Hypertension: Evidence-Based Practice Change

Abstract

This evidence-based project discusses the treatment of uncontrolled hypertension in African American who are about 18-35 years old because this population is believed to be the most vulnerable considering high blood pressure complications, such as cardiovascular disease and strokes. Two groups of patients will be gathered. The first one will receive only medical treatment while the second one will be also educated on lifestyle modifications. The study will be conducted in a local community health center over a 1-year period. Eventually, the most effective intervention will be identified.

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This evidence-based project (EBP) is focused on the issue of hypertension that is familiar to more than 80 million people living in the USA (Clare, 2014). In the majority of cases, professionals associate this long-term medical condition with aging. Nevertheless, many young adults are also affected by it, which proves that there is a necessity to consider a new perspective when dealing with this problem in practice. Researchers state that hypertension depends greatly on people’s lifestyles, which makes it difficult to overcome because human beings are rarely willing to change those things they are used to (Islam, 2017). In particular, smoking, use of drugs, sedentary lifestyle, and poor diet that leads to obesity can cause hypertension.

Practice Issue

High blood pressure is a problem not only for people who suffer from it but also for healthcare professionals who need to help patients to overcome this condition. Hypertension is difficult to diagnose because it may have no symptoms until it reaches a severe form (180/100 mmHg or higher) (Clare, 2014). Moreover, even when the first signs of this disease occur (vomiting and blurred vision, for instance), they tend to be associated with many other health problems. It is significant for professionals to treat hypertension properly because it can lead to heart diseases, strokes, coma, and even death. Currently, there are two ways of dealing with high blood pressure: intake of medication and lifestyle changes. This EBP will be targeted at the identification of the most advantageous intervention for young adults. In particular, attention will be paid to African Americans because they belong to the most vulnerable population (Lackland, 2015). On the basis of this information, the PICOT question will be developed.

PICOT Question

PICOT Question organizer
P Population African Americans ages 18-35 with uncontrolled hypertension receiving care from a community health center
I Intervention or
Issue of interest
ongoing education on lifestyle modifications (healthy eating habits and increased physical activity)
C Comparison medication therapy alone
O Outcome better control of blood pressure; therefore, reduction of the incidence of cardiovascular disease (CVD) and stroke
T Timeframe Over one year period

Search Strategy

The information needed for this EBP was found using ProQuest and PubMed databases. As a result, the possibility to reach evidence-based and peer-reviewed articles no older than 5 years was obtained. They represented Level I, II, and III evidence. The terms used for the search included hypertension, high blood pressure, treatment options, treatment plan, and management, etc. All in all, this search provided an opportunity to support the researchers’ claims and allowed receiving appropriate background for the study that will be conducted on the basis of this EBP.

Summary of the Evidence

Five studies focused on the treatment of hypertension were used to prove the necessity of the project. The synthesis of the information obtained from them reveals that unlike other populations, African Americans who suffer from hypertension are often affected by cardiovascular disease (CVD). In order to overcome this issue, the majority of professionals resorted to educational interventions while some of them believed standard medical care to be enough. The outcomes of these studies proved that the improvement of health literacy allowed avoiding risk factors for hypertension and minimalized CDV and stroke incidence (Beune et al., 2014; Brown et al., 2017; Daniel et al., 2012; Johnson, Ezeugwu, Monroe, Breunig, & Shaya, 2015; Meinema et al., 2015). The majority of these studies lasted for 6 months. The evidence allows claiming that the proposed project is needed because it provides an opportunity to identify the most beneficial intervention for overcoming hypertension.

Purpose of the Project

This EBP will monitor uncontrolled hypertension in African Americans who are 18-25 years old. Attention will be paid to two treatment options: medication therapy and its combination with ongoing education on lifestyle modifications. The purpose of the project will be to identify the most effective intervention. Its contribution to the improved control of blood pressure and reduction of the incidence of CVD and stroke will be considered. For me (as an APRN) this EBP will give an opportunity to realize in what way I should treat my patients when providing them with the required care.

Theoretical Framework

The proposed project can be supported by the self-efficacy theory (SET) that was developed by Bendura. According to it, “a person’s perception of their ability to reach a goal” (“Self-efficacy theory,” 2012, para. 1). This theory is appropriate for the EBP because the main focus is made on the necessity to change patient’s lifestyles. However, professionals only have an opportunity to educate their clients; they have no chance to make patients implement changes if they are not willing to do so. Thus, it is significant for healthcare workers to ensure that their clients believe in their ability to alter their lifestyles and to motivate them to reach this goal.

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Study Design

A quasi-experimental study will be conducted in order to reveal the influence of different types of medication on patients who suffer from hypertension. The chosen design for the EBP will give an opportunity to find out what intervention should be recommended for practice. In particular, it will assess the usefulness of treatment based on antihypertensive drugs only and combination of standard care with education on lifestyle modification. Taking into consideration the fact that this education can only be established after a given period, the study will last for a year.

Setting and Sample

The project will be conducted at a local community health center because of its convenience. The sample will include those patients who will receive treatment because of uncontrolled hypertension. The inclusion criteria will be: 1) race: African Americans; 2) age: 18-35; 3) health condition: absence of previous cases of CVD and strokes. The exclusion criteria will be patients’ health condition: severe illnesses that can cause CVD and strokes. All in all, the sample will include about 50 participants. Both female and male patients will be enrolled because gender peculiarities are not discussed in the paper.

Confidentiality

Participants’ confidentiality should be protected to ensure that they are not going to face any issues after the dissemination of project outcomes. Moreover, the proposed project does not require the necessity to consider each applicant separately. All possible risks associated with the participation will be discussed with the healthcare providers. However, the discussed intervention is not likely to affect people’s health adversely because it is not invasive. In the very report of this EBP, applicants’ names will not be mentioned at all (Adinoff, Conley, Taylor & Chezem, 2013). They will be documented as anonymous.

Intervention

The proposed intervention presupposes two types of treatment recommended to overcome hypertension. The first one is associated with standard care. It includes medication therapy (those drugs that control blood pressure). The second one deals with ongoing education. It means that in addition to the intake of medications, patients will be educated by healthcare providers regarding their condition and required changes. In particular, attention will be paid to lifestyle modifications because bad habits are believed to increase the risk of high blood pressure and the development of its complications. Mainly, recommendations will focus on healthy eating habits and increased physical activity.

Instruments for Data Analysis

Data received due to the project will be assessed with the help of SPSS evaluation software. T-test and chi-square test will be conducted as well to compare patients’ health outcomes. Additional attention will be paid to the incidence of CVD and strokes. Adherence to medical and lifestyle recommendations will be self-reported. The Morisky medication adherence scale and its adapted version will be used for this purpose. The Brief Illness Perceptions Questionnaire will be used to reveal the way patients think of hypertension (Meinema et al., 2015). The Medication Adherence Self-Efficacy Scale will provide an opportunity to identify patients’ beliefs regarding medication intake.

Stakeholders

The stakeholders of these study will be those organizations and people who will be affected by its outcomes or will be interested in them. For instance, they can include patients suffering from hypertension, healthcare professionals, and healthcare organizations. On the basis of this project, they can modify their behavior and alter treatment options to those that are more effective than the currently used ones. The nursing staff of the selected community health center, as well as their patients, will be the key stakeholders of the EBP due to the direct effect made on them.

Implementation

This EBP will be conducted in the following way. The researcher will contact the representatives of the desired setting, providing them with the information about the scope of the project, desired outcomes, and its importance for healthcare. Then, the peculiarities of medical treatment will be discussed with professionals who are going to work with the sample. Educational materials will be developed and shared among the involved individuals for them to evaluate them and recommend changes (if needed). Further, patients will receive required treatment and professionals will note its influence. The overall outcomes will be compared (in control and intervention groups). This data will be analyzed and conclusions will be made so that they can be shared.

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Evaluation of Outcomes

Evaluation of project outcomes will be based on the comparison of the health condition in two groups of patients. In this way, it will be critical to monitor blood pressure every 24 hours, ensuring that all members of the sample follow their typical routine and do not experience any additional stress. A comparison will be managed in two ways: at first, changes within a group will be discussed to reveal if the treatment led to the desired outcomes; then, the results of the control and intervention group will be compared to identify the most effective option.

Dissemination of Project Outcomes

The results of the project will be disseminated in order to provide stakeholders with an opportunity to access required information. In particular, the researcher will develop a report that will highlight all obtained findings and provide the outline of the conducted study. This paper will be published both online and in a peer-reviewed journal.

References

Adinoff, B., Conley, R. R., Taylor, S. F., & Chezem, L. L. (2013). Protecting confidentiality in human research. The American Journal of Psychiatry, 170(5), 466.

Beune, E. J., van Charante, E. P., Beem, L., Mohrs, J., Agyemang, C. O., Ogedegbe, G., & Haafkens, J. A. (2014). Culturally adapted hypertension education (CAHE) to improve blood pressure control and treatment adherence in patients of African origin with uncontrolled hypertension: Cluster-randomized trial. PLoS ONE, 9(3), 1-11. Web.

Brown, A. G., Hudson, L. B., Chui, K., Metayer, N., Lebron-Torres, N., Seguin, R. A., & Folta, S. C. (2017). Improving heart health among Black/African American women using civic engagement: A pilot study. BMC Public Health, 17, 112-123.

Clare, C. (2014). The person with a cardiovascular disorder. In I. Peate, K. Wild, & M. Nair (Eds.), Nursing practice: Knowledge and care (pp. 542-568). New York, NY: John Wiley & Sons.

Daniels, E. C., Powe, B. D., Metoyer, T., McCray, G., Baltrus, P., & Rust, G. (2012). Increasing knowledge of cardiovascular risk factors among African Americans by use of community health workers. The ABCD community intervention pilot project. Journal of the National Medical Association, 104(0), 179-185. Web.

Islam, S. (2017). Ambulatory blood pressure monitoring in the diagnosis and treatment of hypertension. In S. Islam (Ed.), Hypertension: From basic research to clinical practice (pp. 109-117). New York, NY: Springer.

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Johnson, W., Ezeugwu, C., Monroe, D., Breunig, I. M., & Shaya, F. (2015). A pilot study evaluating a community-based intervention focused on the ISHIB IMPACT cardiovascular risk reduction toolkit in African American patients with uncontrolled hypertension. Ethnicity & Disease, 25(2), 162-167. Web.

Lackland, D. (2015). Racial differences in hypertension: Implications for high blood pressure management. The American Journal of the Medical Sciences, 348(2), 135–138.

Meinema, J. G., van Dijk, N., Beune, E. J., Jaarsma, D. A., van Weert, H., & Haarfkens, J. A. (2015). Determinants of adherence to treatment in hypertensive patients of African descent and the role of culturally appropriate education. PLoS ONE, 10(8), 1-14. Web.

Meinema, J., van Dijk, N., Beune E., Jaarsma, D., van Weert, H., & Haafkens, J. (2015). Determinants of adherence to treatment in hypertensive patients of African descent and the role of culturally appropriate education. PLoS, 10(8), e0133560.

Self-efficacy theory. (2012). Web.

Appendix A

Evidence Synthesis

Database: PubMed Study #1 (Beune et al., 2014) Study #2 (Meinema et al., 2015) Study #3 (Johnson, Ezeugwu, Monroe, Breunig, & Shaya, 2015) Study #4 (Daniel et al., 2012) Study #5 (Brown et al., 2017) Synthesis
(p) Population Surinamese and Ghanaian patients (≥20 years) receiving hypertension care in the Dutch primary healthcare centers (PCCs). Hypertensive patients of African descent (Surinam and Ghana) with an SBP ≥140 and a mean age of 53.9±9.8 years registered in Amsterdam PCCs African Americans (18-64 years) with uncontrolled hypertension (135/85 mmHg) receiving care in two Baltimore centers African American churchgoers aged over 18 years. A black female cohort (aged 30–70 years) that included church members in Boston The CDV burden is highest among African Americans. The studies tested the efficacy of community interventions in reducing this risk.
(i) Intervention The intervention group received nurse-driven, culturally sensitive hypertension education (3 tutorials) Culturally appropriate hypertension education (CAHE) – three tutorials Educational intervention based on the IMPACT toolkit (community-based) A 6-hour educational program on ABCD indicators delivered by trained community health workers A community-based CVD reduction engagement based on the Change Club program The studies tested the effectiveness of community-based educational interventions or programs in achieving better SBP control
(c) Comparison Usual hypertension care Guideline-based hypertension care Usual care with no patient education Weekly ABCD lectures delivered by a physician Baseline data on SBP The control arm was subjected to standard hypertension care or physician-led lecturers. One study compared the post-intervention outcomes with baseline data
(o) Outcome The experimental group had an SBP/DBP decrease of 10/5.7 mmHg (compared to 6.3/1.7 of the controls) and a higher compliance with the lifestyle change regimen. CAHE subjects reported higher medication self-efficacy and compliance with therapy and lifestyle changes associated with lower cardiovascular risk after a 6-month period from baseline. Statistically significant reduction in SBP and DBP in the intervention group compared to controls (-34.8 mmHg vs. -5.7 mmHg) after a 6-month follow-up period. The intervention group demonstrated better HbA
1c levels than the control arm. In addition, self-care skills, e.g., blood pressure measurement improved in the two groups
The post-intervention results included improved cardio-respiratory fitness test and SBP outcomes. The educational interventions resulted in a decrease in SBP and HbA1c levels in the treatment group. Thus, CDV and stroke incidence among hypertensive African Americans can be reduced by improving their health literacy to avoid risk factors.
(t) Time Six months Six months Six months Six weeks Six months The study duration was six months; however, one of the interventions lasted six weeks.

Appendix B

Evaluation Table.

Citation Design Sample size: Adequate Major Variables: Independent
Dependent
Study findings: Strengths and Weaknesses Level of evidence Evidence synthesis
Beune, E. J., van Charante, E. P., Beem, L., Mohrs, J., Agyemang, C. O., Ogedegbe, G., & Haafkens, J. A. (2014). Culturally adapted hypertension education (CAHE) to improve blood pressure control and treatment adherence in patients of African origin with uncontrolled hypertension: Cluster-randomized trial. PLoS ONE, 9(3), 1-11. doi:10.1371/journal.pone.0090103 The study used a cluster-randomized trial to compare CAHE-recipients with control subjects. The study involved 146 hypertension patients (CAHE = 75, control = 71). This sample size seems inadequate. Therefore, the study appears underpowered to make meaningful generalizations given the large population of hypertensive blacks. Independent variables: culturally sensitive 30-minute psychotherapy sessions, educational resources, and referral to community support
Dependent variables: SBP reduction and compliance with medication and recommended lifestyle changes
The study found nurse-driven, culturally sensitive education reduces SBP and improves patient compliance with recommended lifestyle changes. Its key strengths include the cluster-randomized trial that eliminated contamination effects during sampling, elaborate study protocol, and low attrition rate (5%). Its weaknesses included the collection of data from one area and lack of blindness that may have affected its internal validity Level I evidence – an RCT The evidence in this study demonstrates that culturally adapted educational programs are effective in the optimal hypertension care for minorities of African descent. Further, lifestyle recommendations for reducing CDV and stroke risk require culturally appropriate health education
Meinema, J. G., van Dijk, N., Beune, E. J., Jaarsma, D. A., van Weert, H., & Haarfkens, J. A. (2015). Determinants of adherence to treatment in hypertensive patients of African descent and the role of culturally appropriate education. PLoS ONE, 10(8), 1-14. doi:10.1371/journal.pone.0133560 A cluster-randomized trial, i.e., a comparison between CAHE intervention and control PCCs giving guideline-based education. The sample size (139 intervention subjects) was relatively low, which limited the number of variables that could be analyzed. Independent variables: CAHE intervention and background characteristics – medication self-efficacy and familial support
Dependent variables: treatment adherence
In this study, medication self-efficacy improves compliance with medication and lifestyle recommendations among patients of African descent. However, CAHE intervention had no impact on self-efficacy and familial/community support. The main strength of this study include the examination of patient-related indicators of treatment adherence based on self-reports and the use of validated instruments, e.g., the Morisky scale, to measure compliance. Its main weakness is the small sample size used. Level I evidence. It is a randomized control trial. Improvement in the clinical outcomes of hypertension patients of African origin in the West is possible through interventions that promote medication and recommended lifestyle –exercise and diet – adherence.
Johnson, W., Ezeugwu, C., Monroe, D., Breunig, I. M., & Shaya, F. (2015). A pilot study evaluating a community-based intervention focused on the ISHIB IMPACT cardiovascular risk reduction toolkit in African American patients with uncontrolled hypertension. Ethnicity & Disease, 25(2), 162-167. https://www.ethndis.org/edonline/index.php/ethndis/article/viewFile/123/99 A randomized controlled design – it involved a comparison of a community-based intervention and standard care. The initial sample (n=54) randomized into the intervention (n=27) and control arms (n=27) was relatively low to attain data saturation. After 6 months, 14 subjects were lost to follow-up. Independent variables: educational intervention based on IMPACT toolkit and standard care
Dependent variables: blood pressure outcomes – SBP and DBP
The intervention group had a significant reduction in SBP from the pre-intervention level compared to the control arm (-34.8 vs. -5.7 mmHg). The DBP reduction was higher in the treatment group than in the standard care subjects (-16.2 vs. 4.4 mmHg). The study’s strength lies in the validation of the ISHIB IMPACT toolkit in improving hypertension outcomes of black patients. Its limitations include low sample size and incomplete follow-up data due to attrition effects. Level I evidence (an RCT-pilot study). Better hypertension control in black patients could be achieved using the IMPACT toolkit. The study provides evidence for the use of validated community-based interventions (education) to improve clinical outcomes and reduce CVD and stroke risk in African American patients with hypertension.
Daniels, E. C., Powe, B. D., Metoyer, T., McCray, G., Baltrus, P., & Rust, G. (2012). Increasing knowledge of cardiovascular risk factors among African Americans by use of community health workers. The ABCD community intervention pilot project. Journal of the National Medical Association, 104(0), 179-185. doi:10.1016/S0027-9684(15)30139-5 A longitudinal, multicenter trial design – it entailed comparing the efficacy of a 16-hour educational program offered by community health workers (CHWs) in churches (intervention) with physician-led weekly lectures (control) The sample of 47 subjects (treatment = 19 and control = 28) was not adequate to cater for the generalizability of the findings and attrition during follow-up. Independent variables: CHW-led ABCD community intervention and physician-driven patient education
Dependent variables: knowledge of CDV risks, health literacy, depression, and clinical measures.
In this study, tailored CHW-driven intervention improved CDV risk awareness, self-care, and HbA1c among black patients with hypertension compared to physician-led training sessions. Its main strengths are intensive educational interventions and multicenter trial that eliminated contamination effects. Its limitations include non-random sampling and small number of subjects. Level II evidence (non-randomized control trial). This study indicates that self-care skills, e.g., blood pressure measurement and proper diet and physical activity levels, delivered by CHWs results in better BP control. Educational interventions tailored to suit African Americans can improve their literacy and clinical outcomes.
Brown, A. G., Hudson, L. B., Chui, K., Metayer, N., Lebron-Torres, N., Seguin, R. A., & Folta, S. C. (2017). Improving heart health among Black/African American women using civic engagement: A pilot study. BMC Public Health, 17, 112-123. A quasi-experimental design – a comparison of post-intervention SBP with baseline values The small sample size (n=28 women) might not have provided adequate statistical power to detect outcome differences at baseline and after the intervention. Independent variable: ‘Change Club’ civic involvement – culturally appropriate education on diet and exercise
Dependent variables: They included psychosocial measures, e.g., self-efficacy, O2 uptake, SBP, and dietary and physical activity outcomes.
A civic engagement strategy can reinforce positive behavior in blacks with hypertension. The findings suggest improvements in physical activity and dietary intake and a reduction in SBP (-12.73 mmHg) compared to baseline data, indicating that community-based involvement methods are effective with African Americans. Its main strength lies in the use of multiple indicators of effectiveness. Its weaknesses include small sample size and the lack of a control arm. Level III evidence The study gives evidence for the use of civic engagement as an effective intervention to reinforce CDV-related behaviors in African American patients with hypertension.
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