Chapter 2. Literature Review

Managing Hypertension in the African-American Population Submitted by Philippa Isioma Ehoro Direct Practice

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Improvement Project Proposal Doctor of Nursing Practice Grand Canyon University Phoenix, Arizona October 23, 2018 © by Philippa Isioma Ehoro, 2018 All rights reserved. GRAND CANYON UNIVERSITY Managing Hypertension in the African-American Population by Philippa Isioma Ehoro Proposed October 23, 2018 DPI PROJECT COMMITTEE: Full Legal Name, EdD, DBA, or PhD, Manuscript Chair Full Legal Name, EdD, DBA, or PhD, Committee Member Full Legal Name, EdD, DBA, or PhD, Committee Member v Table of Contents Introduction to the Chapter …………………………………… Error! Bookmark not defined. Theoretical Foundations…………………………………………………………………………………….5 Review of the Literature ………………………………………………………………………………….11 Main themes …………………………………………… Error! Bookmark not defined. I. Theme 1: Hypertension management and intervention is the main target of concern for the African American population. ……………………………………..11 II. Theme 2: Adherence to medication regimen is a factor that can impact blood pressure in these patients ………………………………………………………………………19 III. Theme 3: Socioeconomic factors and behavioral factors …………………21 Summary ……………………………………………………………………………………………………….26 References …………………………………………………………………………………………………………..31 1 Chapter 2: Literature Review Introduction to the Chapter and Background to the Problem This chapter focusses on highlighting the findings and information put forward from various existing research studies and peer reviewed articles relating to the project topic. The existing knowledge on the topic will be of help in guiding how the research should be structured and designed to give invaluable benefits to the existing body of knowledge regarding hypertension and its management, especially among the African American population. The selected articles were published within the past one decade, but most of them were published in the last five years. The information presented is thus current and vital in shaping decisions on the best approaches to use to manage and control the occurrence of high blood pressure among the African American population. Hypertension or high blood pressure (HBP or BP) is a global concern and its prevalence has greatly increased over the years. BP continues to be a great burden for many, especially in the minority populations with emphasis geared towards the African American population. African American patients have the greatest burden when it comes to hypertension and is more common to present earlier in life than known to be severe than the white patients (Egan, Bakris, & Forman, 2018). Studies have shown that hypertension prevalence is highest in the minority patients’ populations, most especially among the African American population (Charles, Anouk, & Leonard, 2010). Other studies also report that BP affects African American community more than people from other ethnic group in the U.S., and its persistent disparity has been linked to socioeconomic shortcomings (Anderson & Armstead, 1995; Go et al., 2014; Coulon, & Wilson, 2015). Studies have also shown that minority and low income ethnically diverse 2 adolescents are at increased risk for undiagnosed and untreated hypertension and obesity (Ewald, Bond, & Haldeman, 2016). Of note, it tends to be prevalent in older adult than younger adults and disproportionately affects African Americans of all ages with a higher burden of hypertension-related complications than individuals of other races. The major complications resulting from uncontrolled hypertension include heart failure, stroke, Chronic kidney disease and many others (Still, Ferdinand, Ogedegbe, and Wright, n.d). Hypertension is one of the most treated condition in the clinic setting, requiring frequent office or clinic visits in order to attain an optimal blood pressure goal for most patients. Hypertension can be a very debilitating disease that can result to so many health complications; it is the leading cause of cardiovascular complications worldwide, the leading global risk for mortality worldwide and ranks first among all health issues (Gu, Li, Yang, Wang, Bo, & Liu, 2015). The research on how best to manage and handle patients with BP is thus of vital importance to the healthcare sector. This research will help in understanding the major factors leading to high levels of BP among African Americans and the best interventions that can help in reducing the prevalence of the disease as well as apt management of the existing BP patients to ensure that they live healthier and happier lives. The management and control of BP is thus central to the operations and mandate of the department of health and will help to ensure that populations living with BP are best served by the healthcare system. BP can easily be managed and prevented by taking prescribed medication regimen as directed by their provider. However, early detection of the condition through proper history taking, patient self-awareness, proper education on self-management, 3 lifestyle modification, managing daily stress, and partaking in regular physical activity are necessary to improve the quality of life for those with high blood pressure (Wright, Still, Jones, & Moss, 2018). The challenge is to assess the knowledge level of the African American (AA) patients in understanding their disease process and its financial burden in relation to cost. It is estimated that the direct annual cost by 2030 will be 200.3 billion reflecting an increase of 130.4 billion from 2010 (Moughrabi, 2017). As such, inventing better BP management and control mechanisms is of invaluable cost-related benefits to the healthcare sector as well as to the targeted patients. The main sections of this literature review include the background of the problem, the theoretical foundations guiding the research, review of the existing literature – guided by the three themes and subthemes, and finally the summary of the chapter. Background The immense impact of uncontrolled blood pressure has placed a huge impact on the healthcare services, healthcare utilization, and patient outcome. A literature review will discuss how various intervention like knowledge and education, treatment modalities and physical activities can influence the prevalence of uncontrolled blood pressure in the African American community. As the saying goes knowledge is power because with knowledge, one can prevent or halt many complications that can result from improper health behaviors that affects blood pressure. Hypertension, if not well controlled can result to preventable diseases, leading to disability in many. Many BP patients suffer from stroke, myocardial infarction, and renal failure, which in turn results to End Stage Renal Disease (ESRD), which requires dialysis. A patient ends up getting ESRD due to late diagnosis and poor management of BP. According to Kwon et al. (2015), someone in the U.S. has a stroke every 40 seconds 4 and at least one dies from it every 4 minutes. In light of this, it is very imperative that all clinicians particularly take this into consideration so that early detection and treatment can commence by recognizing all patients that have the potential risk factors that might predispose them to this preventable disease, but at the same time, if not controlled, can cause harm to the human body. Ways providers can increase or improve the quality of life of these individuals, is by taking proper history, recognizing risk factors such as age, BMI, environment factors, family history and to encourage life style modification. Of note, lack of physical inactivity is a powerful modifiable risk factor for hypertension. Healthcare providers and clinicians are currently educating many patients on these issues; however, these patients choose not to comply with the provided recommendations, leading to many becoming dependent on the government to care for them due to their inability to work as a result of disability that has resulted from uncontrolled hypertension. Gu et al. (2015) state that many researchers have associated high blood pressure to income inequality and that high blood pressure is more prevalent in the minority community and ethnic minority groups. This is mainly due to lack of awareness, education, and poor access to health services. Search Methods A search of literature review was conducted over the course of one year. During the search, various search engine where used to conduct review of literature on the management of hypertension in the minority populations. The search includes but are not limited to Grand Canyon university Library, PubMed, Google scholar, ProQuest and OVID with the keywords: Uncontrolled blood pressure, Hypertension management, Hypertension in African American, management, lifestyle modification, treatment, safety and mediation adherence. All search was applied and tied to uncontrolled blood pressure 5 in American America patients. They search resulted to over 500 articles but where narrowed down to 100 articles by screening down the list to look for article that pertained to the research in question, duplicated where removed, and those that where not peer reviewed article or have an abstract attached to it. Criterion Learner Score (0, 1, 2, or 3) Chairperson Score (0, 1, 2, or 3) Comments or Feedback INTRODUCTION (TO THE CHAPTER) AND BACKGROUND (TO THE PROBLEM) This section describes the overall topic to be investigated, outlines the approach taken for the literature review, and defines the evolution of the problem based on the gap or need defined in the literature from its origination to its current form. Introduction states the overall purpose of the project. Introduction provides an orienting paragraph so the reader knows what the literature review will address. Introduction describes how the chapter will be organized (including the specific sections and subsections). Introduction describes how the literature was surveyed so the reader can evaluate the thoroughness of the review. Background provides the historical overview of the problem based on the gap or need defined in the literature and how it originated. Background discusses how the problem has evolved historically into its current form. This section is written in a way that is well structured, has a logical flow, and uses correct paragraph structure, sentence structure, punctuation, and APA format. NOTE: Once the document has been approved by your chairperson and your committee and is ready to submit for AQR review, please remove all of these assessment tables from this document. Score 0 (not present); 1 (unacceptable; needs substantial edits); 2 (present, but needs some editing); 3 (publication ready). Theoretical Foundations The main theory that will guide this research is the Health Belief Model. The 6 Health Belief Model theory is known to be one of the health theories that greatly influence health behavior. This model works based on knowledge and understanding of the predisposing conditions and the dangers the signs and symptoms of the condition pose on the health state of the patient. It is mainly an action-oriented approach in the management, treatment, and control of health-related conditions. It uses information and knowledge to instill into patients the knowledge that a health condition has negative consequences on their health, using the information, the model also instills into the patient knowledge that specific actions and behaviors could help in minimizing the severity of the condition or preventing the onset of the condition altogether. The model also instills into patient’s information that their health state is in their hands and that by taking positive action, they can evade the dangers associated with a health condition. It is also noteworthy that this theory is effective in instilling medical compliance among both the healthcare practitioners as well as patients. By doing this, the model ensures that all medications and health guidelines as followed as required, which has better treatment outcomes among patients. Using the model will also ensure that patients are able to follow the physicians’ prescriptions as required, even when in their home setting, which empowers BP control and management. As such, the theory is of great importance in the execution of this research study and will equally have immense benefits to the patients of BP, the at-risk individuals in the target population, as well as the healthcare sector and the government in general. This model was created by groups of Public health Service psychology in the 1950’s as there aim to find out why people were participating in program to improve their health and prevent disease (Butt and Karen, 2015). This model has been used Pires & Mussi (2013) as improvements for performance to aid promote quality as they improve 7 hypertension in African American. Managing hypertension in the African American population is a huge concern for many; as this has increase the burned not only for patients but their families and the healthcare organization at large as the cost of treatment continues to rise. With the health belief theoretical model, these patients’ populations will be able to participate in programs that are relevant to prevent, detect and halt any further risk factors associated with the development of hypertension and will increase their perceptions of the benefit of trying to avoid disease (Butt and Karen, 2015). According to Pires & Mussi (2013), understanding health belief and hypertension control is essential to help these patients to face their risk factors, as they are predictors of behaviors (Pires & Mussi, 2013). After much research on human belief and perceptions, they finally concluded that six factors influence how one’s views about whether or not to take actions to prevent, screen, and control illness (Butt and Karen, 2015). The health belief model identified criteria that one must take when they are ready to act: ➢ Believe they are susceptible to the condition (perceived susceptibility) ➢ Believe the condition has serious consequences (perceived severity) ➢ Believe taking action would reduce their susceptibility to the condition or its severity (perceived benefit) ➢ Are exposed to factors that prompt action (e.g. a reminder from one’s physician) ➢ Believe the cost of taking actions (perceived barriers) are outweighed by the benefit ➢ Are confident in their ability to successfully perform an action (self-efficacy) (Butt and Karen, 2015; Long at al., 2017) 8 Following this criterion can help patients of the African-American decent to improve their approach toward their goal of blood pressure control, as this model is necessary in reducing the prevalence of uncontrolled hypertension in the target population. Themes and Subthemes The major themes of this research are on how to effectively manage uncontrolled hypertension in the African American population of Bexar County in the Southwest part of San Antonio, Texas. Other themes identified need to assess the social economic factors, behavior factors, and medication adherence surround this patient population in other to help them improve their health and avoid the long-term effect of uncontrolled hypertension. The literature reviewed will further elaborate on these themes and subthemes to better understand how this can affect blood pressure control in these individual if they are not properly addressed. The themes and subthemes are outline below: ❖ Hypertension management and intervention ➢ Target organ damage ➢ Safety/Hypertension types ➢ Knowledge ❖ Socioeconomic factors and behavioral factors ➢ Culture/religion ➢ Cost/asses to care ➢ Social interaction ❖ Medication Adherence and Nonadherence ➢ Safety ➢ Close follow ups and remote monitoring 9 ➢ Medication frequency From the outlining of the theory framework and the themes and subthemes above, the use of the Health Belief Model will immensely help in managing and controlling the prevalence of BP in the target populations as it contains numerous cognitive concepts to help predict why people take charge of their health to better control their disease process (Yue et al., 2015). This is mainly because the model enhances the advancement of knowledge and information on the dangers as well as information regarding BP, thus helping patients to be self-aware of their health state and conduct regular personal screening and observation to ensure that they are at their best health state at all times. The model’s events and activities will also help in improving the rate of health seeking among the target population, to ensure that the at-risk individuals get closer supervision and immediate medication whenever their BP state worsens. As such, the Health Belief Model is a one fits all model that will ensure that all the individuals in the target population are influenced to take a positive step in the management and control of their BP state. Criterion THEORETICAL FOUNDATIONS This section identifies the theories or models that provide the foundation for the project. This section should present the theories or models(s) and explain how the problem under investigation relates to the theory or model. The theories or models(s) guide the clinical questions and justify what is being measured (variables) as well as how those variables are related. This section identifies and describes the theories or models to be used as the foundation for the project. This section identifies and describes the seminal source for each theory or model. Learner Score (0, 1, 2, or 3) Chairperson Score (0, 1, 2, or 3) Comments or Feedback 10 Criterion Learner Score (0, 1, 2, or 3) Chairperson Score (0, 1, 2, or 3) Comments or Feedback This section discusses how the clinical question(s) align with the respective theories or models. This section illustrates how the project fits within other research based on the theory or model. This section reflects understanding of the theory or model and its relevance to the proposed project. This section cites references reflecting the foundational, historical, and current literature in the field. This section is written in a way that is well structured, has a logical flow, and uses correct paragraph structure, sentence structure, punctuation, and APA format. NOTE: Once the document has been approved by your chairperson and your committee and is ready to submit for AQR review, please remove all of these assessment tables from this document. Score 0 (not present); 1 (unacceptable; needs substantial edits); 2 (present, but needs some editing); 3 (publication ready). 11 Review of the Literature Hypertension management and intervention is the main target of concern for the African American population. It is imperative that African American patients understand the implication of uncontrolled hypertension. About 92 million disability was attributed to hypertension throughout the world (Abel et al., 2015). Management and intervention are necessary as many of these patients are with metabolic syndrome that predisposes them to acquire other chronic health issues. A study reports that among patients who were aged 45 and older with diabetes, about 40-60 % of these individuals have hypertension. It is often referred to as the silent killer that attack without warning signs and the most contributing factors for chronic disease and mortality (Abel et al., 2015). A retrospective review using electronic health records was conducted in African American patients with hypertension who were managed with one or more hypertensive medication. The study selected patients aged 18 and older who had a diagnosis of hypertension and followed up appointments between January 1, 2013 to December 31, 2013. The aim was to achieve blood pressure control goal and markers of end-organ damage in African-American adult patients and was compared to those who were manage using the JNC -8 hypertension guidelines. 12 Genetics also plays a major role in the development of hypertension in this population of patients. Genetic plays a big role in the development of high blood pressure in many ethnic groups with African American patients as a target when genetic is concerns due to the increase prevalence. It is known that the primary genes that have been examined to further explain this are polymorphisms of the angiotensinogen gene and the insertion or deletion polymorphism of the angiotensin-converting enzyme gene. These genes are known to be the primary cause because of the role they play in the reninangiotensin system, which regulates sodium and water balance, which is a place where sodium sensitivity hypothesis would have its effect (Poston et al., 2001; Eggers, 2015). African American have the highest prevalence of hypertension and many genetic studies have determine and examine this disparity. This study uses health belief model to examine attitudes toward perceived barriers and benefits of genetic testing held by African American multigenerational triads and to determine if it differed by generation, age, education, or income level. About 183 African American women and girls from Detroit were used to conduct a descriptive correlational research between triad membership, age, income, and education level to examine the association of attitudes toward genetic testing. The research finds that an increase in age and education makes a difference in attitudes regarding benefits No statistically significant differences existed on the three subscales when compared by income levels or triad membership. A need for an increased outreach to younger generations regarding genetic service will benefit this individual in the near future to determine the important of early recognition and better control. Hypertension Complications and Target organ damage-Long standing hypertension is a risk factor for target organ damage. According to Still, (n.d) “Adequate 13 BP control should be the focus of primary, secondary, and tertiary interventions, because evidence supports that reduction in blood pressure decreases morbidity and mortality from hypertension-related complications.” Multiple studies have demonstrated that lowering blood pressure significantly decreases rate of cardiovascular morbidity and mortality in older adults with hypertension. African Americans are known to have increased incidence of hemorrhagic stroke than non-Latino whites (Kwon, 2015; Hart et al., 2016). The incident of stroke is 2 to 3 times common in blacks between ages 45 and 65 than white (Howard et al., 2013). These finding suggests racial differences as one of the impacts on the increase incident of stroke risk with increase prevalence and longstanding elevated blood pressure control (Howard et al., 2013). The data also suggest that the striking racial disparity of stroke in these age groups (45 to 64 years) may be reduced by improved BP control (Howard et al., 2013). Egan et al (2018) reports in one study, for every 10 mmHg higher systolic blood pressure increases the risk of stroke by 24 percent in black patients when compared with 8 percent in white patients. unfortunately, hypertension treatment reduces but does not eliminate racial difference in stroke development (Egan et al., 2018). Theoretically, better control can typically move all black from hypertension to prehypertension and would further reduce the incident of stroke 72% and thereby, nearly eliminating the racial disparity (Howard et al., 2013). Hypertension increases the risk for end stage renal disease by 420% than their counterparts (Moughrabi and Lopez, 2017). Studies have also shown that hypertension is a risk factors and the leading cause of cardiovascular incident and ESRD worldwide. Studies also have linked reduction in renal development with fewer functioning nephrons as a contributing factor to the development of end-stage renal disease (ESRD before the age of 50 years, in African Americans (Egan et al., 2018). This is because black patients 14 develop hypertensive nephrosclerosis at an early and as well as a 5- to 18-fold higher incidence of end-stage renal disease (ESRD), which is mostly in ages 25- to 45. Such increase may be linked to geography, with hypertension prevalence of 14 percent in West Africa, 26 percent in the Caribbean, and 55 percent in the United States (Egan et al., 2018). The increase risk in differences can be explained by differences in body mass index since a relationship exists between the occurrence of hypertension and body mass index across black populations (Egan et al., 2018). As stated by the World Health Organizations, hypertension rank the first among the five-leading global risk for mortality in the world” (Gu, Li, Yang, Wang, Bo, & Liu, 2015). In order to prevent or slow this process, the JNC guidelines released back in 2014 after the completion of an evidence-based meta-analysis- has recommended that there are numerous classes of hypertensive management that can be used to reduce the various associated risk factors brought about by uncontrolled blood pressure (Abel et al., 2015). Further recommendation states that thiazide-type diuretic or calcium channel blocker (CCB) should be used in the general black population. The trial conducted on Antihypertensive and Lipid-Lowering Treatment to prevent Heart Attack Trial (ALLHAT) showed that thiazide-type diuretic is more effective in improving heart failure, cerebrovascular, and combined cardiovascular outcome when compared to an angiotensin convertase enzymes inhibitor (ACE-I) (Abel at al., 2015). Schmieder (2010) also indicates that end organ damage can be detected early enough and equally treated if there is close supervision and monitoring of the at-risk patients. According to the research conducted by Schmieder (2010), end organ damage can be detected by pulse wave velocity measurement as well as measuring the intimamedia thickness in the carotid artery. The use of cardio-graphic indices can also help in 15 ascertaining the presence of left ventricular hypertrophy, a common end organ problem in hypertensive patients. The findings of the study also indicate that the close observation of albuminuria as well as the observation of the decrease in glomerular filtration can help in detecting end organ damage among hypertensive patients. The use of magnetic resonance imaging can also come in handy in the identification of cerebrovascular damage when assessing microangiopathic changes in the patient. Early detection of this can help in putting in place mechanisms of stopping the deterioration of the patient’s BP state. Similarly, important in the fight of end organ damage is the fact that reducing the blood pressure is the number one intervention in reducing the damage of organs. Dealing with blockades that occur in the renin angiotensin-aldosterone system is also essential in the management and control of end organ damage. Giuseppe et al. (1994) also state that the use of ambulatory blood pressure monitoring can be of great help in managing end organ damage among BP patients. The research conducted by Giuseppe et al. (1994) also suggests that there is a direct link between the average 24-h blood pressure values and the end organ damage. The blood pressure variability also has a direct implication on the treatments selected to help in hypertension treatment. Setia, Subramaniam, Jam Chin Tay, Boon Wee Teo, Tay, & Teo, (2017), reports hypertension to be an important risk factor for most target organ damage such as CAD, CKD, and stroke. Studies reports hypertension have been associated with many deaths; 45% of deaths have been associated with heart disease and that of stroke to be 51% (Setia et al., 2017). In 2008, the prevalence of hypertension was about 40 % in adults aged 25 and above and about 7.5 million death was linked to uncontrolled blood pressure each year worldwide (Setia et al., 2017). These can be prevented if only effective treatment 16 can be applied promptly as soon as diagnoses is confirmed as effective treatment regimen has been shown to reduce the risk of stroke by 35 to 40 %, 15-25 of myocardial infraction, and 64% of heart failure (Setia et al., 2017). The JNC 8 guidelines recommends four main class of drug to effectively manage elevated blood pressure: angiotensin-converting enzymes (ACEIs), Calcium channels blockers (CCB), angiotensin receptor blockers (ARB), and diuretics (Setia et al., 2017). It is very imperative that blood control is maintained especially in those with comorbidities. For these group of patients, the target blood pressure goal according to JNC 8 guidelines should be
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