female population. APNs can
then screen these women for HTN especially those with
multiple risk factors for the development of HTN. An
individualized plan of care with education most appropriate
to that client can then be developed. The goal of both the
screening tool and the educational pamphlet is to make the
African American peri-menopausal female aware of her risk
for HTN and give her the education she needs to achieve
self-efficacy.

The focus of this project is to develop a screening
protocol that guides the APN in developing an individualized
plan of care for the peri-menopausal African American
female. The second part of this project is to develop a
pamphlet that will educate this population in an attempt to
give them self-efficacy to prevent CHD by early intervention

against HTN.

CHAPTER 2

CONCEPTUAL FRAMEWORK

The Health Belief Model (Figure 1) is applicable when
assessing hypertension and its effects on African American
women (Pender, 1996). The premise of the HBM is that
failure to engage in health promoting activities is the
belief that these activities will not improve the condition.
The second assumption is that the illnesses are not
perceived as life threatening enough to warrant health
promotion (Weick, 1997). Hypertension is such a disease
'that in its earlier stages it is basically asymptomatic.
Health belief is important if individuals are to believe
that they are empowered to influence their risk for further
illness. This model can aid the APN in identifying and
promoting healthy behaviors in the African American peri-
menopausal female population.

The HBM is based on a combination of five variables
that can determine if an individual will take a preventative
health action (Glanz, Lewis, & Rimer, 1997). The first
variable is whether the person feels she is susceptible to a
disease. An example is that the woman does not perceive
that not monitoring her blood pressure (BP) is a risk to her

future health. The second variable is whether the person

5

HEALTH BELIEF MODEL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INDIVIDUAL MODIFYING LIKELIHOOD
PERCEPTIONS FACTORS OF ACTION
Demobraphic Variables Pe reeiv ed De I!
(age ,sex, race, ethnicity, etc.) of action
Sociopaychologic variables
[I . 3 ’ - class, peer minus
and reference-group pressure,
etc.)
._.p
Structural variables Perceived Barriers
(knowledge about disease, to preventive action
prior contact with disease)
Perceived
Threat
of the disease
Perceived _> Cues to Action Likelihood of Action
Susceptibility (Media campaigns, advice recommended preventive
to the disease from others, reminder from health action
Perceived Seriousness 1mm“ gin” “my °"
. end)
of the disease

 

 

 

 

 

Fim 1. Health Belief Model (Pender, 1996).

believes the disease is serious in its consequences. If
hypertension goes untreated the consequence is worse than
the treatment. The third variable is whether a perceived
benefit of action is advantageous. If the women's actions
are able to prevent HTN there is a perceived benefit to the
action. The fourth variable is whether there are barriers
to action. These are opinions already learned or believed
that are different from those actions that promote health.
The last variable is whether cues to action, give motivation
to take a specific course. In addition to APN interventions
these are media campaigns, advice from others, awareness of
illness from social contact.

These five factors fit into the three basic areas of
modification in the HBM: individual perceptions, modifying
factors, and likelihood of action (see Figure 2). The
strength of the HBM is that it enables the peri-menopausal
African American woman to understand her likelihood of
disease and her self-efficacy in preventing a disease. For
behavioral changes to succeed, the woman must feel
threatened by her current behavioral patterns and believe
that specific protocol changes will be beneficial resulting
in a valued outcome (Glanz, Lewis, & Rimer, 1997).

To better understand how the Health Belief Medel
relates to the problem of hypertension in the African
American peri-menopausal women several words need to be

defined. The following words or phrases are defined for

.7

Application of Health Belief Model to Peri-Menopausal

African American Female
(Osbourn & Hartman, 1999)

INDIVIDUAL MODIFYING
PERCEPTIONS FACTORS

 

Demobraphic Variables

African American Female, 40
to 50 year olds
Sociopsychologic variables

Income, education, family,
friends, religion and cultural

Structural variables

Knowledge of hypertension
and long term risk factors
related to non compliance or
lack of knowledge with
screening protocols.

l

Pe i ed S ll ill Perceived Threat
Doesnotseeherself Low: “01.3 I

. . causepersontothinkno
threatenedbyrllnessthatrs l' s

 

 

 

 

 

Dependent on: culture,

 

 

 

 

 

 

 

Perceived Seriousness beliefs, f 'l ’ reli .
Hypertension reducable.
i
Cues to Action

Vital signs: Elevated BP,
perceived lack of educational
information, pamphlet, famibi
history, genogram, APN
interventions, media exposure,
elevatede cholesterol and
positive risk factors.

 

 

 

LIKELIHOOD OF
ACTION

 

beliefs ‘ ’

 

Perceived Benefits

of changing related behavior

specific to lowering BP.

Feeling better and decrease long

term illness. Potential increasing

lifespan, and quality of life
minus

Perceived Barriers

Lack of symptoms, history of
cooking a certain way, lack of
exercise, cost of medications, low
selfeflicacy.

 

 

asymptomatic. _.) _.> V

 

IikelilroodofAetion

Low: will not change present
behavior unless education and
teaching individualized to
person at her own level of
understanding.

 

Fim 2. Adapted Health Belief Model for the Peri-Menopausal African American Female.

8

 

 

this purpose: hypertension, peri-menopausal women, self-
efficacy, temporal orientation, ethnicity, poverty status,
and life experiences.

H¥Dfilhfinfiigni For the purpose of this paper
hypertension is diagnosed if the diastolic pressure is
greater than 90 mm Hg during 2 or more consecutive clinical
visits or when the average systolic blood pressure measures
> 140 mm Hg during 2 or more consecutive visits (McCance &
Huether, 1994).

Peri;mengpansal_ugmen; These are defined as women in
the time period around or about the cessation of the menses,
known as menopause. Natural menopause occurs at the age of
50 to 51 for the average female (The Merck Manual, 1992).

Seltzeffigacy; Self efficacy is the belief that the
person can perform the behavior required to meet the need
and produce positive outcomes based on the disease process
(Glanz, Lewis, & Rimer, 1997).

Tempgza1_gzientatign; This term is defined as the time
perspective an individual holds with regards to disease and
its management (Brown & Segal, 1996). Results from the
Brown and Segals (1996) research reveal that African
Americans were more present oriented than whites regarding
their daily experiences with managing hypertension. Present
orientated people see themselves less susceptible to
consequences because they fail to see the future

implications of their present health choices.

African_American_femaler For the purpose of this paper
African American female is defined as any women who
identifies herself as having African American heritage.

ng_1nggmg; Low income reflects not only the lack of
money but also the lack of adequate housing, nutrition, and
access to health care that impacts the risk factors of the
African American population.

Religign§_fleligf§; African American persons have a
strong belief in the powers of spirituality. They view
their health as a harmony or disharmony with God. Health
promotion activities may be viewed as futile if their health

is a consequence of God's will (Jennings, 1996).

10

CHAPTER 3

REVIEW OF LITERATURE

Hypertension has been a significant health concern in
the US for at least the last three decades. The cost of
hypertension is not only high in dollar amounts spent
annually, but it also affects a large percentage of the
American population and increases morbidity and mortality.
The annual cost of drug therapy exceeds 8 billion dollars
(Neaton et al., 1993). The annual mortality rate due to
hypertension is over 37,000 and it affects 50 to 60 million
Americans (American Heart Association, 1995). The diagnosis
of hypertension is relatively easy and cost effective. It
is based on an average of 2 or more BP readings. Then those
readings are staged based on the level of the severity and
if the systolic and diastolic fall into different stages,
the higher stage is assigned. Early detection and treatment
greatly reduces morbidity and mortality, which also
decreases the overall dollar cost (Schumann & Emerson,
1998).

Eathcnhxsiglcax

There are two different types of hypertension, primary

or essential and secondary. Although there are different

theories about the causes, the pathophysiology of primary

11

Table 1.

:1 'E' l' E E] i I E Ii 1' I i
elder

 

Category Systolic (mm Hg) Diastolic (mm Hg)
Normal <130 <85
High normal 130-139 85-89
Hypertension

Stage 1 (mild) 140-159 90-99

Stage 2 160-179 100-109
(moderate)

Stage 3 (severe) 180-209 110-119

Stage 4 (very >209 >119
severe)

 

(The Fifth Report of the Joint National Committee on
Detection, Evaluation, and Treatment of High Blood Pressure,
1993).

hypertension is unknown which accounts for 90-95% of the
diagnoses. The renin-angiotensin-aldosterone system plays a
key role in blood pressure control, but its role in primary
hypertension is not known. Renin is released in the
presence of decreased renal perfusion, hypovolemia,
increased circulating catecholeamines, increased sympathetic
nervous system outflow, increased arteriolar stretch, and
hypokalemia. Renin converts angiotensin to angiotensin I,
which then innervates with angiotensin-converting enzyme to
form angiotensin II, a potent vasoconstrictor (McCance &
Huether, 1994). Angiotensin II then stimulates aldosterone,
which stimulates the renal tubule to reabsorb water and
sodium and excrete potassium (McCance & Huether, 1994). The
reason that it is difficult to pinpoint hypertension to this

system is that there are both low renin or high renin

hypertensives. African Americans and elderly hypertensives

12

tend to have lower plasma renin levels, which are associated
with increased intravascular volumes and younger
hypertensives have higher plasma renin levels, which are
associated with an increased cardiac output (Abul-Ezz,
Bunke, Singh, & Shah, 1997). BP is also influenced by a
number of other factors including atrial natriuretic factor,
endothelin, endothelium-derived relaxing factor, calcium-
regulating hormones, kininogen, and vasopressin (Schumann &
Emerson, 1998).

Secondary hypertension accounts for only 5-10% of
hypertension and as is implied, it is caused by another
disease process. This type of hypertension is often
controllable. The major causes of secondary hypertension
are: renal artery stenosis, renal parenchymal disease,
estrogen use, coarctation of the aorta, pheochromocytoma,
hyperaldosteronism, Cushing's syndrome, hyperthyroidism, and
hyperparathyroidism (Schumann & Emerson, 1998).

Why is it so important to prevent or keep tight control
of hypertension? Not only is hypertension a major cause of
death, but it is a significant preventable risk factor in
the development of coronary heart disease, congestive heart
failure (CHF), cerebrovascular accidents (CVA), hypertensive
heart disease, and end-stage renal disease (ESRD) to name a
few. The annual costs for each of these diseases are
excessive. Not to mention the impact these diseases have on

the individual and family.

13

Hypertensive heart disease is diagnosed when an
individual has both hypertension and left ventricular
hypertrophy (LVH). Prior to the development of LVH, there
are both physiological and hemodynamic compensatory changes
that occur. LVH is recognizable as there has already much
damage to the heart muscle and is indicative of long-
standing, advanced hypertension. The risk of morbidity and
mortality increases markedly after LVH has developed.
Hypertensive African American men and women are three to
four times more likely to develop LVH than their white
counterparts (Savage, 1991). There is a twofold to ninefold
increase in the chance of stroke, cardiac failure, a
significant cardiac event, or symptomatic peripheral
arterial disease. Approximately 30% of patients with LVH
die within 5 years of the development of LVH (Savage, 1991).

In the 1980's the cost of ESRD was approaching more
than 3 billion dollars annually. This is an area, which is
especially significant for African Americans because almost
two thirds of all dialysis patients are African American
although they only constitute approximately 12% of the total
population. Forty percent of this population developed ESRD
secondary to hypertension. The white population has the
lowest incidence of ESRD in the US. Pathophysiologically,
hypertensive African Americans have a 20% lower renal blood
flow than their white counterparts with a similar BP. In

addition, they have smaller renal accurate arteries,

14

decreased sodium excretion, and are more likely to have
proteinuria (Shulman & Hall, 1991).

Unfortunately, one of the reasons for the
disproportionate number of African Americans with ESRD may
be due to Medicaid and Medicare. In some states anti-
hypertensive medications are not covered until another
complication develops such as ESRD. A survey done in
Georgia on individuals with diastolic pressures greater than
105 found that almost 50% of African Americans were unable
to afford refills of medication in comparison to 9% of
whites (Shulman, Martinez, Brogan, Carr, & Miles, 1986).

In the US, CHF is the number one reason for admission
to the hospital for older adults. Although medications have
improved the treatment of CHF and the death rate has
recently decreased, CHF is still a chronic, disabling, and
often fatal disease. African American men and women are
almost twice as likely to have CHF, this being explained by
the occurrence of risk factors: hypertension, smoking,
diabetes, higher average BMI, and LVH. A recent study on
the racial differences and hospitalization for CHF found
that hypertension had a significant correlation with
hospitalization, except in women with controlled
hypertension who were younger than 60. The participants all
had similar health insurance (Alexander, Grumbach, Selby,
Brown, 6 Washington, 1995). Persons who survive a
myocardial infarction (MI) or other hypertension related

diseases are at greater risk for developing CHF. Among

15

white Medicare recipients CHD is the most common secondary
condition to CHF whereas in their African American -
counterparts hypertension is the most frequent secondary
condition (Centers for Disease Control, 1980-1995).
Therefore the primary prevention for CHF is preventing
hypertension and MI's through healthy lifestyle choices and
the use of anti-hypertensive medications if necessary.

In the US, strokes are responsible for a significant
number deaths and disabilities yearly. Strokes account for
6-7% of the annual mortality rate. The degree of disability
varies from individual to individual. The stroke patient
may fully recover or may have some degree of paralysis,
which accounts for a large number of admissions to extended
care facilities. The mortality rate for African American
males is 52.2 per 100,000 which is 97% higher than in white
males and for African American females it is 39.6 per
100,000 which is 71% higher than their white counterparts.
Young African Americans are approximately three times more
likely to suffer an ischemic stroke than their white
counterparts. The key risk factors for strokes are:
hypertension, diabetes, excessive alcohol intake, cigarette
smoking, heart disease, and sickle cell anemia. Other risk
factors include: obesity, sodium, potassium, and calcium
intake, stress, and access and attitudes about health care.
Hypertension is by far the most important risk factor for
strokes; therefore it is imperative that BP control is

maintained (Caplan, 1991).

16

Warm

In the past 30 years the incidence of mortality from
CHD has declined because of prevention and advanced
technology. In spite of this heart disease remains the
leading cause of mortality in the US among both men and
women. It is responsible for approximately one out of every
three deaths. Strokes account for 6-7% of all deaths, so
CHD is responsible for about 40% of all deaths in the US
(American Heart Association, 1995). This accounts for
750,000 deaths per year. It is the leading cause of death
of men by 45 years of age and women by 65 years of age.
African American men and women have a significantly higher
risk of mortality from CHD than their white counterparts.

Of great concern is the overall health of US teenagers.

Cigarette smoking and obesity in this age is on the rise
while participation in regular physical activity has been
decreasing. This is of great concern for the future health
of this age group because they are putting themselves at
risk for early onset CHD. Worldwide the incidence of CHD is
increasing. It is predicted that by the year 2020, CHD will
be the number one cause of both morbidity and mortality.
The reason for this is the eradication of malnutrition and
infectious disease as the primary cause of death; thus the
population is aging and cigarette smoking is continually on
the rise in the developing nations (Hennekens, 1997).

There are a number of risk factors that put people at

higher risk for CHD. Some of these are modifiable and some

17

are not. Family history and genetics are believed to play a
part in the development of CHD. However what needs to be
taken into account along with genetics is the environment.
In the.Ni-Hon-San study, Japanese men who lived in two
Japanese cities, Hawaii, and the San Francisco were followed
and significant differences were found. Those men living in
Japan had the lowest incidence of CHD and those in San
Francisco had the highest incidence of CHD. This study
concluded that even though persons may be genetically
similar, lifestyle practices may have a greater impact on
the development of CHD (Hennekens, 1997). This is important
for health care providers to understand and explain to their
clients. Some clients may feel that there is nothing they
can do to prevent CHD, because it runs in their family.
When, in fact, if they make lifestyle changes then they can
reduce their chances considerably for the developing CHD.
The three risk factors which are definitely unmodifiable are
race, age, and gender.
WW

With the increasing life expectancy of women, CHD is
the number one cause of death and disability among women
over forty years old. The mortality from CHD for women is
50%, whereas breast cancer accounts for one death for every
nine women. Only 7% of women realize that CHD is the number
one cause of death among women, most believing that cancer
is their biggest risk. Forty percent of women die with

their first myocardial infarction (MI). The most

18

significant difference in CHD between men and women is the
onset of the disease. Women are diagnosed with CHD ten
years later than men and CHD is extremely rare in women less
than 40 years old. Estrogen protects peri-menopausal women
from developing early onset CHD (Jensen 8 King, 1997).

The risk factors for the development of CHD are similar
in both men and women; however what is different is the
impact of each of these risk factors on women. The
following conditions put one at risk for the development of
CHD: diabetes, hypertension, obesity, lipid levels, smoking,
and age. Diabetes is a significant precursor to CHD;
however female diabetics are much more likely to develop CHD
than their male counterparts. Male diabetics are twice as
likely as nondiabetic males to develop CHD, whereas female
diabetics are 5-7 times more likely to develop CHD than
their nondiabetic counterparts. Obesity in American women
is fairly common. Thirty-four percent of white women and
fifty percent of African American women are considered
obese, which is a BMI greater than 32.3. BMI is the weight
in kilograms divided by height in meters squared. Obesity
is the greatest risk factor for CHD in women under forty
(Moser, 1997).

Hypertension, like diabetes, is a powerful risk factor
for CHD. Hypertension in peri-menopausal women increases
the risk of mortality from CHD tenfold. In postmenopausal
women there is a higher incidence of CHD than in men. In

women.over 45 years old, 60% of white women and 79% of

19

African American women have hypertension. At least one
third of those women do not realize that they have
hypertension and only 20% have adequate control. Exercise
and weight control are effective means for controlling blood
pressure, although if blood pressure remains uncontrolled
anti-hypertensive therapy is indicated. Anti-hypertensive
therapy is effective for both women and men and is perhaps
the most beneficial for African American women (Moser,
1997).

W

The Framingham study (1975) was one of the first long
range studies to look at coronary heart disease. Others had
been attempted but were not completed due to the complexity
of the study. This study looked at healthy, asymptomatic
individuals over a 20 year period for the development of
CHD. Even though periodic physical examinations by a
physician were recommended in the 1950's in the US the trend
was to only go to the physician if one had symptoms. When
the Framingham study was initiated, it was believed that one
would wait to see a physician indefinitely, however this was
found not to be true with the healthy, asymptomatic patient
(Dawber, 1980).

The Framingham study was conducted in Framingham
Massachusetts, between 1950 and 1974. The participants in
the study were randomly selected from Framingham and were
examined biannually. The total sample was 6,507 of which

5127 were considered free of CHD. There were 3074 men and

20

3433 women in the sample. It is difficult to say that this

sample was representative of a larger population. There

were virtually no African Americans or Asians living in

Framingham and the composition of the white population did

not necessarily match white populations elsewhere. However

it was decided for this study that the population would be

large enough to compare subgroups. The following hypotheses

were tested: 1

1. CHD increases with age. It occurs earlier and more
frequently in the male sex.

2. Persons with hypertension develop CHD at a greater rate
than those who are normotensive.

3. Elevated blood cholesterol level is associated with an
increased risk of CHD.

4. Tobacco smoking is associated with an increased
occurrence of CHD.

5. Habitual use of alcohol is associated with increased
incidence of CHD.

6. Increased physical activity is associated with a
decrease in the development of CHD.

7. An increase in thyroid function is associated with a
decrease in the development of CHD.

8. A high blood hemoglobin or hematocrit level is
associated with an increased rate of development of
CHD.

9. An increase in body weight predisposes to CHD.

21

10. There is an increased rate of development of CHD in
patients with diabetes mellitus.
11. There is a higher incidence of CHD in patients with

gout (Dawber, 1980 p. 54-58).

For the purpose of this paper, hypertension as a risk
factor will be discussed. At the time of the Framingham
study anything below 160/95 was considered normotensive. At
this time it was recognized that those dying from
atherosclerotic diseases often times had high blood pressure
and that hypertension was a manifestation of'a disease
process such as renal disease. However, high blood pressure
was considered benign in the absence of other diseases.
First it was found that systolic and diastolic blood
pressures increase with age. However this increase is
slight and accounts for only a small percentage of
hypertension. Certain individuals developed a substantially
higher blood pressure than would be expected from age alone.
These persons were then divided into two groups: those with
higher blood pressures at any earlier age and those who were
normotensive at an earlier age but their pressure rose at a
rapid rate to reach hypertensive levels. The increase with
age was noted more with women than men. In the age group
35-39 women had an average BP of 122/78 and men 132/83. In
the 55-59 age group the opposite was true as women had an
average BP of 150/90 and men 140/87. In the age group of
45-49 BP was almost identical in both sexes. Although the

study hoped to determine what causes BP to rise more in some

22

individuals than others, the only correlate that was found
was weight gain (Dawber, 1980). -

For both men and women regardless of age, the incidence
of CHD increases from normotensive to borderline to
hypertensive. In younger men followed for 24 years, those
in the hypertensive group were more than two times as likely
to develop CHD. In women the ratio was greater although the
onset of CHD occurred later in life. Both hypertensive men
and women were three times more likely to suffer a stroke
than their normotensive counterparts. The Framingham study
discovered that elevated BP is a significant risk factor for
the development of CHD, although at the time of the study
the benefit of lowering BP was unknown (Dawber, 1980).

.- a. -‘. - '1‘.‘,"$ ;. ;..- -.: ..e p. -: ° .
11mm

The first National Health and Nutrition Examination
Survey (NHANES I) provided data from a nationwide
representative biracial sample of civilian
noninstitutionalized US residents aged 1-74, excluding
Alaska, Hawaii, and reservation lands of American Indians.
From this data several follow up studies have been done that
show the ethnic differences between African Americans and
whites in relation to hypertension and CHD risk factors.

The first of those is the NHANES I Epidemiological Follow-up
study (NHEFS). The sample in this study consisted of 1641
African American and 9660 white persons between the ages of

25-74 from the NHANES I who did not have a history of CHD.

23

Significant risk factors for the development of CHD among
African American women were age, systolic blood pressure
(SBP) > 140, and smoking and among African American men age,
SBP > 140, serum cholesterol, and low family income. From
this study it is believed that 19% of the incidence of CHD
among African American women and 34% among African American
men could have been prevented if the SBP was maintained
below 140 (Gillum, Mussolino, & Madans, 1998).

The NHEFS showed that hypertension is more common in
both African American men and women. Out of this has come
the question; is hypertension more severe among US African
Americans or is hypertension more common? One of the
beliefs has been that hypertension is more severe in the
African American population. What was found is that it is
just more prevalent and as a result the higher morbidity and
mortality rates associated with hypertension is more common
among African Americans. There is no evidence to date that
African Americans have a genetic predisposition to
hypertension and the reason that morbidity and mortality is
higher in this population is because hypertension is just
more common (Cooper, Liao, & Rotimi, 1996).

The data shows that in both African American men and
women, SBP is 10 mm Hg higher and diastolic BP (DBP) is
greater than 5 mm Hg higher than their white counterparts.
African American men and women are about three times more
likely to have severe hypertension. But on the individual

level those with severe uncontrolled hypertension were more

24

likely to suffer end organ damage and increased mortality.
What has been found is that adequate blood pressure control
among African American hypertensives significantly decreases
the difference in the African American/white mortality ratio
(Cooper, Liao, & Rotimi, 1996). The question that remains
is why is hypertension more common-among African Americans.
This study identifies other factors that increase the
likelihood of hypertension in this group.

The next variable from_the NHANES that was looked into
was weight change in African American and white women in
relation to socioeconomic status and level of education.

The mean weight change was higher for African American women
(3.8 + 9.6) versus white women (2.8 + 8.0). African
American women who were overweight at the initial survey
gained a higher percentage of weight at the follow-up.
Although African American women were found to have a greater
weight gain, this study is not suggesting that just being
African American is a risk factor for weight gain: other
variables not looked at in this study need to be taken into
account. The significance of weight gain also found in the
Framingham study is that obesity is a risk factor for
hypertension. Variables that affected weight gain were low
family income and low educational attainment < 12th grade
(Kahn, Williamson, & Stevens, 1991).

Another study that looked at ethnic differences in
blood pressure and CHD is the CARDIA (Coronary Artery Risk

Development in Young Adults Study). The CARDIA study is a

25

longitudinal study that looked at many variables that may

account for the racial differences in blood pressure and

risk factors for CHD. The sample consisted of 5116 young

African American and white men and women, ages 18-30, of

varying socioeconomic status. The sample was drawn from

Birmingham, Ala., Chicago, IL, Minneapolis, MN, and Oakland,

CA. The study hoped to answer the following questions:

1. Are there differences in systolic and diastolic blood
pressures and pulse rate between African American and
white young adults?

2. Are there differences in body mass index (BMI),
lifestyle, and psychosocial characteristics between
African American and white adults?

3. Are systolic and diastolic blood pressure related to
BMI, lifestyle, and psychosocial characteristics in
young African American and white adults?

4. Are observed patterns of differences in blood pressure
and pulse rate associated with differences in BMI,
lifestyle, and psychosocial characteristics? (Liu et
al., 1989).

Before the exam, the subjects were asked to fast for 12
hours and to avoid smoking and physical exercise for 2 hours
prior to the exam. After a 5 minute rest in a quiet room
pulse and BP were recorded. In addition the participants
had to fill out a questionnaire. The results of the study
are as follows: African American participants had a higher

SBP than their white counterparts in every age, sex, and

26

education group. The findings were statistically
significant in every group except for men aged 18-24 with
more than 12 years of education and women 18-24 with less
than or equal to 12 years of education. In every age, sex,
and education group the African American population tended
to have a slightly higher DBP; however the findings were
only significant in men and women aged 25-30 with more than
12 years of education (Liu et al., 1989).

In addition, African Americans had significantly lower
average duration on the treadmill, which was considered in
overall physical fitness. African Americans had a lower
percentage of alcohol drinkers and they had a higher number
of smokers although they smoked fewer cigarettes than their
white counterparts. African Americans had lower calcium and
potassium intake, higher hostility scores, and fewer years
of education than their white counterparts in every age and
sex group. BMI was significantly higher in African American
men aged 25-30 and African American women aged 18-24 and 25-
30. In this study there were greater differences in the SBP
and DBP between groups as the participants got older.
Therefore it is reasonable to assume from this study that
the most important time to prevent hypertension especially
in the African American population is in early adulthood or
sooner. The interventions should focus on decreasing BMI,
lifestyle choices, and ways to decrease psychosocial stress

(Liu et al., 1989).

27

Another area of study from the CARDIA study is the
relationship of cardiovascular risk factors to left
ventricular (LV) mass. Left ventricular hypertrophy is a
strong independent indicator for morbidity and mortality in
adults. In the young healthy subjects men in general have
more LV mass than women. LV mass in this study was found to
be correlated across age, gender, BMI, subscapular skinfold
thickness, height, and SBP. The importance of this data is
that LV mass may increase prior to elevation in blood
pressure secondary to BMI and obesity (Gardin et al., 1995).
We

The main goal of the atherosclerosis risk in
communities study (ARIC) is to investigate the cause and
natural course of subclinical atherosclerosis and its
clinical outcome. The sample consists of 15800 persons of
both genders, ages 45-64 selected from four communities:
Forsyth County, NC, Jackson, Miss., Minneapolis, MN, and
Washington County, MD. This particular aspect of the study
was looking at population awareness and control of
hypertension and hypercholestrolemia. Eighty-four percent
of those with hypertension were aware of their diagnosis and
of those only 50% had their conditions both treated and
controlled. WOmen were more likely to be aware and treated
for their condition. African American women had the highest
level of awareness about hypertension, but African American
hypertensives were less likely receive treatment for the

disease and as with the other studies hypertension was more

28

prevalent in the African American population. The
associations for race persisted after adjustment for
education, income level, and obesity status.

As is expected those from a higher socioeconomic status
were more likely to have their hypertension treated and
controlled. Individuals who quit smoking were more likely
to be treated for hypertension. Family history of CHD or
hypertension was positively associated with awareness and
treatment of hypertension. However, increased awareness did
not significantly affect adequate control of hypertension.
Less access to care, lack of health insurance, and the cost
of medication are significant factors that are inhibiting
treatment and control of hypertension in persons in the
lower socioeconomic status (Nieto et al., 1995).
W

The Nurses Health Study is a longitudinal study, which
has a sample size of 82,473 08 female nurses ages 30-55 who
have been followed every 2 years since 1976. The follow-up
rate is 95%. By 1992 there were 16, 395 diagnosed cases of
hypertension. It was found that those with a higher BMI
were at increased risk for hypertension. Women who have
long-term weight gain after the age of 18 have a 48% chance
for developing hypertension in comparison to women who have
a medium weight gain in mid-life have a 21% chance of
developing hypertension. Weight loss is an effective
intervention for reducing the risk of hypertension (Huang et

al., 1998).

29

E 'i . J E H l . . IE i E .
The literature supports that hypertension in African

American women is a significant health concern. The
following risk factors show that African American women are
more likely than their white counterparts to develop
hypertension at an earlier age. Family history is
associated with the prevalence of hypertension. There is
also a positive correlation in BP measurement between mother
and daughter in the African American population. Increased
BMI, skin fold thickness, and abdominal obesity are
associated with higher BP readings in African American
women. This is of particular concern because when comparing
every age group there is a higher percentage of obesity in
African American women in comparison to their white
counterparts. The racial differences for the higher blood
pressure readings in the third decade of life are likely
linked too: BMI and cigarette smoking is higher in African
Americans and physical fitness and alcohol consumption is
lower in African Americans (Gillum, 1996).

Socioeconomic status and psychosocial variables also
have important implications in the development of
hypertension. African American women with college education
had a lower incidence of hypertension than those without
college, however in both cases the prevalence is higher than
in white women. African Americans living in the inner city,
with low education, in poverty are more likely to have

hypertension. Studies that have controlled for

30

socioeconomic, psychosocial, or biomedical variables have
not eliminated the African American-white BP difference in
the Us (Gillum, 1996). Through the literature review
African American women of all ages have been shown to be at
increased risk for the development of hypertension;
therefore for the purpose of this project all African
American women will be considered at risk.
WWI:

The signs and symptoms of hypertension often times are
vague and vary from person to person. One may have
headaches, lightheadedness, dizziness, visual disturbances,
or numbness and tingling in the extremities. However, the
reason that routine screening for hypertension is so
important is that in most cases the individual is
asymptomatic. Hypertension is often called the silent
killer because of the lack of symptoms. Often times when it
is diagnosed end organ damage has occurred. Therefore it is
imperative that those who are normotensive and not at high
risk have their BP checked minimally every 2 years and those
at high risk and normotensive should be checked annually
(American Heart Association, 1995).

The review of the literature highlighted some of the
major studies related to hypertension and its comorbidities.
Hypertension is a major modifiable risk factor for CHD
including myocardial infarctions, strokes, and CHF and ESRD.
It is also linked with non-insulin diabetes especially in

the African American women. Hypertension is a serious

31

health problem among both African Americans and white
Americans; however the problem is much more significant and
severe in African Americans. When comparing African
American and white women, African American women have a
higher blood pressure at every decade of life and develop
hypertension at an earlier age. Hypertension and the
comorbities associated with it, is more prevalent in African
American women is more likely to be inherited, and is linked
with obesity. The purpose of this project is to develop a
screening protocol and an educational pamphlet, which
considers the unique cultural and health behaviors of
African American women. The screening protocol includes
both a screening tool and a genogram, which will aid in
identifying each client's specific risk factors for the
development of hypertension. This serves two purposes; it
alerts the APN which areas to focus on and it educates the
African American woman of her risk factors. The educational
pamphlet then serves as a guide for the APN to educate the
client and gives some needed information about her risk and

ways to reduce that risk.

32

CHAPTER FOUR

PROJECT DEVELOPMENT

The purpose of this project is to develop a screening
protocol and educational pamphlet for the peri-menopausal
African American woman who is seen during a primary care
visit. Realizing that all these women are at risk for
hypertension the APN can use this information to identify
who would benefit from further intervention and continue to
screen those who may be at risk. In an extensive review of
the literature many major concerns for this unique
population were revealed. The need for intervention is
critical when the client is young because hypertension tends
to progress without symptoms. The peri-menopausal African
American woman has been found to develop the disease at a
younger age, is more likely to develop end organ failure and
is found to have a greater number of preventable risk
factors.

Since at least 1979, the government has emphasized the
importance of health promotion, health protection, and
clinical preventative services amongst the whole population
with a special emphasis on minorities (McGinnis, Richmond,

Brandt, Windom, & Mason, 1992). In Healthy People 2000, the

33

National objectives for hypertension prevention and control

in African American women are as follows:

1.

5.

6.

Increase to > 90% the number of persons with high blood
pressure who are taking action to control their blood
pressure by taking medication and making life style
modifications (low fat, low salt diet, exercise).
Reduce the number of overweight African American women
to less than 30%.

Increase to > 30% the number of persons who engage in
light to moderate physical activity for >30 minutes per
day.

Reduce to < 15% the number of persons age 6 and older
who engage in no leisure time physical activity.
Decrease salt and sodium intake.

Increase to greater than 90% the proportion of adults
who have had their blood pressure measured within the
preceding 2 years and can state whether their blood
pressure was normal or high (Department of Health and
Human Services, 1991).

To date these objectives have not been met and

hypertension continues to be one of the priority areas.

Even though drug therapy has been found to be effective in

the treatment and control of hypertension in African

American women, this population still experiences one of the

highest rates of hypertension-related mortality (Gillum,

1996). Therefore it is imperative that the APN identifies

34

and educates this population in order to prevent
hypertension and the mortality associated with it.
T9213

There are four tools that are included in this project.
The first is the screening protocol (Appendix A), the second
is the instructions for use of the genogram (Appendix B),
the third is the genogram (Appendix C), and fourth is the
.educational pamphlet (Appendix D). The Health Belief Model
provides the foundation for the above tools. These tools
were developed to be used in conjunction with one another to
provide a comprehensive ongoing plan of care. The APN is an
appropriate primary care provider to use the screening tool,
implement the genogram, and educate based on the educational
pamphlet.

The-screening tool will be used by the APN. When
asking if the clients know their blood pressure and blood
pressure history the APN is assessing the perceived
susceptibility and seriousness of hypertension. The
demographic variables (age, race, and sex) define the
population and are unmodifiable. One of the cues to action
relates to the taking a family history and doing a genogram.
The perceived threat is addressed when asking if she feels
threatened by hypertension and if she feels she has any
control over the outcome.

This tool uses an acronym to remind the APN of the
specific areas of concern in the screening process. The

acronym BP HELPED will be the trigger for the assessment: B-

35

Blood pressure (Do you know what your blood pressure is?)
(Blood pressure history-record of it), P-Perceived Knowledge
of Disease (Ask if she feels threatened by high blood
pressure) (Do you think you have any control over the
outcome of high blood pressure), H-History (personal
history, family history, genogram), E-Efficacy (Do you
believe you can take the actions necessary to prevent high
blood pressure?), L-Lifestyles (Do you smoke cigarettes,
drink.alcohol, or have increased stress in your life? If
you do are you willing to take the steps necessary to make
positive lifestyle choices?), P-People you know with high
blood pressure (How do the people you know manage their high
blood pressure? Are they successful? Can you learn
something from them?), E-Exercise (How much exercise do you
get? What type of exercise of exercise is it? What kind of
neighborhood do you live in? Any changes in weight in the
last 5 years?), D-Diet and Drugs (Diet history-24 hour
recall. Low sodium diet-limiting sodium use)--Drugs (Are
you on or ever been prescribed blood pressure medications?
What do you know about blood pressure medications? Do you
use any home remedies? Ex. Garlic cloves or capsules,
vinegar, aloe vera juice, multiple vitamin therapy and
various combinations of these products.)

The genogram displays information graphically in an
orderly fashion. It provides structural, relational and
functional information on a family. It provides a quick

reference for complex family patterns and a source for

36

determining how clinical problems are connected in the
context of family (McGoldrick & Gerson, 1985). Genograms in
general provide much information about the family; however
for this project the focus is on the medical history. The
genogram is generally done with the initial assessment and
is revised as necessary.

The genogram (see Appendix C) is the effective tool
used to evaluate the family history of hypertension.
Hypertension runs in families and by using a genogram with
the woman, she is better able to visualize her
vulnerability. Assessing her perceived threat of illness,
which is based on the HBM may motivate her to take action.
The genogram can be done during the primary care visit in a
short period of time. Instructions for completing the
genogram are provided to guide the APN (See Appendix B). A
three-generation genogram is done to reflect the familial
tendencies toward the disease.

The educational pamphlet was developed with the African
American female in mind. It was designed to focus on her
special needs. The idea is not that the APN just hands her
the pamphlet but instead goes over the pamphlet with the
patient to focus on the areas which are of particular
concern to each individual client. .The first section of the
pamphlet provides an area for the client's blood pressure
today and gives her room to make a diary if she chooses.

The pamphlet is meant to be taken home and serve as a

resource for the client.

37

The pamphlet is also based on the Health Belief Model.
The cover page depicts familial tendencies based on a
picture of three generations of African American women.

This was chosen because it focuses on the sociopsychologic
variable of family from the HBM. The first page of the
pamphlet provides cues to action by providing the client's
own blood pressure and educational information. The second
page (risk factors) incorporates the individual's
perceptions of perceived susceptibility and the seriousness
of the disease. By making clients aware of their
suspectibility and the seriousness of the disease, the
objective is that the APN is increasing her perceived threat
of illness.

The headings for page three and four were titled to
promote self-efficacy. It tells clients that they have the
ability to promote their health which may lead to positive
outcomes. The goal is that the client's likelihood of
action will increase. Page three gives the client
suggestions of what she can do which in turn acts on her
likelihood of action by decreasing their perceived barriers.
How it is done is on page 4. Promoting self-efficacy will
increase their likelihood of action because their level of
understanding about hypertension will increase. By
individualizing the education and teaching to their level of

understanding APNs are promoting self-efficacy.

38

W

The screening tool is to be used with the genogram
during the 40 to 50 year old African American female's
annual visits to her primary care provider. If no annual
visits are scheduled the tool can be initiated during any
health care encounter. This was designed to be a concise
and efficient way of teaching in a short span of time. The
intent is that this will allow this population to become
aware of their increased risk for hypertension.

While the Vitals are taken the blood pressure would be
written in the informational pamphlet to be given to the.
client during the appropriate time of the visit. The BP
HELPED acronym will be a quick reminder of the questions
that the APN needs to cover. If the blood pressure is
elevated then the acronym can become a part of the chart to
be updated with further visits. The genogram will be done
with the client so that she is aware of her family
tendencies for hypertension and other disease processes.
This will also become a part of the chart. The pamphlet
will be reviewed with every client in the target population
and this will be documented in the chart and reviewed
annually. _

WW As mentioned
earlier the tools were designed to be concise and time
efficient. During the initial visit the genogram and
screening tool should take 5-10 minutes to complete.

Because 10 minutes can take up a significant portion of a

39

health care visit, it is important to realize that although
the focus is preventing hypertension the interventions key
in on having an overall healthy lifestyle. In follow-up
visits just the problem areas need to be covered which may
take only five minutes unless the client has many questions
or concerns. The pamphlet is designed to be part of an
ongoing process. The convenient aspect about blood pressure
monitoring is that it is quick, cheap, and is offered in a
variety of places outside of the primary care office
(grocery stores, drug stores, and shopping malls to name a
few). This gives the client the opportunity to check and
see how effective her interventions have been. After
explaining the importance of blood pressure monitoring, the
pamphlet provides adequate space for monthly monitoring of
blood pressure so that information can be shared with the
APN at the annual visit.

The following section

will focus on research that was not presented in the
literature review. The development of the screening tool
and educational pamphlet are based on a review of the
literature that is grounded in the African American
population. The paper discusses that African American
females get hypertension at an earlier age and suffer more
co-morbidities than their white counterparts but, being
African American is not an independent risk factor for
hypertension (Thomas, Quinn, Billingsley, & Caldwell, 1993).

In any decade of life hypertension is more severe in African

40

Americans than in whites (American Heart Association, 1995).

The literature has shown that African American females
have a high awareness about the risk of hypertension,
however this group is least likely to have their blood
pressure under control (Nieto, 1995). This could be due in
part to where African American females get their health care
information. It is more likely that African American women
get their information through informal sources such as
church, the grapevine, someone who has the disease, and the
media. African American women are less likely to get their
health care information from a health care professional
whereas white women are more apt to obtain their information
from this source (Schoenberg, Amey, & Coward, 1998).

The family history is significant in assessing for
hypertension. A family history is associated with an
increased prevalence and earlier onset of hypertension. A
significant correlation has been found between the blood
pressure of mothers and daughters among African Americans
(Gillum, 1996). A strong family history of the early onset
of heart disease, increasing age, and race are significant
risk factors for the development of hypertension which can
not be modified (Haan, 1996). It is imperative that family
history is discussed in great detail with every peri-
menopausal African American female.

There are many attitudes in this population, which are
difficult to overcome in order to promote self-efficacy.

One has to do with the strong religious beliefs in this

41

population. Spirituality has a strong influence on
lifestyle and health care behaviors. A commonly held belief
among the African American population is that illness may be
either natural or unnatural, and influenced by being in
harmony or disharmony with God. Disease may be the
consequence of God's will; health promotion activities may
be viewed as futile (Jennings, 1996). In addition this
population believes God is responsible for protecting the
health of individuals and that illness is alleviated through
strong faith in God and the use of prayer (Russell & Jewell,
1992).

It is difficult to encourage health-promoting
activities to the healthy individual. This is especially
true with hypertension because it is generally present
without symptoms and the individual feels fine. It is
generally believed that the condition is not life
threatening so self-efficacy is hampered due to the
perceived lack of illness. The next belief is that there is
nothing that can be done. The first step to empowering
individuals is that they must believe that they can
influence the outcome of a condition for which they are at
risk (Wieck, 1997).

Lifestyle modification probably encompasses some of the
most challenging health-promoting activities especially when
individuals do not.feel sick presently and are not thinking
about their future health. The challenge to the APN is to

motivate the client to be a futuristic thinker. One way to

42

do this is to encourage small changes and build on each
positive change. There has been found to be a significant
correlation between obesity and hypertension in African
American women. The Framingham study found that obesity is
a significant risk factor for the development of CHD
(Dawber, 1980). Approximately 50% of African American women
and 30% of white women are more than 20% above there
desirable weight levels (Wenger, 1998). Abdominal obesity
which is associated with a higher incidence of heart disease
and hypertension is more common in African American women
(Wenger, 1998). -

Cultural attitudes towards obesity vary. The cultural
definition for obesity tends to focus on cosmetics and
overall body image. The white culture tends to focus on the
cosmetics of obesity and has body image disturbances whereas
the African American culture tends to be more accepting of
its body image. If the African American woman is overweight
but has a positive body image, APNs should use that self
acceptance when making a plan of care. The focus should be
on realistic weight loss goals which promote overall health
(Kumanyika, 1995). '

Smoking cessation is another area that is difficult to
conquer. Twenty-two percent of African American women are
smokers (American Heart Association, 1995). The CARDIA
study found that there is a higher percentage of African
American females aged 25-30 who smoke, but they tend to

smoke fewer cigarettes than their white counterparts (Liu et

43

al., 1989). In recent years the overall number of smokers
has decreased, however the number of adolescent smokers is
increasing. Smoking is the single most significant health
concern for women. There is no evidence in the literature
about cultural differences when it comes to smoking
cessation. An interesting statistic related to women and
smoking is that as obesity decreases, the number of female
smokers increases and vice versa (Wenger, 1998).

Little research has been done on alcohol consumption by
African American females. The CARDIA study did find that
there are a lower percentage of African Americans who drink
(Liu, 1989). As has been said for many years, the key word
is moderation. That is equivalent to one to two ounces of
alcohol a day. Anymore than that has been found to increase
blood pressure (Helfant, 1993).

The next concern is exercise. The literature reveals
many cultural differences and attitudes towards overall
physical activity. African Americans participate in regular
physical exercise less often than whites do, regardless of
level of income or education (Wenger, 1998). Almost 68% of
African American women lead a sedentary lifestyle and 43%
percent report no leisure time physical activity (American
Heart Association, 1995). Time for rest is more valued in
the African American culture than exercise. Many African
Americans consider their work and daily activities as
exercise. For professional African American women, exercise

during lunch hour is not an option because it messes up

44

their appearance. African American women like to exercise
in the evening in a group atmosphere with friends or
relatives. Friends tend to have the greatest influence in
the area of exercise. One of the myths found in the African
American culture is that they do not view exercise as a
treatment for hypertension. They are more likely to believe
that regular hard physical activity is the cause of high
blood pressure (Airhihenbuwa, Kumanyika, Agurs, & Lowe,
1995).

‘The Joint National Committee on Detection, Evaluation
and Treatment of High Blood Pressure'(1997) developed the
diet DASH which stands for Dietary Approaches to Stop
Hypertension. The guidelines in the pamphlet on diet are
based on the recommendations of this diet. The reason the
diet is not just handed out is because at this point the
attempt is to get the client to make healthier life choices.

This diet has been shown to decrease blood pressure in
individuals with a slightly elevated blood pressure.

Sodium is known to increase blood pressure by retaining
water. The difficulty in measuring sodium is that often
times persons don't know what foods contain a lot of sodium
or they don't consider the salt they cook with. A possible
hypothesis for increased sodium sensitivity in African
American women may be related to a decreased renal excretion
of sodium, which may be linked to living in.a tropical
environment where sodium is scarce (Gillum, 1996). Other

dietary issues that play a part in hypertension in African

45

Americans are low levels of calcium, potassium, and
magnesium. Primary prevention of hypertension includes
following a low fat diet and reducing salt intake (Gillum,
1996). In the African American culture the female matriarch
is held in high esteem and the diet in the family is heavily
influenced by her, which can have a generational effect.

Brown and Segal (1996) found in their research.that
African Americans are 30% more likely than white Americans
to use home remedies. The home remedies that respondents
use to treat hypertension include vinegar, garlic cloves and
capsules, aloe vera juice, multiple vitamins and various
combinations of these products. Although random clinical
trial data is limited, the research suggests that
antioxidants delay or prevent progression of atherosclerosis
which in turn modifies the known risk factors of CHD (Haan,
1996). The antioxidants vitamin E, vitamin C, and b-
carotene are found in many multivitamin preparations. The
pamphlet encourages this preventative therapy and suggests
that this be incorporated in all diets. I

Folic acid, a B vitamin, has been found to decrease
homocysteine levels. High homocysteine levels are
associated with an increased risk for atherosclerosis.
Women are not getting enough folic acid in their diets. The
Food and Drug Administration recommends that women have a
daily intake of 400 micrograms (mcg) of folic acid per day
and 800 mcg if they are pregnant. Since the people

considered here are still in their childbearing years

46

recommending a multivitamin with 400 mcg of folic acid will
not only serve as a preventative measure for their coronary
health, but it may also decrease birth defects related to
folic acid deficiencies (Women's Health Watch, 1998).

Stress effects people in different ways. Stress has
been found to increase the risk of hypertension. Increased
stress over long periods of time is positively correlated
with hypertension (Helfant, 1993). African American women
report more life events than white women (Liu et al., 1989).
Living in areas with high levels of poverty, crime, and
mobility is associated with increased blood pressure
(Gillum, 1996). African Americans who accept racial
discrimination were found to have a higher blood pressure
whereas those who challenge it had lower blood pressures.
African American working class women are most likely to
accept discrimination and as a result have higher blood
pressure (Krieger 8 Sidney, 1996). As APNs it is important
to discuss with the patient ways to decrease stress in one's
life.

The pamphlet design was based on Price 8 Everett's
(1995) research on how to make a pamphlet for the African
American population. Often times pamphlets are written at
too high of a grade level. This article suggests that the
writing should be done at the 6th grade level. One and two
syllable words should be used and sentences should be
concise. Use simple fonts and present one idea at a time.

Use culturally relevant illustrations, photos, and cartoons.

47

Headings should be used to introduce new ideas. The article
focuses on the special considerations needed to deliver

health information to this unique population.

48

CHAPTER FIVE

IMPLICATIONS FOR THE ADVANCED PRACTICE NURSE

The educational and screening tools can be utilized in
many different ways by the advanced practice nurse (APN).
Clients obtain preventative health care information from a
variety of sources but not all of the information gained is
accurate. This protocol will offer the APNs the opportunity
to assess their clients' risk factors while simultaneously
building a rapport with them. At this time adequate
information specific to the peri-menopausal African female
has been fragmented. This screening protocol will
incorporate many aspects of the preventive care needed and
will give APNs necessary resources to impact this unique
population.

W

The present focus in today's health care environment is
prevention and primary health care and because of that the
role of the Nurse Practitioner continues to emerge. The
costs associated with hypertension and its co-morbidities
are extensive. This is especially important with African
American women since they are at higher risk for
hypertension at any age and are more likely to develop an

end organ disorder. The mortality rate from CHD has been

49

declining in recent years, however the death rate for
African American women remains four to five times higher
than their white counterparts (Gillum, 1996). This has many
important implications for the APN practice. APNs have
never been in such a unique position to be able to impact
health care through primary prevention. By screening this
population extensively, the APN can intervene early with the
goal being to prevent the onset of hypertension. In primary
prevention the practice of the APN encompasses many roles.
The roles include but are not limited to assessor, change
agent, client advocate, practitioner, and educator. APNs
utilize all of these roles when working with this unique
population. By using the screening protocol and educational
pamphlet APNs not only advance their practice but they will
also have a positive impact on the client, her family, and
the health care system.

The American Nurses Association (ANA) (1992) defined
the APNs role in clinical practice. “They conduct
comprehensive health assessment. Demonstrate a high level
of autonomy and possess expert skill in diagnosis and
treatment of complex responses of individual, families, and
communities to actual or potential health problems. They
formulate clinical decisions to manage acute and chronic
illness and promote wellnessJ‘ The APN as a
practitioner/clinician is educated and trained to diagnose
and treat a full range of human responses to actual and

potential health concerns. APNs provide rationale for the

50

chosen treatment process. APNs have specialized knowledge
and skills to deal with the human responses to the actual or
potential health problems (Calking, 1984). When APNs use
the screening protocol they are identifying with the clients
their actual or potential risk factors for developing
hypertension. The screening protocol changes the
individuals' perception and susceptibility to the disease by
making clients aware of the perceived seriousness of
hypertension and their own risk factors for it. Based on
the modifiable factors the APN will use this screening
protocol and educational pamphlet for 40-50 year old African
American females to educate them on their positive risk
factors and thus impact on their perceived threat for
hypertension.

The role of assessor is defined as one who uses a
database to identify health care, community, or system needs
and from that formulates impressions, interprets and makes
judgments. Through a literature review the peri-menopausal
African American females were identified as a group.in need
of additional screening and education in relation to the
prevention of hypertension. Peri-menopausal African
American women are identified as at risk because their
health care needs are often neglected secondary to their
other life roles and responsibilities. The screening tool
BP HELPED was designed using.the demographic and
sociopyschologic variables identified in the Health Belief

Model. The tool takes into account the risk factors,

51

cultural beliefs and health care practices specific to this
population.

The role of change agent comes from a social
interaction and problem-solving process where the change
agent provides new ideas that may guide and encourage
individual clients to change by influencing their norms,
values, and skills. The success of the change agent depends
largely on their communication style and ability to take the
clients' cultural beliefs into account in order to build a
open and trusting relationship (Strunk, 1995). The APN who
uses this screening protocol is not only assessing each
clients' risk for hypertension but is also building on the
strengths the client already possesses in order to
facilitate change that further promotes the clients' health
and prevents disease. The APN as a change agent is
incorporated in the HBM by educating the client about their
specific risk factors; the goal is that clients will want to
take action to decrease their modifiable risk factors. By
decreasing the modifiable risk factors in the peri-
menopausal African American female, the APN may also impact
the overall health of the client's family.

Being a client advocate is an essential component of
the APNs practice in order to bring about positive change.
The ANA's “Code” for nurses with interpretive statements
(1985) defines client advocacy as viewing the clients as the
primary decision makers in matters concerning their own

health, treatment, and wellbeing. The goal of nursing

52

actions is to support and enhance the client's
responsibility and self-determination to the greatest
extent. Truth telling and the process of reaching informed
choice underlie the exercise of self-determination, which is
basic to respect for persons. The idea of client advocacy
is one of the major premises of the HBM. By using the HBM
to prevent hypertension in African American females, the
APNs goal is to give the clients the necessary information
and motivation to increase her self-efficacy.

The role of educator is the basis for this project.
The idea is not only to educate the peri-menopausal African
American female but also the APN and make other APNs aware
of the increased risk of hypertension in this population and
the need for prevention. The African American population
tends to lack knowledge or believe in the value of health
promotion and disease prevention. They are frustrated by
the lack of appropriate and relevant health information
(Wieck, 1997). The screening protocol and educational
pamphlet were designed to meet this need. The screening
protocol provides the APN and the African American female
with the individuals' own risk factors which are necessary
in order to initiate change. The educational pamphlet has
information that is generalizable to African American
females. It is intended to be used as a guide for the
individual client.

The ability to change one's health attitudes and make

significant lifestyle changes is much more difficult than

53

“taking a pill," The need for personal responsibility for
one's own primary prevention continues to affect both
economic and quality of life issues. Primary prevention in
hypertension is an important issue because if hypertension
develops and goes untreated the likelihood of comorbid
conditions significantly increases. With appropriate
information African American women can have a great impact
on their families concepts and household priorities for
prevention. The APN must respond to these needs by focusing
on primary prevention and educating the patient and the
family at every opportunity. Combining the APN roles of
assessor, change agent, practitioner, client advocate, and
educator are necessary to be successful when promoting
primary hypertension prevention.
With

The literature review identified that in any decade of
life African American women are at increased risk for
developing hypertension. However research related to this
population is quite limited. It was not until the 1970's
with the NHANES study that African American women were
identified as a population at risk for hypertension and
heart disease. In subSequent studies this population
continued to be found at higher risk for developing
hypertension and its comorbities. However no studies have
been done to clarify what specific interventions would
impact the prevention of the development of hypertension in

African American women. Based on this information the APN

54

would be the appropriate practitioner to initiate research
based protocols. Research based interventions are necessary
if the nursing profession is to be recognized for its role
in primary prevention.

The mortality from CHD is over 50% in the United
States. The approximate annual cost of CHD is 50-100
billion dollars in lost wages and medical interventions
(Haan, 1996). Hypertension related morbidity and mortality
rates in African Americans are 3 to 5 times more frequent
than their white counterparts (Saunders, 1991). In today's
health care environment the focus is cost containment
through primary prevention. This offers the APN the avenue
to impact the health care system through cost containment by
screening and educating an identified at risk population
with research based interventions.

Healthy People 2000, a federal government health care
initiative, has three broad goals: increase the span of
healthy life for all Americans, reduce health inequalities
among Americans, and achieve access for all Americans to
preventative services (McGinnis, Richmond, Brandt, Windon, 8
Mason, 1992). One of the Preventative Service Objectives
not met was the reduction of the prevalence of people who
are overweight, an important risk factor for high blood
pressure (McGinnis, Richmond, Brandt, Windon, 8 Mason,
1992). One of the groups identified as at risk are African

Americans. Coupled with the fact that this population has

55

been identified as at risk and is under researched the need
for APN based research is apparent.

Based on the work of Jennie Hahn (1996) with dietary
teaching of diabetics the APN can clearly initiate research
base education to peri-menopausal African American women.

In her community based Outreach Diabetic Education Program
Ms. Hahn was able to make her teaching specific to the
population based on trial and error of interventions. She
was able to interview a small representative group and
determine the best way to reach them for teaching. The 20
representative people told the dieticians where to hold the
meetings and how the peopIe would learn so they could repeat
the dietary cooking demonstrations. Before this the
attendance to the meetings were less than three people. The
outcome was that the group went from 31 participants three
years ago to 200 now. Although this was based on dietician
interventions the same could be done by the APN in a
collaborative group to teach primary prevention. The
research needs to be sensitive to the specific cultural
needs of this minority population.

Another area of research is the influence of the church
on the prevention of hypertension in African American
females. Previous research has found that health promotion
activities that are supported by the church have had
positive outcomes in this population. However the research

is limited and some of the outcomes are difficult to

measure. In a study on church based asthma education, it

56

was hoped that the participants would learn to manage their
asthma better and have more knowledge about the disease
process, however there were no reported outcomes that were
measurable (Ford, Edwards, Rodriguez, Gibson, 8 Tilley,
1996). Further research is needed in this area to see if
the church is an appropriate site for health promotion
activities in this population.

The influence of the family is also an area that needs
further study. There are few studies that have looked at
the influence of family and compliance with a certain health
regimen. In studies that looked at the African American
family, where a positive family relationship was reported,
there was more compliance with a certain regimen and less
forgetting. Further research may focus on the role of the
family on the prevention of hypertension.

Probably one of the most important areas of study in
relation to hypertension is to find what is the most likely
mechanism for hypertension in African American females. If
this was better understood, then more effective
interventions could be determined through research studies.
Some examples of the possible mechanisms are: obesity,
central obesity, and insulin resistance, to name a few.
Once more is known determining all of the risk factors for
the development of hypertension in this population would be
easier. The research tells repeatedly that African American
women are more likely to develop hypertension, but what is

difficult to find is a reason for this as well as research

57

relating to preventing hypertension in this particular
population. _

There are so many opportunities for research for the
prevention of hypertension in the peri-menopausal African
American female. There are limited studies done on women
and CHD in general let alone on African American women.

This group has been seen to get this disease at such an
earlier age and with greater co-morbidity but the research
needed to justify interventions is greatly lacking. Much of
the interventions that is used today is proven to be
effective in white males because that is where the greatest
majority of the research related to hypertension and CHD has
been done. It can only be assumed that this treatment can
be generalized to other populations. Only through valid
research can it be assured that the interventions will be
effective for other unique populations.

The APN has many available opportunities to improve the
overall health of the peri-menopausal African American
woman. At this point it is unclear how the screening
protocol and educational pamphlet will impact this
population. When using these tools it is the responsibility
of the APN to develop a mutually agreed upon plan of care
with the client and to document the goals and outcomes.
However in order to test the effectiveness of the tools a
research project should be done, that could test different
variables with the overall goal being that the client would

remain normotensive and make positive lifestyle choices.

58

CHAPTER SIX

CONCLUSION

Peri-Menopausal African American females are clearly
identified as a population at risk for developing
hypertension that can lead to co-morbid diseases. The
disease develops earlier in this population and is more
severe (American Heart Association, 1990). Research shows
that primary prevention and early diagnosis greatly reduces
morbidity and mortality (Schumann 8 Emerson, 1998). This
disease has very few symptoms and this population has a
history of limited access to primary care providers. These
two factors put this population at risk because they do not
receive enough early, routine, and preventive health care
(Weick, 1997). African and white Americans differ in their
experiences and management of hypertension. .The information
given to African American women fails to teach them health
prevention in'a way that is relevant and appropriate. They
also do not believe in health promotion and disease
prevention or lack of knowledge to incorporate it in their
daily lives (Weick, 1996).

The purpose of this project is to develop a screening
protocol and an educational pamphlet that targets the peri-

menopausal African American female in the primary prevention

59

of hypertension. The use of the genogram in determining
familial tendencies towards hypertension and related co-
morbid conditions provides important visual cues for both
the APN and client. The teaching and screening of risk
factors is important to this project because it can make
women aware of their vulnerability for the disease. The
BPHELPED screening tool uses the risk factors found in the
research as specific to this population. The acronym
reminds the APN to cover all the areas of screening and
prevention. The pamphlet is to be used by clients as a tool
not only to monitor their own progress by recording the
blood pressures throughout the year but also to share the
information with their families.

It is understood that much more needs to be done with
health promotion and disease prevention in this unique
population. This scholarly project is designed to identify
the needs of peri-menopausal African American females in
regards to hypertension. Knowledge is a very important
aspect in promoting self-efficacy. Increasing the clients'
knowledge base about hypertension is an attempt to promote
their self-efficacy. The Health Belief Model provides the
foundation for understanding and teaching of health care and
promotion. The APN is an appropriate practitioner to be at

the forefront of these endeavors.

6O

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65

APPENDICES

 

Appendix A
B? HELPED

is for Blood Pressure

Do you know what your blood pressure is?

Do you keep a diary of your pressures?

Have you ever been told you have high blood pressure?

is for Perceived knowledge of disease

Do you feel threatened by high blood pressure? _

Do you know what high blood pressure can do to you?
Do you think you have any control over the outcome of
high blood pressure?

is for History
Personal history
Family history (Genogram)

is for Efficacy
Do you believe you can take the actions necessary to
prevent high blood pressure?

is for Lifestyles
Do you drink alcohol? How much?
Do you smoke cigarettes? How much?
Do you think you have stress in your life?
If you have said yes to any of these questions are you
willing to take the steps necessary to make positive
life style choices?

is for People you know with high blood pressure
How do they manage their high blood pressure?
Are they successful?
What can you learn form them?

is for Exercise
How much exercise do you get?
What kind of exercise is it?
_Do you live in a safe neighborhood to walk?
Any changes in weight in the last 5 years?

is for Diet and Drugs
Diet history (24 hour recall)
Use of salt during cooking or eating
Are you taking any medication for your high blood
pressure?
Have you ever been prescribed medication for high blood
pressure?
What do you know about blood pressure medication?
Have you ever used home remedies to treat high blood
pressure? (Example Garlic cloves or capsules, aloe vera
juice, multivitamin)

66

Appendix B

Directions for the Genogra-

The circle represents a female and the square represents

female. _

1. The index person or the client is represented by the
double circle.

2. For deceased persons the circle or square is x-ed out
with the age of death.

3. Two people who are married are connected by lines that
go down and across.

4. If a couple has children then each child's figure hangs
down from the line that connects the couple.

5. Children are drawn left to right starting with the
eldest.

6. The ages of the individuals are marked inside the
symbols.

7. Place medical history underneath each members symbol.

8. The goal is to include a three generational genogram
with the client's generation being the most recent.

9. Sign and date the genogram as it is done and updated

(McGoldrick 8 Gerson, 1985).

67

Appendix D

Pamphlet

MI

CVA

HTN

HTN

1910-1985

1900-1980

Appendix C

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