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1Running head: HIGH BLOOD PRESSURE PREVENTION
Prevention Strategies for High Blood Pressure:
A Rural Community Approach
Jasmine Wagner
University of Hawai’i at Hilo
Committee Chair:
Dr. Katharyn Daub
Committee Member:
Dr. Jeanette Ayers-Kawakami
2HIGH BLOOD PRESSURE PREVENTION
Acknowledgements
There are many people that have guided and supported me to make this Practice Inquiry Project
(PIP) possible. I would like to send a big mahalo nui loa the Wai’anae community for being
open to learning on the prevention strategies for high blood pressure and sharing feedback on the
topics.
I would like to thank the University of Hawai’i at Hilo School of Nursing for allowing me to be
part of the Doctor of Nursing Practice (DNP) Program and encouraging future nurse practitioners
to educate communities in Hawai’i.
I want to thank Dr. Katharyn Daub for being my PIP chair and mentor. Thank you for inspiring
me. Your guidance has allowed me to successfully deliver this project. Thank you for
supporting me and taking time to guide me through this project. You are truly phenomenal!
I would also like to thank Dr. Jeanette Ayers-Kawakami for being my committee member. You
have helped steer my project in the right direction. Your advice was much appreciated.
A special thanks to Bobbie Elisala, MSN, FNP. Thank you for all your support and
encouragement! I am fortunate to have had you throughout my journey.
Many thanks to the Honolulu Community Action Program and Leeward District Service Center
Manager, Val Tavai for supporting this project.
A big thanks to my family who showered me with unconditional love and support. To my
children, Skylee, Shayla, Scarlett, Jordan, Jacob, Arthur, and Colt, I love you all! To my mother,
Helena, thank you for always being there for me and supporting me through my endeavors. To
my father-in-law, Dale, and mother-in-law, Teresa, thank you for your tremendous support,
perseverance, and encouragement.
3HIGH BLOOD PRESSURE PREVENTION
Lastly, I would like to acknowledge and thank my husband, Carlos. Mahalo nui loa for your
unconditional love and support. You are my world.
4HIGH BLOOD PRESSURE PREVENTION
Abstract
High blood pressure (HBP) increases the risk for dangerous and potentially fatal health
conditions. HBP is a leading cause for heart disease and stroke in the United States (U.S.).
Heart disease and stroke are among the top causes of mortality in the U.S. HBP is known as the
“silent killer” because signs and symptoms are not always apparent. Individuals who live in
rural communities and lack education and access to medical services are at a higher risk for
developing HBP and are more likely to die from heart related complications compared to
individuals living in suburban or urban communities. According to literature, 15% of the
American population lives in rural areas. There are modifiable risk factors, which can lower the
risk of HBP. The outcome of this project is to increase awareness of HBP and identify
modifiable risk factors to reduce the incidence of HBP among rural community members.
Evidence-based education was provided to the community to improve outcomes. The project
setting was held at Honolulu Community Action Program (HCAP) on the Leeward Coast of
Oahu. A convenience sample was used for this project. A quantitative research design was used
to gather data. Materials used included a pre-questionnaire, a post-questionnaire, and an open-
ended questionnaire. Data was analyzed and organized in an Excel spreadsheet. This project
was also evaluated for validity and accuracy. The goal of this Practice Inquiry Project (PIP) was
to identify risk factors for HBP among community members, and to use this evidence-based
information to educate on effective strategies to reduce the risk of HBP.
5HIGH BLOOD PRESSURE PREVENTION
Table of Contents
Acknowledgements………………………………………………………………………………..2
Abstract……………………………………………………………………………………....……4
Chapter 1…………………………………………………………………………………………8
Introduction and Background……………………………………………………………………..8
Risk factors………………………………………………………………………………8
Cost of Managing High Blood Pressure…………………………………………………10
Problem Statement…………………….…………..……………………………………..10
Significance of the Problem……………………………...………………………………11
Expected Outcomes….………………………………………………………………..…11
Chapter 2………………………………………………………………………………………..12
Background and Project Description…………………………………………………………….12
Comprehensive and Focused Review of the Literature…………...…………………..…12
Background and Significance of Community…...……………………………………….13
Goal of the Project…..…………………………..……………………………………….14
Specific Aim 1…………………………………………………...………………………14
Specific Aim 2…………………………………………………...………………………14
Specific Aim 3………………………………………………...…………………………14
Chapter 3……………………………………………………………………………..…………..15
Project Design and Evaluation Plan……………………………………………………………...15
Research design…………...…..…………………………………………………………15
Framework…………………………...…………………………………………………..15
Project Setting……………………...…………………………………………………….16
6HIGH BLOOD PRESSURE PREVENTION
Target Population………………………………………………...................................…16
Recruitment.…….………………………………………………………………………..16
Timeline and Steps for Project Implementation…………………………………………17
Methods…………………………………………………………………………………..18
Data Analysis Methods………………………………………………………….……….18
Human Subject Protection……………………………………………………………….18
Chapter 4…………………………………………………………………………………..……..19
Results…………………………………………………………………………………...……….19
Background characteristics……………………………………………………...……….19
Pre-overall & Post-overall questionnaire………………………………………………..19
Pre-questionnaire & Post-questionnaire……………………………………………..….20
Week 1………………………………………………………………………………..…20
Week 2………………………………………………………………………………..….21
Week 3………………………………………………………………………………..….21
Week 4………………………………………………………………………………..….21
Project Evaluation…………………………………………………………………….….22
Chapter 5………………………………………………………………………………………....23
Discussion and Conclusion….…………………………………………………………………...23
Project Limitations……………………………………………………………………….23
Implications for Practice…………………………………………………………………24
Conclusion……………………………………………………………………………….24
References……………………………………………………………………………………......25
Appendix A………………………………………………………………………………………28
7HIGH BLOOD PRESSURE PREVENTION
Appendix B………………………………………………………………………………………29
Appendix C………………………………………………………………………………………30
Appendix D………………………………………………………………………………………31
Appendix E………………………………………………………………………………………32
Appendix F………………………………………………………………………………………33
Appendix G………………………………………………………………………………………34
Appendix H………………………………………………………………………………………35
Appendix I…………………………………………………………………………….…………36
Appendix J…………………………………………………………………………….…………38
Appendix K………………………………………………………………………………………39
8HIGH BLOOD PRESSURE PREVENTION
Chapter 1
Statement of the Problem
Introduction and Background
High blood pressure (HBP) or hypertension increases the risk for dangerous and
potentially fatal health conditions. HBP is a leading risk factor for heart disease in the United
States, and heart disease is the leading cause of mortality. HBP affects both men and women
equally. However, more men, under the age of 45, are affected more than women of the same
age. In contrast, more women, over the age of 65, are affected more than men of the same age.
African Americans develop HBP more than any other ethnic background (American Heart
Association, 2019). The American Heart Association (2018) estimates 103 million adults living
in the United States have HBP. Nearly half of individuals with HBP do not have their blood
pressure under control (Center for Disease Control, 2018). The normal, elevated, and HBP
readings from American Heart Association (2019) can be found in appendix H.
High blood pressure is known as the “silent killer” because signs and symptoms are not
always apparent. One in five adults with HBP are unaware they have it (CDC, 2018). In 2014,
more than 410,000 Americans died from HBP related deaths, which equates to more than 1,100
deaths each day (CDC, 2018). According to the American Heart Association (2018), death rates
caused by HBP increased by 38% from 2005 to 2015. The elimination of HBP can reduce
cardiovascular deaths by 30.4% among males and 38.0% among females (AHA, 2018). There
are modifiable risk factors to help reduce the incidence of HBP.
Risk Factors
There are two major risk factor groups for HBP. The first is modifiable risk factors,
which are factors that can be changed. Some modifiable risk factors include: physical activity,
9HIGH BLOOD PRESSURE PREVENTION
diet, maintaining a healthy BMI, limiting alcohol intake, controlling high cholesterol, diabetes,
smoking and tobacco use, and stress. The second is non-modifiable or fixed risk factors, which
are factors that cannot be changed. Some non-modifiable risk factors include: family history of
HBP, advanced age, race, and having chronic kidney disease. The Data from the Nurses’ Health
Study report that diet and lifestyle changes are main factors that can prevent HBP among females
(AHA, 2018).
Consuming a heart healthy diet can prevent and help manage HBP. The Dietary
Approaches to Stop Hypertension “DASH” diet is a heart healthy plan to lower blood pressure.
The DASH diet includes eating foods rich in fruits and vegetables, whole-grains, low fat daily
products, skinless poultry and fish, nuts and legumes, and non-tropical vegetable oils. In
addition, limiting saturated and trans fat, sodium, red meat, sweets and sugar-sweetened
beverages can help lower blood pressure. The World Health Organization (WHO) recommends
a low sodium diet to reduce HBP, cardiovascular disease and stroke. A study conducted by Ha
(2014), found the DASH significantly lowered systolic and diastolic blood pressure among
individuals with hypertension. The DASH diet had a greater effect on systolic BP. The study
found a decrease in systolic blood pressure of 11.5mmHg in participates with hypertension.
Dietary guidelines suggest no more than 1,500mg of sodium per day for individuals with
hypertension. People should be aware of hidden sources of salt in foods and condiments.
Incorporating the DASH diet and low sodium diet can significantly reduce blood pressure. In
addition, a healthy diet can improve weight management, which is crucial for a healthy lifestyle
and prevention of HBP.
The prevalence of overweight and obesity is on the rise. Between 1980 and 2013, adults
who are overweight and obese rose by 27.5% (AHA, 2018). In 2008, 1.46 billion adults were
10HIGH BLOOD PRESSURE PREVENTION
estimated to be overweight or obese. Education on diet and exercise can significantly reduce the
risk of developing HBP.
Lack of physical activity can lead to multiple health issues, with one major issue being
HBP. Physical activity can help to lower blood pressure. The American Heart Association
(2018) recommends 150 minutes per week of moderate to vigorous physical activity. These
activities include but not limited to brisk walking, hiking, jogging, running, bicycling,
swimming, or dancing. Tobacco use also increases the risk for HBP. Tobacco use is the leading
cause of preventable deaths, and nearly half a million Americans die each year from tobacco use
(American Heart Association, 2018).
Cost of Managing High Blood Pressure
The cost to treat HBP is also on the rise. Managing HBP cost the nation $48.6 billion
annually (CDC, 2018). These costs include heath care related services; medications to treat
HBP, and absence from work. The American Heart Association predicts by 2035 a total direct
cost of HBP will be estimated at $220.9 billion. In addition, pharmacological intervention costs
are also increasing. According to IMS Health National Prescription Audit, the number of
prescriptions for antihypertensive medications increased from 613.7 million to 653 million
between 2010 and 2014 (AHA, 2018). The cost to fill the 653 antihypertensive medications in
2014 was $28.81 billion.
Problem Statement
High blood pressure increases the risk for dangerous and potentially fatal health
conditions. HBP is an ongoing chronic condition that affects many people in the Wai’anae
community of O’ahu. Wai’anae has an estimated population of 13,000 individuals (U.S. Census
Bureau, 2010). Most of the population is mature adults, and according to the CDC (2017),
11HIGH BLOOD PRESSURE PREVENTION
33.5% of adults over the age of 20 have HBP. Native Hawaiians and Pacific Islanders make up a
large percentage of the Wai’anae community who are at a higher risk for developing HBP
compared to other ethnicities. Education on HBP prevention strategies is vital for the Wai’anae
community to decrease the risk of developing HBP.
Significance of the Problem
In 2016, heart disease and stroke were the first and fourth cause of death in Hawai’i.
Lack of awareness and lack of education are major factors for developing HBP among rural
communities. Those who live in rural communities are at a higher risk for developing HBP
compared to individuals who live in the suburban or urban communities. There are modifiable
risk factors that can decrease the risk of developing HBP for rural communities.
Expected outcomes
The outcome of the project is to increase awareness of HBP and identify modifiable risk
factors to reduce the risk of HBP among rural community members. Evidence based education
is provided to further improve outcomes.
12HIGH BLOOD PRESSURE PREVENTION
Chapter 2
Background and Project Description
Comprehensive and Focused Review of the Literature
The clinical question that drove this literature review was, “For rural community
members at risk for increased blood pressure, what are modifiable risk factors to prevent high
blood pressure?” Several database searches were conducted for literature review which include:
American Heart Association, Centers for Disease Control and Prevention, CINAHL, Conchrane
Library, EBSCOhost, Google, and Pub Med. The time frame was limited to 2014-2019. Key
words used included: “high blood pressure,” “hypertension,” “high blood pressure in adults,”
“risk factors for high blood pressure,” “rural community,” “low socioeconomic status,” “DASH
diet,” “high salt diet,” and “community level intervention.” The literature search provided
evidence on HBP among rural community members.
High blood pressure is a leading cause of death around the world. Understanding what
can cause HBP and being aware of ways to prevent this disease is crucial to prevent health
complications. The prevalence of hypertension in 2025 is projected to increase by 60% (Diaz &
Shimbo, 2013). Currently, 33% of the world’s population has hypertension. According to the
CDC (2017), American’s living in rural areas has a higher risk of developing blood pressure than
their urban counterparts.
There are ways to prevent hypertension, such as increasing physical activity and
consuming a healthy diet. Activities that can help prevent hypertension include aerobic exercise,
resistance training, high intensity, interval training, accumulated exercise, and walking.
Interventions can benefit the communities’ knowledge and understating of hypertension. In
addition, primary prevention can decrease the risk for hypertension and is one way to increase
13HIGH BLOOD PRESSURE PREVENTION
awareness on hypertension and promote health to the community. Lifestyle modification, such
as a well balanced diet, reducing sodium, smoking cessation, regular physical activity, and
avoiding excessive alcohol consumption is recommended to reduce hypertension (Aronow
2017).
Background and Significance of Community
The Wai’anae community is located on the Leeward side of Oahu, which is about an hour
drive from downtown. The land in Wai’anae is 5.4 square miles. The Wai’anae coast is
considered rural with some farmlands in the valleys but predominately residential. Wai’anae
does not get much rain and is considered a dry and desolate area. However, during the summer
months, Wai’anae will get more rainfall than any part of the island due to humid sea breezes that
blow against the Wai’anae mountain range. This leaves the mountains with lush green
vegetation. Wai’anae has a hidden homeless camp, which is 19 acres, and is located in the
Wai’anae Boat Harbor. There are more than 240 adults and children who reside in the Wai’anae
Boat Harbor area.
The United States Census is updated every 10 years. The most recent census count was
in April of 2010 with an estimate of 13,000 individuals residing in Wai’anae (U.S. Census
Bureau, 2010). Most of the population is adults. Persons under the age of 18 are 32.5% of the
population (U.S. Census Bureau, 2010). There is less than 1% variation between the male and
female population with females being 0.6% higher than males in numbers. Mixed race is the
predominant race of Wai’anae at 44.8%. Native Hawaiians or other pacific islander is second at
30.6%. The third greatest race of the population is Hispanic at 15%.
14HIGH BLOOD PRESSURE PREVENTION
Goal of the Project
The goal of this PIP is to identify risk factors for HBP among rural community members,
and use evidence based information to educate regarding effective strategies to reduce the risk of
HBP.
Specific Aim 1
Assess the level of awareness that contribute to HBP among rural community members.
Objective 1. Determine baseline understanding by administering a pre-overall
questionnaire consisting of 5 questions.
Objective 2. Administer a pre-questionnaire consisting of 5 questions related to the
educational session provided.
Specific Aim 2
Provide evidence-based education.
Objective 1. Identify modifiable and non-modifiable risk factors for HBP.
Objective 2. Use American Heart Association Five Simple Steps to Control Blood
Pressure.
Specific Aim 3
Evaluate the project for validity and accuracy to decrease HBP risks.
Objective 1. Determine if awareness on HBP was effective by administering a post-
questionnaire and post-assessment questionnaire.
Objective 2. Evaluate participants’ individual thoughts regarding the project using an
open-ended questionnaire.
15HIGH BLOOD PRESSURE PREVENTION
Chapter 3
Project Design and Evaluation Plan
Research Design
The project design was a practice intervention design. The implementation of the project
was done over four weeks. Each week offered an educational session on ways to reduce the risk
of HBP using American Heart Association’s Five Simple Steps to Control Blood Pressure. An
overall pre-questionnaire was administered prior to the start of the first week to determine a
baseline understanding. Prior to each educational session, a pre-questionnaire was administered
and after the educational session, a post-questionnaire was administered. A post-overall
questionnaire was administered at the conclusion of the project.
Framework
The Iowa Model: Evidence Based Practice to Promote Excellence in Health Care was
selected as the theoretical framework to guide this practice inquiry project (Appendix K). The
Iowa Model was developed to help identify issues, find solutions, and implement changes while
using evidence based methods. The Iowa Model was chosen for this project because of the
importance of using evidence-based practice to guide research. Permission to use the Iowa
Model was approved by the University of Iowa Hospital and Clinics.
There are several steps within the Iowa Model.
1. Step 1 includes identifying triggering issues where evidence base practice change is
needed.
2. Step 2 is stating the question or purpose for the project.
3. Step 3 requires an interdisciplinary team to be formed.
16HIGH BLOOD PRESSURE PREVENTION
4. Step 4 is assembling and synthesizing the body of evidence. This also includes
conducting a related literature search. If there is sufficient evidence and research the
model suggest conducting and implementing research. The next step is to integrate and
sustain the practice change. The final step is to disseminate results. The Iowa Model fit
this project well because of the focus on evidence-based methods to improve patient care
(Iowa Model Collaborative, 2017).
Project Setting
Project setting took place at The Honolulu Community Action Program (HCAP) in
Wai’anae, which is located on the Leeward Coast of Oahu. HCAP is a private, non-profit
organization that offers many programs and services on Oahu to economically challenged
communities since 1965. HCAP’s mission statement is, “POI: Providing Opportunities and
Inspiration to enable low-income individuals or families to achieve self-reliance.” Most of
HCAP members are predominately Native Hawaiian and reside in Wai’anae. Community
members gathered at HCAP once a week for this project.
Target Population
The target population included adult participants that reside in the Wai’anae community.
Eligibility criteria for participants include adults, male and female, over the age of 18, who live
in the Wai’anae community and are able to read, write and speak English, and have an interest in
prevention strategies for HBP. Community members were included or excluded based on the
recruitment statement prior to implementing the project.
Recruitment
Participants were recruited from the Wai’anae community. A convenience sampling
method was used to recruit participants. The sample size goal was 10-15 participants. Before
17HIGH BLOOD PRESSURE PREVENTION
the start of the project, a recruitment statement was verbally delivered in person to members who
attend HCAP in Wai’anae. Each member was informed about the project, the four-week
timeline, educational sessions, and questionnaire surveys that were part of the project. In
addition, every member was informed regarding the eligibly criteria and voluntary participation.
Timeline and Steps for Project Implementation
The Wai’anae community was the starting point for this project. Participation subjects
came from the targeted community. Assessment of HBP was obtained by pre-questionnaire and
data was collected. Education on HBP was conducted over the course of four weeks and
consisted of American Heart Association (2019) Five Simple Steps to Control Your Blood
Pressure. The five steps include:
1. Knowing your numbers
2. Working with your doctor
3. Make a few lifestyle changes
o Maintain a healthy weight
o Eat healthier
o Reduce sodium
o Get active
o Limit alcohol
4. Check your blood pressure at home
5. Take you medication.
A post-questionnaire was administered after the educational teaching and the data was collected.
An evaluation on the project was administered and collected after the four weeks. All data was
analyzed appropriately and put into a Word spreadsheet.
18HIGH BLOOD PRESSURE PREVENTION
Methods
The methods for this project follow the same outline found under specific aims and
objects on 14.
Data Analysis Methods
A quantitative study was done for data analysis. Data was collected using structured
multiple-choice questionnaires. An information sheet was used to obtain information on risk
factors for HBP. In addition, an open-ended questionnaire was administered after the project.
Data was analyzed using pie charts and frequency distribution graphs.
Human Subject Protection
The University of Hawai’i at Hilo School Nursing Department approved this project to
proceed. Application for this practice inquiry project was submitted to the Institutional Review
Board (IRB) and approved to conduct this study. The population consisted of community
members in a rural setting. Each participant was informed of voluntary participation and the
option to opt out at anytime. Each participant, who voluntarily wanted to participate, was
provided with an informed consent prior to the start of the project (Appendix I). All information
remained confidential and names were never collected.
19HIGH BLOOD PRESSURE PREVENTION
Chapter 4
Results
Background Characteristics
All the participants were above 50 years old. There were a total of 17 participants that
filled out the information sheet (Appendix A). The participant age range of 50-59 years old
accounted for 18%, and participants age 60 years and older accounted for 82%. Majority of the
participants were female (88%). The participants self-identified as either American Indian or
Alaska Native, Asian, Black, Native Hawaiian or Other Pacific Islander, White, or Other. The
sample had a high number of Native Hawaiian or Other Pacific Islander (71%), and lower
numbers of White (18%), American Indian or Alaska Native (6%), and Other (6%). Highest
level of education completed was somewhat distributed evenly, with the exception of no post
college graduates. Thirty-five percent of the participants had some college, 29% graduated high
school, 18% graduated from college, and 18% had less than a high school diploma. Ninety-four
percent of the participants had health insurance and 6% had no health insurance. Eighty-two
percent of the participants said they smoked tobacco. Fifty-three percent of the participants said
they have HBP. When asked about following a health diet, 53% of the participants said most of
the time, 24% said sometimes, 12% said always, and 12% said never.
Pre-Overall Questionnaire & Post-Overall Questionnaire
During week one, prior to the start of the project, a pre-overall questionnaire was
administered to determine a baseline understanding for HBP (Appendix B). There were 16
participants that filled out the pre-overall questionnaire. During week four, after the end of the
project, the same overall questionnaire was administered to determine if the educational teaching
sessions were effective. There were 15 participants that filled out the post-overall questionnaire.
20HIGH BLOOD PRESSURE PREVENTION
Results for the over-all questionnaire show a significant increase between pre-overall and post-
overall scores. There was a 12% increase in knowledge for question one. There was a 30%
increase in knowledge for question two. Question three depicted a 43% increase in knowledge.
Question 4 demonstrated a 42% increase in knowledge, and question 5 showed a 79% change in
knowledge (Table 1).
Table 1.
Pre-Questionnaire and Post-Questionnaire
In total, there were four pre-questionnaires and four post-questionnaires administered
over the course of the four-week implementation portion of the project. The pre-questionnaire
was completed before the start of the educational session and the post-questionnaire was
completed after the educational session. The cumulative results were compared to observe
changes.
Week 1
The topics covered in week one were Risk Factors for HBP, Check your Blood Pressure
at Home, and Know Your Numbers (Appendix C). There were 15 participants during week one.
The pre-score cumulative determined 81% of participants felt they were educated about the topic
of HBP. After the educational session, the post-score demonstrated that 95% of participants felt
21HIGH BLOOD PRESSURE PREVENTION
they were much more educated on the topic of HBP. There was a 14% increase in pre-post test
scores.
Week 2
The topics covered in week two were the life style changes: Maintain a Healthy Weight
and Get Active (Appendix D). During week two, there were 13 participants. The pre-score
cumulative determined 72% of participant felt they were educated about the topic of HBP. After
the educational session, the post-score demonstrated that 95% of participants felt they were much
more educated on the topic of HBP. There was a 23% increase in pre-post test scores.
Week 3
Week three covered the lifestyle changes: Eat Healthier, Reduce Sodium, and Limit
Alcohol (Appendix E). There were 15 participants during week three. The pre-score cumulative
determined 72% of participants felt they were educated about the topic of HBP. The post-score
demonstrated that 96% of participants felt they were much more educated on the topic of HBP.
There was a 24% increase in pre-post test scores.
Week 4
The topics during week four included: Working with your Doctor and The Importance of
Taking your Blood Pressure Medication (Appendix F). During week four, there were 13
participants. The pre-score cumulative determined 82% of participants felt they were educated
about the topic of HBP. After the educational session, the post-score demonstrated that 97% of
participants felt they were much more educated on the topic of HBP. There was a 15% increase
in pre-post test scores.
22HIGH BLOOD PRESSURE PREVENTION
Project Evaluation
There were two multiple-choice questions and four open ended questions for the project
evaluation (Appendix G). The first question, “I enjoyed the presentation,” 100% of the
participants responded “very much.” The second question, “I will benefit from this
presentation,” 100% of the participants responded “very much.” The remaining four questions
were open-ended questions. The participants had various answers for the first question, “What
modifiable risk factors have you learned that can decrease the risk of high blood pressure,”
included responses were avoiding salty foods, looking for foods to eat with low salt, exercising,
and taking medication as prescribed by your doctor. The most common response for the
question, “What part of the project did you like the best,” included topics such as diet and
exercise, managing your medication and working with your doctor. For the question, “What part
of the project did you like the least,” the majority of the participants responded “none” or “I liked
it all.” The last open-ended question was “additional comments,” and responses included, “thank
you,” “very informative,” “N/A,” and some were left blank.
23HIGH BLOOD PRESSURE PREVENTION
Chapter 5
Discussion and Conclusion
Studies show there is a link between lack of education and increased HBP. One aim of
this project was to use evidence based information to educate on prevention strategies. This aim
was met by providing evidence-based education over the course of four weeks. Another aim for
this project was to increase awareness of HBP and identify modifiable risk factors. The findings
from this project concluded that this aim was met by the increase in post-questionnaire scores.
Education and health promotion is necessary to improve population health. The patient
education was delivered successfully within this project. It is important to target and educate
high-risk communities, such as the rural population, to improve their health. There is an
abundance of information on how to control BP, and the results discussed from this project is
consistent with the information found in the literature. This PIP demonstrates that providing
education to rural community members increases awareness on the topic.
Project Limitations
There were some limitations with this project. The use of a convenience sample may
have been a limiting factor. This project obtained a small sample size of less than 20 participants
per day. Another limiting factor may have been the fact that all participants were collected from
HCAP in Wai’anae. Other limitations include the participants that were interested in the topic
and met the requirements to participate. However, this project was to target Wai’anae
community members who met the requirements of the study. There are not many studies on how
prevention strategies for HBP affect rural communities and their awareness on HBP. More
studies should be done to lower the risk of HBP and increase knowledge on the subject.
24HIGH BLOOD PRESSURE PREVENTION
Implications for Practice
Education is key to increase awareness and decrease the risk of hypertension. Nurse
practitioners should advocate for those in the community in making preventive programs
accessible. Nurse practitioners can provide education on preventive strategies to empower the
community to make healthier choices. This project aids DNP practitioners in providing
education programs to improve health outcomes and awareness of hypertension in rural
populations. The findings for this project can help DNP practitioners who seek to improve
awareness for their patients about HBP. DNP practitioners can contribute by discussing the five
simple steps to lower the risk of HBP. Due to the small sample size of this project, more studies
on prevention strategies for HBP are needed in a larger population target.
Conclusion
High blood pressure remains a leading risk factor for heart disease. The prevention of
HBP is a public health challenge, but education on prevention strategies can help decrease the
incident of HBP for this rural community. Educating the public on American Heart Association
Five Simple Steps to Control Blood Pressure is an effective way to increase awareness on HBP
and decrease the modifiable risk factors. This project on the five simple steps to control blood
pressure can aid DNP practitioners or other healthcare professionals in providing education
programs to improve health outcomes and increase awareness of HBP in rural populations. DNP
practitioners can contribute by discussing the five simple steps to lower the risk of HBP. Future
research can use this project as a baseline to increase awareness on HBP.
25HIGH BLOOD PRESSURE PREVENTION
Reference
American Heart Association. (2018). Getting Active to Control High Blood Pressure. Retrieved
from
http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/MakeChangesThatM
atter/Getting-Active-to-Control-High-Blood-
Pressure_UCM_301882_Article.jsp#.WuuaZMgh3wc
American Heart Association. (2019). Five simple steps to control your blood pressure.
https://www.heart.org/HEARTORG/Conditions/HighBloodPressure/AboutHighBloodPre
ssure/Five-Simple-Steps-to-Control-Your-Blood-Pressure_UCM_301806_Article.jsp
American Heart Association. (2018). Heart Disease and Stroke Statistics – 2018 Update: A
Report From the American Heart Association. Retrieved from
http://circ.ahajournals.org/content/137/12/e67
American Heart Association. (2019). Know your risk factors for high blood pressure. Retrieved
from https://www.heart.org/en/health-topics/high-blood-pressure/why-high-blood-
pressure-is-a-silent-killer/know-your-risk-factors-for-high-blood-pressure
American Heart Association. (2017). Monitoring your blood pressure at home. Retrieved from
http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/KnowYourNumbers/
Monitoring-Your-Blood-Pressure-at-Home_UCM_301874_Article.jsp#
American Heart Association. (2019). Understanding blood pressure readings. Retrieved from
https://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-
pressure-readings
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America’s Health Rankings. (2018). High blood pressure in United States in 2017. Retrieved
from https://www.americashealthrankings.org/explore/annual/measure/Hypertension/
state/ALL
Aronow W. S. (2017). Lifestyle measures for treating hypertension. Archives of medical science
: AMS, 13(5), 1241–1243. doi:10.5114/aoms.2017.68650
Centers for Disease Control and Prevention. (2016). High blood pressure facts. Retrieved from
https://www.cdc.gov/bloodpressure/facts.htm
Centers for Disease Control and Prevention. (2017). Hypertension. Retrieved from
https://www.cdc.gov/nchs/fastats/hypertension.htm
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https://www.cdc.gov/bloodpressure/measure.htm
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from five leading causes. Retrieved from
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Diaz, K. M., & Shimbo, D. (2013). Physical Activity and the Prevention of Hypertension.
Current Hypertension Reports, 15(6), 659–668.
Ha, S. K. (2014). Dietary Salt Intake and Hypertension. Electrolytes & Blood Pressure: E & BP,
12(1), 7–18.
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Iowa Model Collaborative. (2017). Iowa model of evidence-based practice: Revisions and
validation. Worldviews on Evidence-Based Nursing, 14(3), 175-182.
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https://www.census.gov/quickfacts/table/BZA010213/1574450/accessible#footnotes.
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Appendix A
Let’s Prevent High Blood Pressure
INFORMATION SHEET
1. What age group do you fall into?a. 18-29b. 30-39c. 40-49d. 50-59e. 60 and over
⮚ Which gender do you most identify?a. Maleb. Femalec. Other
⮚ Which race do you most identify?a. American Indian or Alaska Nativeb. Asianc. Blackd. Native Hawaiian or Other Pacific Islandere. Whitef. Other
⮚ What is the highest grade you completed?a. Less than high schoolb. High school graduatec. Some colleged. College graduatee. Post-college graduate
⮚ Do you have health insurance?a. Yesb. Noc. Not sure
⮚ How often do you eat fast food or processed foods?a. Neverb. Rarelyc. Oftend. Always
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Appendix B
High Blood Pressure Overall Pre & Post Questionnaire
PLEASE CIRCLE ONE
⮚ High blood pressure leads to the number one cause of death in the United States. What is the leading cause of death in the United States?
a. Cancerb. Diabetesc. Heart diseased. Stroke
⮚ Which of the following is considered a normal blood pressure?
a. 142/90 mmHgb. 118/78 mmHgc. 139/80 mmHgd. 152/110 mmHg
⮚ What do you think are risk factors for high blood pressure?
a. Smokingb. Lack of physical exercisec. Diet high in saltd. Overweighte. Stressf. All of the above
⮚ What is the maximum amount of salt consumption recommended per day?
a. 1,150 mg (1/2 teaspoon)b. 2,300 mg (1 teaspoon)c. 3,450 mg (1 ½ teaspoons)d. 4,600 mg (2 teaspoons)
⮚ How much exercise is recommended weekly for adults (such as brisk walking, dancing, gardening)?
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a. 1 hourb. 2.5 hoursc. 4 hoursd. 5 hours or more
Appendix C
Health Topic:Risk Factors for High Blood Pressure
Check Your Blood Pressure at Home and Know Your Numbers
PLEASE CIRCLE ONE
1. What are non-modifiable risk factors for high blood pressure?
a) Family historyb) Agec) Genderd) Racee) All of the above
2. What are modifiable risk factors for high blood pressure?
a) Unhealthy dietb) Lack of physical activityc) Drinking too much alcohold) Smokinge) All of the above
3. Which of the following is important when taking your blood pressure at home?
a) Be stillb) Sit correctlyc) Measure at the same time every dayd) Take multiple readings and record the resultse) All of the above
4. A normal blood pressure is considered:
a) Less than 120/80b) 130/89c) 149/95d) Above 140/90
5. There are steps you can take to keep your blood pressure in a healthy range.
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a) Trueb) False
Appendix D
Health Topic:Maintain a Healthy Weight, Get Active
PLEASE CIRCLE ONE
1. What is body mass index (BMI)?
a) Diagnostic tool of body fatb) A screening tool that determines if you are at a healthy weight based on your
height and weightc) Interpreted the same for adults, teens, and childrend) Not important
2. What are ways to maintain a healthy weight?
a) Reduce screen timeb) Exercise regularlyc) Follow a healthy dietd) Eat fruits and veggies dailye) All of the above
3. What is an example of moderate to intense aerobic activity?
a) Brisk walkingb) Water aerobicsc) Gardeningd) Dancinge) All of the above
4. How much moderate to intense physical activity should you aim for each week?
a) 1 hourb) 2.5 hoursc) 4 hoursd) 5 hours
5. Benefits to being more active include:
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a) Lower risk of high blood pressureb) Better sleepc) Less weight gain and obesityd) Better quality of lifee) All of the above
Appendix E
Health Topic:Eat Healthier, Reduce Sodium, Limit Alcohol
PLEASE CIRCLE ONE
6. According to the Dietary Guidelines, what is a healthy eating pattern?
e) A variety of vegetablesf) Whole fruitsg) Whole grainsh) Fat-free or low fat dailyi) Variety of protein foodsj) All of the above
7. According to the Dietary Guidelines, what does a healthy eating pattern limit?
f) Saturated fatsg) Tans fatsh) Added sugarsi) Sodiumj) All of the above
8. How much salt does the Dietary Guidelines for Americans and American Heart Association recommend a day for adults?
f) Less than 1,150 mg (1/2 teaspoon)g) Less than 2,300 mg (1 teaspoon)h) More than 3,450 mg (1 ½ teaspoons)i) More than 4,600 mg (2 teaspoons)
9. What is excessive alcohol use?
e) Binge drinkingf) Heavy drinkingg) Alcohol use by anyone under 21 years oldh) All of the above
10. The Dietary Guidelines for Americans defines moderate alcohol consumption as:
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f) 1 drink for women and 2 drinks for men per dayg) 2 drinks for women and 4 drinks for men per dayh) 4 drinks for women and 4 drinks for men per dayi) 6 drinks for women and 6 drinks for men per day
Appendix F
Health Topic:Work with Your Doctor
Importance of Taking Blood Pressure Medication
PLEASE CIRCLE ONE
11. Having a good doctor-patient partnership is important to control your blood pressure and reach your treatment goals.
k) Truel) False
12. It is important to ask your doctor about your blood pressure at your checkups.
k) Truel) False
13. Which of the following are substitutes for blood pressure medications?
j) Naturopathic approachesk) Waterl) Over the counter medicationsm) There is no substitute for blood pressure medications
14. High blood pressure cannot be cured, but it can be managed with:
i) Life style changes j) Medication when neededk) A and Bl) High blood pressure cannot be managed
15. Taking blood pressure medication as directed by your doctor is ______ important.
j) Sometimesk) Alwaysl) Never
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Appendix G
Project Evaluation
1. I enjoyed the presentation
a) Very muchb) Somewhatc) Not reallyd) Not at all
2. I will benefit from this presentation
a) Very muchb) Somewhatc) Not reallyd) Not at all
3. What modifiable risk factors have you learned that can prevent high blood pressure?
4. What part of the project did you like the best?
5. What part of the project did you like the least?
6. Additional comments:
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Mahalo Nui Loa for your participation!
Appendix H
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Appendix I
University of Hawai'iConsent to Participate in a Research Project
Jasmine Wagner, Student InvestigatorProject title: Strategies to Prevent High Blood Pressure: A Rural Community Approach
Aloha! My name is Jasmine Wagner and you are invited to take part in a research study. I am a graduate student at the University of Hawai'i at Hilo in the Department of Nursing. As part of the requirements for earning my graduate degree, I am doing a research project.
What am I being asked to do? If you participate in this project, you will be asked to fill out a survey.
Taking part in this study is your choice. Your participation in this project is completely voluntary. You may stop participating at any time. If you stop being in the study, there will be no penalty or loss to you.
Why is this study being done?The purpose of my project is to evaluate the effectiveness of education on prevention strategies for high blood pressure in a rural community. I am asking you to participate because you live in a rural community area.
What will happen if I decide to take part in this study?You will fill out surveys that consist of multiple choice and open-ended questions. It will take 5-10 minutes per survey. The survey questions will include questions like, “A normal blood pressure is considered?” “What are ways to maintain a healthy weight?” “What are modifiable risk factors for high blood pressure?” You will receive education on a blood pressure health topic then take a survey based on the health topic information. The surveys will be paper format and provided to you in person.
What are the risks and benefits of taking part in this study?I believe there is little risk to you for participating in this research project. You may become stressed or uncomfortable answering any of the survey questions. If you do become stressed or uncomfortable, you can skip the question or take a break. You can also stop taking the survey or you can withdraw from the project altogether.
There will be no direct benefit to you for participating in this survey. The results of this project may help improve if education on prevention strategies for high blood pressure is effective.
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Privacy and Confidentiality: I will not ask you for any personal information, such as your name or address. Please do not include any personal information in your survey responses. I will keep all study data secure in a locked filing cabinet in a locked office/encrypted on a password protected computer. Only my University of Hawai'i advisor and I will have access to the information. Other agencies that have legal permission have the right to review research records. The University of Hawai'i Human Studies Program has the right to review research records for this study.
Compensation:There is no compensation for participating in this research project.
Future Research Studies:After removing identifiers, the data from this study collected will not be used or distributed for future research studies.
Questions: If you have any questions about this study, please email me at [email protected]. You may also contact my faculty advisor, Dr. Katharyn Daub, at 808-932-7067 or email at [email protected]. You may contact the UH Human Studies Program at 808.956.5007 or [email protected] to discuss problems, concerns and questions, obtain information, or offer input with an informed individual who is unaffiliated with the specific research protocol. Please visit http://go.hawaii.edu/jRd for more information on your rights as a research participant.
Filling out the survey will be considered your consent to participate in this study.
Please keep a copy of the consent form for your records.
Mahalo!
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Appendix J
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Appendix K
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