Pay Attention to Hypertension (PAtH): Findings from a cardiovascular health promotion intervention for adults with intellectual disabilities participating in Special Olympics programming

Abstract

Background

Cardiovascular disease (CVD) affects adults globally. People with intellectual disabilities (PWID) may be at higher risk of CVD and associated risk factors (e.g. obesity, hypertension, and diabetes). We developed Pay Attention to Hypertension (PAtH), a cardiovascular health promotion intervention, and tested its impact on changes in blood pressure (BP), lifestyle behaviours and health‐related empowerment among PWID.

Methods

PAtH was developed with a Special Olympics community organisation that supports PWID in developing self‐confidence and social skills through participation in sports. The 6‐month intervention consisted of 1‐h individualised virtual sessions delivered monthly by nursing students/novice nurses. Sessions covered specific themes, including monitoring BP, adopting healthy lifestyles and managing stress, and were individually tailored to the capacities and needs of participants. A single group pre–post‐intervention design was used to assess the intervention's effects among participants who completed the intervention and data collection. Data included baseline and follow‐up BP measurements from 7‐day logbooks and questionnaires assessing lifestyle behaviours [physical activity (PA), screen time and diet], and health‐related empowerment.

Results

Seventy‐four participants were included in the analyses. Between baseline and follow‐up, there were no changes in systolic and diastolic BP, PA or leisure screen time. The proportion of participants who reported adding salt when cooking decreased from baseline to follow‐up (19.7% vs. 12.7%, P = 0.034), and we found improvements for several items measuring health‐related empowerment (P ≤ 0.003).

Conclusion

Improvements in health‐related empowerment were found following PAtH. More intensive interventions may be needed to result in changes in lifestyle behaviours and BP. The integration of adapted cardiovascular health promotion initiatives within well‐established community organisations such as Special Olympics is a promising avenue to contribute to cardiovascular health promotion among PWID.

Introduction

Cardiovascular disease (CVD) is a leading cause of morbidity and mortality and a major contributor to reduced quality of life (Mensah, Roth, & Fuster, 2019). Among people with intellectual disabilities (PWID), evidence is inconsistent on whether the prevalence of CVD is lower (Cooper et al., 2015), higher (Wang et al., 2023) or similar (De Winter, Van Den Berge, Schoufour, Oppewal, & Evenhuis, 2016) compared with the general population. Some studies have reported that PWID are at high risk of living with obesity (Flygare Wallén, Ljunggren, Carlsson, Pettersson, & Wändell, 2018), hypertension (Lin, Lin, & Lin, 2010; Schroeder, Dubois, Sadowsky, & Hilgenkamp, 2020; Wang et al., 2023) and diabetes (Axmon, Ahlström, & Höglund, 2017; Flygare Wallén et al., 2018) and of acquiring multiple CVD risk factors (Room, Timmermans, & Roodbol, 2016). A recent study conducted in a large international sample of 33 000 adults with intellectual disabilities who participated in health promotion programmes revealed that almost half (48%) had high blood pressure despite a relatively young sample mean age (31 years) (Schroeder et al., 2020).

The disparities in cardiovascular health of PWID can be partially explained by modifiable factors, namely, lifestyle behaviours (O'Leary, Taggart, & Cousins, 2018). Several studies have documented that PWID frequently engage in low levels of physical activity (PA), high levels of sedentary behaviour, and consume unhealthy diets (Moss, 2009; Phillips & Holland, 2011; Gephart & Loman, 2013; Chow, Choi, & Huang, 2018). Cardiovascular health disparities may be further exacerbated by reduced access to health promotion and healthcare services adapted to the specific needs and abilities of PWID (Krahn, Hammond, & Turner, 2006; Lalive d'Epinay Raemy & Paignon, 2019).

To mitigate the burden of CVD and promote optimal health among PWID, interventions have been developed to reduce risk factors and promote healthy lifestyle behaviours. Such interventions have focused on measuring and tracking weight and blood pressure (BP), increasing PA, improving dietary intake, increasing self‐efficacy and empowerment for the adoption of healthy lifestyle behaviours and improving the management of underlying conditions (e.g. hypertension and diabetes) (Lante et al., 2014; Dunkley et al., 2017; Neumeier et al., 2017; Marks, Sisirak, Magallanes, Krok, & Donohue‐Chase, 2019; Michalsen et al., 2020; Rubenstein et al., 2020). However, several of these interventions have not adopted a holistic approach to cardiovascular health promotion and focused on specific lifestyle behaviours such as diet and exercise (Dunkley et al., 2017; Neumeier et al., 2017; Marks et al., 2019). One study examined the fitness models of the Special Olympics Inc., which are centred on inclusive PA and goal‐setting behaviours among PWID, and found improvements in body weight and BP within 4 to 12 weeks (Rubenstein et al., 2020). These findings support the benefits of integrating health promotion programmes in existing infrastructures that already support PWID to improve health and well‐being. Accordingly, PAtH was developed in collaboration with a Special Olympics chapter; however, it sought to promote cardiovascular health from a more comprehensive approach, encompassing not only PA and diet but also other health‐related behaviours such as stress and anxiety management.

Special Olympics Canada promotes access to sports and PA for PWID through provincial chapters located across the country (Special Olympics Canada, 2023). In 2019, the Special Olympics Quebec (SOQ) chapter held a Health Promotion Clinic during which 323 adults with intellectual disabilities were screened for cardiovascular risk factors. It was found that 67% had overweight/obesity, 22% had elevated BP previously undiagnosed and 32% engaged in less than 60 min/week of PA (Special Olympics Quebec, 2019). In response to these numbers and to major disruptions in lifestyle behaviours caused by the COVID‐19 pandemic, the SOQ chapter initiated a partnership with a School of Nursing to develop and test a virtually‐delivered cardiovascular health promotion and education programme that could be individually tailored to the needs and capacities of PWID. The Pay Attention to Hypertension (PAtH) intervention was developed jointly between nurses with expertise in health promotion and behaviour change and SOQ staff with expertise in the promotion of physical activity among PWID. PAtH is a cardiovascular health promotion intervention grounded in the Ottawa Charter for Health Promotion principles (Government of Canada, 2017), namely, that of enabling PWID to increase control over and improve their health by developing personal skills. To do so, we adapted existing resources (e.g. Canada Food Guide, Heart and Stroke Foundation) to provide support and educational opportunities to PWID in setting and monitoring health behaviour goals, managing stress, and monitoring blood pressure using strategies tailored to each participant's individual needs, capacities and preferences. Simultaneously, PAtH served to enhance the training of senior nursing students and recent nursing graduates to provide health promotion care to PWID. Herein, we describe the PAtH intervention and estimate its impact on participants' systolic and diastolic BP, lifestyle behaviours (PA, screen time and diet) and on empowerment to engage in health‐promoting behaviours.

Methods

Study design and population

A single group pre–post‐intervention design was used to evaluate the effects of PAtH on outcomes of interest. Participants were recruited among PWID taking part in SOQ programmes who had mild to moderate levels of intellectual disabilities. To be eligible, participants had to be at least 18 years old and able to understand French or English well enough to minimally provide assent for participation. Participants had varying levels of autonomy (e.g. most lived with their parents/caregivers while others lived in supervised residences or by themselves) and communication abilities. Participants apt to do so were asked to provide consent for participation in the study; all other participants provided assent, and consent was obtained from a person legally authorised to do so. A total of 150 PWID were pre‐selected by the SOQ team and invited to participate in PAtH. Of these, n = 92 had been identified as having elevated BP at the 2019 SOQ Health Promotion Clinic, n = 48 were known to have poor lifestyle behaviours (e.g. smokers and low PA), and n = 10 were young adults identified through the SOQ School Programme. Among those invited to PAtH, 94 participants/caregivers provided consent/assent to take part in the current study. Of the remaining 56 identified PWID, some were not interested or not available to participate in PAtH, whereas others could not be matched with a nurse/nursing student within the study timeline.

Description of the intervention

PAtH is a 6‐month intervention with monthly individual virtual sessions delivered by recent nursing graduates and senior nursing students following a 3‐h training on the intervention procedures, content and approaches to engage with PWID. Detailed documentation was summarised in a Nurses' Guide. Nurses were supported by a team of senior nurses and by the SOQ team throughout the delivery of the intervention. Each PAtH session lasted approximately 1 h, was delivered through Microsoft Teams (v.1.6.00.11166), and covered topics related to monitoring BP and adopting lifestyle behaviours that support cardiovascular health. Figure 1 summarises the topics covered in PAtH.

Figure 1.

An overview of sessions in Pay Attention to Hypertension (PAtH).

As part of the intervention, participants received a BP monitor (Life source UA 767 FAM) along with a Participant Guide, which included simple instructions with graphical information on healthy lifestyle habits, BP monitoring, interpretation of BP values, and actions to be taken in case of abnormal BP values. A logbook to record BP measurements was also included. During the first PAtH session, nurses verified medical information previously provided in a medical intake form and assessed participants' lifestyle behaviours using a standardised questionnaire described under Data collection and measurements. Next, nurses explained and demonstrated how to monitor and record BP. They also instructed participants on how to proceed in case of abnormal BP values and associated alarming symptoms; this information was reinforced in subsequent sessions, as needed. At any time during the intervention, nurses could refer participants to a physician for situations requiring medical attention.

In the second session, nurses supported participants in establishing a health‐related SMART goal based on the initial assessment of lifestyle behaviours and participants' preferences. This goal, along with barriers, facilitators, and strategies towards the attainment of the goal, were discussed in each subsequent session, with new goals established as needed. Subsequent sessions also covered specific cardiovascular health promotion topics, namely, management of stress and anxiety (Canadian Mental Health Association, 2020; Health Canada, 2020; Heart&Stroke, 2020a), healthy eating (Health Canada, 2023), increasing PA and reducing sedentary behaviour (Ross et al., 2020), and tobacco cessation and safe alcohol consumption (Heart&Stroke, 2020c, Heart&Stroke, 2020b). Importantly, nurses adapted each session's information to the health literacy levels of participants, their personal needs, and other circumstances (e.g. physical disabilities). Participants were generally accompanied by a parent, caregiver or educator during the virtual sessions to facilitate communication.

Data collection and measurements

Data were collected between June 2021 and February 2023 using three data sources. First, participants/caregivers completed a standard medical intake form used for all SOQ activities, which provided information on past and current medical history. Second, baseline and follow‐up questionnaires were administered to assess lifestyle behaviours, health‐related empowerment, and sociodemographic characteristics, as well as satisfaction with the programme (follow‐up only). Questionnaires were administered to participants, with the help of a caregiver when needed, via Teams using the screen sharing mode. The questionnaires were programmed in Qualtrics and included pictograms and images to assist participants in understanding questions and response items. Prior to data collection, questionnaires were pilot‐tested with one SOQ member with intellectual disability who provided suggestions to increase relevance and understandability of questions. The baseline questionnaire was administered by nurses during the first PAtH session, while the follow‐up questionnaire was completed 1–2 months following the last session (to assess sustained intervention effects) with trained research staff not involved in the intervention delivery. Participants were asked to monitor and record their BP for 7 days, both at baseline and at follow‐up. All measurements are detailed below.

Blood pressure

Participants were instructed to monitor their BP for 7 days by obtaining two measures at 1‐min intervals twice per day and to record these in their logbooks. Participants were instructed to obtain measurements while seated with the back and arms supported, legs uncrossed, feet flat on the floor, and the BP cuff on a bare arm, aligned with the brachial artery and at heart level. Participants were also instructed to rest for 5 min prior and not to smoke, drink coffee, eat chocolate or exercise 1 h before measuring their BP. Upon completing the 7‐day monitoring, participants sent a picture of their logbook to their nurse for assessment and analysis. The mean systolic and diastolic BP measurements were computed at baseline and follow‐up and used as the primary outcomes for this study. Additionally, we defined hypertension as a mean systolic BP ≥ 135 mmHg or diastolic BP ≥ 85 mmHg for non‐diabetic participants and ≥130 or ≥80 mmHg for systolic and diastolic BP, respectively, for participants with diabetes, or the reported use of at least one anti‐hypertensive medication (Myers, Kaczorowski, Dawes, & Godwin, 2014).

Lifestyle behaviours

PA was assessed using four items of the International Physical Activity Questionnaire short form (IPAQ Group, 2005) and total minutes of moderate‐to‐vigorous PA per week was computed (Lee, Macfarlane, Lam, & Stewart, 2011). Data were also categorised as meeting vs. not meeting PA recommendations for adults (18–64 years old), that is, engaging in at least 75 min of moderate‐ and/or vigorous‐intensity PA per week combined with muscle‐strengthening activities on two or more days per week (World Health Organization, 2020). Screen time was assessed using a questionnaire for habitual leisure screen time (e.g. TV viewing and video games) on weekdays and weekends. Total daily weighted average screen time was computed as mean daily hours of screen time. Additionally, screen time was categorised according to guidelines, which recommend no more than 3 h/day of leisure screen time (Ross et al., 2020). Dietary intake was assessed using a short food frequency questionnaire, including questions on habitual intake of sweetened beverages, fruits and vegetables, and foods high in sodium. For this last component, only the most common high‐sodium foods eaten by Canadians were included (Health Canada, 2018), and questions from the SALT analysis tool (Cooper, Simpson, & Klutka, 2020) were adapted to evaluate added sodium intake.

Health‐related empowerment and satisfaction with the intervention

Health‐related empowerment was assessed using nine items adapted from the Gothenburg Young Persons Empowerment Scale (Acuña Mora et al., 2018). Items were related to four dimensions, namely, knowledge and understanding, personal control, decision‐making and enabling others, with responses recorded as ‘yes’ versus ‘no or maybe’. Questions were adapted to PAtH's cardiovascular health promotion context such that questions on knowledge and understanding were specific to BP management, while items for other dimensions related to healthy lifestyles and health in general. Upon completing the follow‐up questionnaire, participants were asked about their overall satisfaction with PAtH and whether they would recommend PAtH to a friend.

Sociodemographic characteristics and medical history

Age and sex were obtained at baseline. Perceived socioeconomic status was evaluated by using a graphical representation of a ladder (Cundiff, Smith, Uchino, & Berg, 2013) where the participants placed themselves according to their perceived status; the values of the ladder ranged from 1 (lowest) to 10 (highest) socioeconomic status. These values were categorised as low (levels 1 to 3), moderate (levels 4 to 7) and high (levels 8 to 10) perceived socioeconomic status level. This method has been used previously in other studies among PWID (McMahon, Hatton, Hardy, & Preston, 2022). Food insecurity was assessed using the Food Insecurity Experience Scale (FIES) (Food and Agriculture Organization of the United Nations, 2023) with the main objective of adapting the session on nutrition to participants' food security level. Participants were classified as food insecure if they answered ‘yes’ to at least one item of the FIES. Living arrangements and degree of intellectual disability (mild/moderate vs. severe/profound) were obtained from SOQ staff who are well acquainted with participating members/families. Lastly, data extracted from the medical intake forms included participant's history of CVD, diabetes and use of prescription medications.

Data analyses

Descriptive analyses were conducted. We used the following tests to compare baseline and follow‐up data for participants with complete data: (1) for dichotomous variables, we used the McNemar test; (2) for categorical variables with three or more categories, we used the McNemar–Bowker symmetry test for nominal variables, and the Wilcoxon signed ranked test for ordinal variables; and (3) for continuous variables we used paired Student's t‐tests. The significance level was set at P ≤ 0.05. When statistically significant differences were found in categorical variables, post hoc tests were performed using the pairwise McNemar test and post hoc Bonferroni test to identify categories between which changes were statistically significant. Analyses were performed using IBM SPSS Statistics version 28.0.

Results

Ninety‐four participants started the intervention; of these, 74 completed the six PAtH sessions and the follow‐up questionnaire (78% retention rate), and 66 completed the follow‐up BP logbook (Figure 2). Reasons for the loss to follow‐up were lack of time, generally from caregivers to support participants in completing the questionnaire and BP measurements, lack of interest from participants, as well as the perceived burden of the BP monitoring protocol.

Figure 2.

PAtH participant flow chart.

The sociodemographic characteristics of the participants are presented in Table 1. At baseline, the mean age of the participants was 31.7 ± 8.5 years; 58% were female, and 20% reported some form of food insecurity. Most participants lived with their family or in a group home, whereas 25% lived alone. Most participants were accompanied by a family member, caregiver or educator for the completion of the baseline (71.6%) and follow‐up (62.2%) questionnaires.

Table 1.

Sociodemographic characteristics and medical history of participants who completed baseline and follow‐up data collection (n = 74)

Variables	% (n) or mean ± SD
Age at baseline, years	31.7 ± 8.5
Age at follow‐up, years	32.4 ± 8.5
Female sex	58.1 (43)
Living arrangements
With family	60.8 (45)
In‐group home	13.5 (10)
Alone	25.7 (19)
Degree of intellectual disability
Mild/moderate	98.6 (73)
Severe/profound	1.4 (1)
Food insecure a	20.4 (13)
Perceived socioeconomic status a
Low	26.1 (18)
Moderate	53.6 (37)
High	20.3 (14)
History of diabetes mellitus	12.2 (9)
History of cardiovascular health problems	13.5 (10)
Under the care of a doctor/nurse for known cardiovascular health problems	10.8 (8)

Abbreviation: SD, standard deviation.

^a n = 63 for food security and n = 69 for perceived socioeconomic status due to incomplete answers.

On average, participants reported 24.1 ± 5.7 bp measurements at baseline and 21.1 ± 7.2 measurements at follow‐up. The proportion of participants with high systolic and diastolic BP, as well as the mean systolic and diastolic BP, were similar at baseline and follow‐up (Table 2). Throughout the intervention, a total of five participants were referred to a physician due to elevated BP measurements: one initiated antihypertensive medication, one received adjustments to their medications, and three received recommendations for lifestyle behaviour changes. Four participants were found to be hypotensive, of which two participants with symptoms were referred to a physician, and all four received education regarding how to recognise signs and symptoms of hypotension, strategies for fall prevention, and when to seek medical attention.

Table 2.

Comparison of blood pressure at baseline and follow‐up ^a (n = 66)

Variables	Baseline	Follow‐up	P‐value
Systolic BP
Mean ± SD	112.9 ± 10.3	114.0 ± 11.0	0.241
High systolic BP % (n)	1.5 (1)	3.0 (2)	1.000
Diastolic BP
Mean ± SD	72.9 ± 7.3	74.1 ± 7.5	0.057
High diastolic BP % (n)	10.6 (7)	13.6 (9)	0.687
Use of antihypertensive medication % (n)	12.1 (8)	13.6 (9)	1.000
Hypertension % (n)b	18.2 (12)	25.8 (17)	0.125

Abbreviations: BP, blood pressure; SD, standard deviation.

^a Participants recorded an average of 24.1 bp measurements at baseline and 21.1 bp measurements at follow‐up.

^b Hypertension is defined as a mean systolic BP ≥ 135 mmHg or diastolic BP ≥ 85 mmHg for non‐diabetic participants and ≥130 or ≥80 mmHg for systolic and diastolic BP, respectively, for participants with diabetes, or the reported use of at least one anti‐hypertensive medication in the medical intake form.

Lifestyle behaviours and health‐related empowerment results are shown in Tables 3 and 4, respectively. The proportion of participants meeting PA recommendations was 35% at baseline and 45% at follow‐up, and the proportion of participants meeting screen time recommendations was 51% at baseline and 64% at follow‐up, neither reaching statistical significance. As for dietary intake, no changes were found, except for the addition of salt when cooking, which fewer participants reported doing ‘often or always’ at follow‐up (12%) compared with baseline (19%) (P = 0.034). This change was most important among participants who moved from often/always to sometimes, although it did not reach statistical significance on the Bonferroni test.

Table 3.

Comparison of lifestyle behaviours at baseline and follow‐up (n = 74)

Variables	Baseline	Follow‐up	P‐value
Physical activity
Moderate‐to‐vigorous PA (min/week), mean ± SD	256.6 ± 274.2	288.4 ± 278.5	0.471
Meet PA recommendations, % (n)	35.1 (26)	44.6 (33)	0.248
Screen time
Leisure screen time (hours/day), mean ± SD	3.7 ± 2.6	3.3 ± 1.9	0.183
Meet leisure screen time recommendations, % (n)	51.4 (37)	63.5 (46)	0.136
Dietary habits
Sweet beverages, % (n)
Once or less/week	36.5 (27)	40.54 (30)	0.208
2–4 times a week	16.2 (12)	20.27 (15)
5 or more times/week	47.3 (35)	39.19 (29)
Fruits, servings, % (n)
Once or less/day	39.2 (29)	41.9 (31)	0.869
2–3 times/day	48.7 (36)	44.6 (33)
4 or more times/day	12.2 (9)	13.5 (10)
Vegetables, servings, % (n)
Once or less/day	24.3 (18)	24.3 (18)	0.847
2–3 times/day	66.2 (49)	67.6 (50)
4 or more times/day	9.5 (7)	8.1 (6)
Addition of salt when cooking a
Never	43.6 (31)	32.4 (23)	0.034 b
Sometimes	36.6 (26)	54.9 (39)
Often or always	19.7 (14)	12.7 (9)
Addition of salt at the table a
Never	66.7 (48)	61.1 (44)	0.623
Sometimes	29.1 (21)	31.9 (23)
Often or always	4.1 (3)	6.9 (5)

Abbreviations: PA, physical activity; SD, standard deviation.

^a Smaller sample size due to incomplete answers.

^b In post hoc tests comparing often/always at baseline with sometimes at follow‐up, P = 0.057 before and P = 0.171 after Bonferroni corrections.

Table 4.

Comparison of health‐related empowerment at baseline and follow‐up (n = 74)

Variable	Baseline	Follow‐up	P‐value
Knowledge and understanding
I know what to do to keep my BP healthy, % (n)
No or maybe	68.9 (51)	25.7 (19)	<0.001
Yes	31.1 (23)	74.3 (55)
I know how to recognise that my BP is high, % (n) a
No or maybe	79.5 (58)	45.2 (33)	<0.001
Yes	20.5 (15)	54.8 (40)
I know when to contact my healthcare provider for my BP, % (n)
No or maybe	74.3 (55)	50.0 (37)	0.005
Yes	25.7 (19)	50.0 (37)
Personal control
I believe I have the abilities to manage my health, % (n)
No or maybe	28.4 (21)	17.6 (13)	0.134
Yes	71.6 (53)	82.4 (61)
I believe I have control over my health, % (n)
No or maybe	21.6 (16)	5.4 (4)	0.008
Yes	78.4 (58)	94.6 (70)
Decision‐making
I can speak to my healthcare providers about what is important to me, % (n) a
No or maybe	31.5 (23)	13.7 (10)	0.004
Yes	68.5 (50)	86.3 (63)
I believe I can talk about my health with the people who are important to me, % (n)
No or maybe	13.5 (10)	4.1 (3)	0.065
Yes	86.5 (64)	95.9 (71)
Enabling others
I have the abilities to support athletes like me in making healthy choices, % (n) a
No or maybe	28.8 (21)	32.9 (24)	0.690
Yes	71.2 (52)	67.1 (49)
I feel comfortable telling others what they can do to stay healthy, % (n) a
No or maybe	28.2 (20)	29.6 (21)	1.000
Yes	71.8 (51)	70.4 (50)

Abbreviation: BP, blood pressure.

^a Smaller sample size due to incomplete answers.

In terms of empowerment, we found improvements on all items measuring knowledge and understanding related to how to monitor BP and manage high BP values (P ≤ 0.030). We also found improvements on two items related to personal control and decision‐making, namely, in the proportion of participants who believe they have control over their health (P = 0.008) and are able to speak to their healthcare provider about things that matter most to them (P = 0.004). Finally, virtually, all participants were satisfied with PAtH (97%) and would recommend PAtH to a friend (99%) (not shown in the table).

Discussion

PAtH was developed for virtual delivery during the COVID‐19 pandemic in response to data showing a high proportion of elevated BP, overweight/obesity and unhealthy lifestyle habits among PWID who participate in SOQ activities. PAtH aimed to provide adapted health promotion and education on hypertension and lifestyle habits that support cardiovascular health over a 6‐month period. Following the intervention, we did not observe any changes in BP. In terms of lifestyle behaviours, although no changes in PA, screen time and diet were observed, results point towards improvements in the desired direction. Improvements were found in health‐related empowerment measures, namely, in knowledge and understanding of BP management. These small improvements in lifestyle behaviours, complemented with increased empowerment through greater knowledge, may provide fertile grounds for future improvements in lifestyle behaviours and, ultimately, in BP and cardiovascular health.

The prevalence of hypertension at baseline and follow‐up among PAtH participants (18% and 26%, respectively) was much lower than that reported in a study relying on data from an international sample of PWID of similar age (31 ± 11 years old) participating in Special Olympics programming where 48% were found to have hypertension (Schroeder et al., 2020). Measurement protocols and potential measurement errors could explain this difference. Schroeder et al. defined hypertension based on a single BP measurement, whereas we relied on an average of multiple measurements taken over 7 days, which is more closely aligned with hypertension diagnostic guidelines (Hypertension Canada, 2024). Additionally, PAtH participants self‐measured their BP following teaching and all participants used the same BP monitoring device. In contrast, the international study by Schroeder and colleagues relied on multiple devices and clinician‐assessed BP. The latter is a common reason for white coat hypertension among PWID, which can overestimate the prevalence of hypertension (Bo et al., 2009). Compared with the general Quebec, Canada population, for which hypertension is estimated to be prevalent in 4% of adults ages 25–44 years (Ministry of Health and Social Services of Quebec, 2018), the higher prevalence in our study reflects the ‘at risk’ PWID who were targeted for participation in PAtH (e.g. previously identified as having elevated blood pressure, overweight/obesity or poor lifestyle habits).

PAtH did not target pharmacological management of hypertension directly; however, nurses prompted participants taking antihypertensive drugs to follow their doctor's recommendations and referred participants to their healthcare provider when abnormal BP measurements were noted. Previous reports suggest that medication use in this population can be improved by providing health literacy and education regarding the management of chronic diseases, as well as through the coordination of care and support (Salzberg et al., 2022). The individualised tailoring to each participant's context, needs, preferences and abilities allowed PAtH nurses to increase participants' health literacy, as evidenced by the improvements in knowledge and understanding of BP monitoring and management.

Although we found no impacts on BP, other studies have reported decreases in BP among PWID following participation in health promotion interventions (Pett et al., 2013; Martinez‐Zaragoza, Campillo‐Martinez, & Ato‐Garcia, 2016; Messiah et al., 2019; Rubenstein et al., 2020). Contrary to PAtH, these interventions were delivered in person (Pett et al., 2013, Martinez‐Zaragoza et al., 2016, Messiah et al., 2019, Rubenstein et al., 2020), provided access to supervised PA sessions (Pett et al., 2013; Martinez‐Zaragoza et al., 2016; Messiah et al., 2019), and explicitly included a family‐support component (Pett et al., 2013; Martinez‐Zaragoza et al., 2016; Rubenstein et al., 2020). The latter has been found to be a substantial facilitator of healthy lifestyle behaviours among PWID, particularly for PA (Pett et al., 2013; Harris, Melville, Murray, & Hankey, 2018; Marks et al., 2019). In PAtH, the involvement of caregivers was discretionary to the participants and their families, and 25% of participants did not live with a parent/caregiver given their high level of autonomy. The involvement of families, caregivers or friends within the interventions may promote further support and reinforcement for health‐related behaviours (Pett et al., 2013). Future interventions might benefit from seeking support from the most influential members of PWID social networks, given the strong and consistent relation between support from one's social network and lifestyle behaviours across different populations, including PWID (Peterson et al., 2008).

Similar to our study, another 6‐month virtual health promotion programme for PWID and obesity (n = 35), which aimed for weight loss and improvements in glucose and lipid profiles, reported no changes in BP (Neumeier et al., 2021). Changes in BP likely require sustained lifestyle behaviour changes beyond a 6‐month period, as well as more intensive interventions. In PAtH, we did not find statistically significant changes in PA or dietary behaviours, which are key mediators for improvements in BP. In addition to being a relatively short intervention, it was delivered by senior nursing students and recent nurse graduates with limited experience in working with PWID. Although nurses had the required knowledge to deliver PAtH in addition to being supported by a team of senior nurses and SOQ health educators, these nurses were still novice. A similar intervention delivered by more experienced nurses may have resulted in more important changes in outcomes.

Regarding the lack of changes in PA and screen time, previous health‐promotion interventions that reported improvements in PA among PWID included regular in‐person training sessions (Heller, Mccubbin, Drum, & Peterson, 2011; Martinez‐Zaragoza et al., 2016). Although in‐person sessions may support PA, sustainability of behaviour changes may be a challenge (Heller et al., 2011, Martinez‐Zaragoza et al., 2016). Another study reported that the use of virtual platforms to deliver PA sessions offers a sustainable approach for PWID to engage in PA as it requires minimal caregiver involvement, eliminates the need for transportation to an exercise facility, and provides a virtual space for socialisation (Ptomey et al., 2017), which are common barriers for PA in this population (Caton et al., 2012; Roll, 2018). Given that PAtH was designed to be delivered virtually during the COVID‐19 pandemic, the potential benefits of PA and reducing screen time may have been hampered by broader public health measures such as closures of indoor PA facilities and limited opportunities for in‐person socialisation.

With regard to dietary behaviours, we found that fewer participants reported the addition of salt when cooking but no changes in other dietary behaviours. Previous studies that included nutritional health promotion focused primarily on weight loss as the primary outcome without reporting on dietary outcomes (Heller et al., 2011). Other interventions that reported improvements in dietary behaviours focused specifically on providing nutritional education, which may explain their notable impact on diet compared with PAtH, which focused on a number of lifestyle behaviours, including diet (Ptomey et al., 2018; Subach, 2018). Moreover, given that PWID may have limited control over food purchasing and preparation, future interventions may benefit from more actively involving caregivers in nutrition‐related topics (Subach, 2018).

Importantly, we observed improvements in three out of four health‐related empowerment domains examined, particularly in relation to knowledge and understanding of BP management. These findings suggest that PAtH was successful at increasing participants' perceived abilities to take care of and act towards their own health, specifically with respect to their BP and cardiovascular health. There is a paucity of health promotion intervention studies with PWID that examined health‐related empowerment. Yet this is an enabling process for health (Castro, Van Regenmortel, Vanhaecht, Sermeus, & Van Hecke, 2016) that leads to higher participation in care and self‐management skills (Acuña Mora et al., 2018) and should be considered a valuable milestone in future health promotion interventions among PWID.

Among the strengths of PAtH, participants had one‐on‐one access to a nurse, an approach that facilitated adapting the intervention to the participant's needs, and which had not been used in previous initiatives (Ptomey et al., 2017; Rubenstein et al., 2020; Neumeier et al., 2021; Niemeier, Wetzlmair, Bock, Schoenbrodt, & Roach, 2021). We also targeted a range of cardiovascular health promotion topics, whereas previous health promotion interventions among PWID have generally focused on PA and diet (Willems et al., 2018; Messiah et al., 2019; Rubenstein et al., 2020; Neumeier et al., 2021; Niemeier et al., 2021). Moreover, we used methods to measure and monitor BP closely aligned with hypertension diagnosis guidelines (Myers et al., 2014; Hypertension Canada, 2024).

As part of the limitations of our study, it was difficult for some participants to follow the BP monitoring and recording protocol; this was reported as a reason for drop‐out. Although not all participants attained the desired 28 measurements of BP, we obtained 24 and 21 measurements on average at baseline and follow‐up. Another limitation was our lower‐than‐expected recruitment rate leading to a relatively small sample size with limited power to detect small effects. Our ability to recruit participants was limited by the availability of nurses/nursing students to deliver the intervention, given that they were heavily solicited by healthcare institutions to provide patient care during the pandemic. Matching potential participants with nurses was also challenging given schedule conflicts (nurses were mostly available in the evenings after work/school while participants preferred to have their sessions during the day) and incompatible language preferences (with French and English both being used in Quebec, Canada). Additionally, loss to follow‐up was high, especially between the end of the intervention and the follow‐up data collection; however, delaying the follow‐up to 1–2 months following the last PAtH session allowed us to estimate more sustained effects of the intervention. We did not collect data on the SMART goals selected by participants, thus precluding evaluation of the nature of specific goals and whether these were achieved. The lack of a control group, the attrition, and the reliance on self‐reported data which are prone to measurement error, limit our ability to estimate the effects of the intervention. Lastly, our findings may not be generalisable to all PWID, given the sampling of participants from the SOQ community who may already be more aware of the benefits of healthy active lifestyles.

Conclusion

Overall, PAtH was useful in strengthening knowledge and empowerment related to cardiovascular health among PWID. This may be a first step preceding future changes in lifestyle behaviours that could ultimately contribute to improved cardiovascular health and BP. The integration of adapted cardiovascular health promotion initiatives within well‐established community organisations such as Special Olympics is a promising model towards greater cardiovascular health equity among PWID. Future studies should examine the effects of higher intensity interventions, possibly through combined virtual and in‐person activities that are adapted to the preferences and autonomy level of each participant, to further improve health among PWID.

Author contributions

A. Van Hulst, L. Sanzone and T. Delmas conceptualised the study. R. E. Ponce‐Alcala conducted the analyses and drafted the initial manuscript. All authors contributed to participant recruitment, data collection and interpretation of the results. Additionally, all authors critically reviewed the manuscript for important intellectual content and approved the submission of its final version.

Source of funding

This study was funded through a Special Olympics Canada Research Grant and through in‐kind support from Special Olympics Quebec. AVH is supported by a Fonds de la recherche du Québec – Santé research award.

Conflict of interest

The authors report no conflicts of interest.

Ethics statement

Ethics approval was obtained from the Institutional Review Board (IRB) of the Faculty of Medicine and Health Sciences of McGill University, Montreal, Canada. The IRB works under the published guidelines of the Tri‐Council Policy Statement 2, in compliance with the Plan d'action ministériel en éthique de a recherche et en intégrité scientifique (MSSS, 1998), and the Food and Drugs Act (17 June 2001); and acts in accordance with the US Code of Federal Regulations that govern research on human subjects (FWA 000045445). The IRB working procedures are consistent with internationally accepted principles of good clinical practice. The IRB internal study number is A05‐B36‐21A, and the Info‐Ed file number is 21‐04‐031. Participants or a person legally apt to do so provided informed consent prior to participating in this study.

Ponce‐Alcala, R. E. , Cuerrier, A. , Sanzone, L. , Delmas, T. , Roberge, K. , and Van Hulst, A. (2025) Pay Attention to Hypertension (PAtH): Findings from a cardiovascular health promotion intervention for adults with intellectual disabilities participating in Special Olympics programming. Journal of Intellectual Disability Research, 69: 65–78. 10.1111/jir.13189.

Data availability statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.