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. Author manuscript; available in PMC: 2018 Nov 1.
Published in final edited form as: Clin Nurse Spec. 2017 Nov-Dec;31(6):311–318. doi: 10.1097/NUR.0000000000000331

Opportunities for the Advanced Practice Nurse to Enhance Hypertension Knowledge and Self-Management among African American Women

Lenette M Jones 1, Marie-Anne S Rosemberg 2, Kathy D Wright 3
PMCID: PMC5679274  NIHMSID: NIHMS898805  PMID: 28991014

Abstract

Purpose

Despite increased awareness and the advent of methods to manage the disease, hypertension is poorly controlled among African American women. This study explored hypertension knowledge and blood pressure in a sample of African American women.

Design

A descriptive, cross-sectional design was used to collect survey data on hypertension knowledge.

Methods

African American women attending a church conference were invited to complete a questionnaire, which included the Check Your High Blood Pressure Prevention IQ survey, and had their blood pressures measured.

Results

Of the 151 women who participated, 62% were diagnosed with hypertension. Many of the women - even those not diagnosed with hypertension - had elevated blood pressures. Although the average scores showed that the women scored well on the survey, there were four items on the survey that a percentage the women had difficulty with - questions about (1) stress as a cause of hypertension, (2) symptoms associated with high blood pressure, (3) whether or not hypertension could be cured, and (4) the amount of exercise needed to help reduce blood pressure.

Conclusions

Despite efforts to increase awareness and control of hypertension, considerable misconceptions about the disease were found in this sample of African American women. To improve self-management of hypertension among this group, advanced practice nurses need to directly address these misconceptions.

Introduction

Hypertension, defined as having a systolic blood pressure reading of 140 mmHg or higher and a diastolic blood pressure reading of 90 mmHg or higher, affects over 75 million individuals in the United States.1 Despite increased awareness of hypertension's etiology and efforts to mitigate the complications associated with this disease, hypertension remains a major public health concern, with less than half the affected population having the disease under control, and costing the nation over $48.6 billion annually.1-8 Lack of self-management of hypertension increases one's risks for developing heart disease and stroke.9-11 Some women do perceive themselves as being at risk for developing hypertension, however women with hypertension have a higher risk of cardiovascular related death than men.12 African American women have the highest risk, as they are disproportionately affected by hypertension and hypertension-related complications.9,13

Among African American women diagnosed with hypertension, almost half have do not have their blood pressure under control (47.3%) compared with European American women (43.2%).14 In addition, African American women are more likely to be diagnosed with hypertension at a younger age, have higher blood pressure readings, and die earlier from complications related to hypertension, when compared to European American women.9,14 Because of such disparities, it is important to explore African American women's knowledge and their approach to hypertension self-management. Interventions are needed that address the cultural and gender needs specific to African American women. The first step in developing interventions that appropriately target this problem begins with understanding how African American women currently conceptualize hypertension and manage it.

Hypertension is a chronic disease that necessitates consistent behavior changes that are maintained over time.9 Self-management of hypertension requires a skill set that includes problem-solving, decision-making, finding and utilizing resources, and taking action to reduce and maintain blood pressure.15 Patients with hypertension need information about the condition and must have an accurate understanding to manage it successfully. Blood pressure self-management may include a change in dietary or exercise patterns, as well as medication adherence.9

The patient-provider relationship is an important factor in promoting self-management of hypertension.16,17 Becoming aware of patients' understanding of hypertension is essential to reduce knowledge deficits that could influence health outcomes. Nurses are well positioned to work to reduce the disparity in hypertension among African Americans because they are taught to monitor, treat, and educate patients; advanced practice nurses can also prescribe medications and develop individualized treatments plans.18-21 However, the majority of the responsibility then rests with the patients, as they are to apply the information and recommendations obtained from the advanced practice nurse to their daily life in order to self-manage at home.

There are several potential barriers to self-management of hypertension. First, some patients do not conceptualize the disease as chronic; they expect that hypertension can be cured and that medications are only required for symptoms.22,23 In addition, previous studies have shown that participating overweight and obese African American women reported that they were not attempting to lose weight.24-26 Research has also demonstrated that lack of knowledge regarding hypertension and the necessary diet changes are a barrier to self-management of the condition for some African American women.27 Other barriers to treatment may include patient-specific factors (beliefs, behavioral norms, health literacy) and the intricacies of the patient-provider relationship.16,28

Cultural influences shape beliefs about hypertension and therefore impact self-management behaviors.29 Little is known about how African American women's knowledge and beliefs about hypertension may affect their approach to self-management of blood pressure. Therefore, the purpose of this study was to examine hypertension knowledge and blood pressure levels in a sample of African American women.

Methods

The methods employed in this study have been described elsewhere.30,31 A brief description is provided here for clarity.

Design

We used a descriptive cross-sectional study design. In 2013, a convenience sample of women attending a Midwestern regional church conference were invited to participate in the study. The University of Michigan Institutional Review Board (IRB) granted the work IRB-exempt status. In addition, the conference administrators granted permission for the study to be conducted. In order to be eligible to participate in the study, the women were required (1) to self-identify as African American and (2) to be age 18 years or older. Individuals who were unable to provide spoken consent to participate were excluded from the study.

Data collection procedures

Once they expressed interest in participating in the study, individuals were directed to a quiet area in the conference center that was reserved for the study. Given the IRB exemption status, completion of the questionnaire signified consent to participate in the study. The first page of the questionnaire provided written information about the study. This information included an explanation that participation in the study was completely voluntary and that the participants could change their mind and decide not to participate in the study at any time. In addition, the principal investigator was available to answer questions related to the study. Each participant received a $10 gift card for her participation.

Data sources

There were two types of data sources for this study: (1) an anonymous questionnaire booklet and (2) blood pressure measurement. The questionnaire took approximately 20 minutes to complete. The questionnaire included a demographic section (i.e., inquiring about age, education, income, and marital status). The questionnaire also included another section about hypertension knowledge. Participants' knowledge of hypertension was assessed with a 12-item survey developed by the National Heart, Lung, and Blood Institute – the Check Your High Blood Pressure Prevention IQ survey.32 This survey has been used in previous studies with African American samples.33 The Flesh-Kincaid reading level of this tool was 3.5. Topics included the cause and management of hypertension, as well as family history of hypertension. Participants could select either true (scored as a 1) or false (scored as a 0). An overall score was calculated by summing the responses. Possible scores ranged from 0 – 12, with higher scores indicating more accurate knowledge about hypertension.

Upon completion of the questionnaire, each participant's blood pressure was measured using a protocol developed from the Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7) guidelines.9 All blood pressure measurements were taken after the participant had been sitting for at least five minutes, in a chair with back support, with legs uncrossed. The Omron Elite 7300W Women's Advanced Blood Pressure Monitor was used to measure each participant's blood pressure.34 This model had been validated in previous studies; the average error reported was 1.2 mmHg (SD = 5.2)/3.3 mmHg (SD = 5.5).35 Each participant received her blood pressure measurement results. She was advised if her blood pressure was safe, was slightly elevated and requiring follow-up with a provider, or was dangerously elevated and required immediate follow-up with a provider. Women (n = 40) with blood pressure readings greater than 150/110 mmHg were advised to immediately seek care from the nearest emergency room.

Statistical analyses

Questionnaires that were not complete (n = 5) were excluded; there were a total of 151 complete questionnaires available for analysis. SPSS software (Version 24) was used to conduct the analyses. Descriptive statistics were used to summarize the data. Pearson product moment correlations were conducted to explore the relationship between systolic blood pressure scores and hypertension knowledge scores. Independent-samples t-tests were conducted to compare hypertension knowledge scores for women with controlled blood pressure and women with uncontrolled blood pressure. Linear regression was used to assess the effect of demographics (age, income, education, diagnosis of hypertension, employment status) on hypertension knowledge scores.

Results

Participants

A total of 151 individuals participated in the study. The majority of the participants had at least some college education (85.5%), were married or partnered (43.6%), and were working full-time (43.7%). The mean age of the sample was 55.2 (SD = 13.3), with ages ranging from 19 to 82 years. Sixty-two percent of the women stated that they had been clinically diagnosed with hypertension by a healthcare provider.

As shown in Table I, the women were further divided into groups to examine the differences between women who were normotensive and women with elevated blood pressures – 64% of the sample had systolic blood pressure less than 140 mmHg (n = 96) and 36% of the sample had systolic blood pressure greater or equal to 140 mmHg (n = 55). There were some differences between the groups. The women in the elevated blood pressure group were more likely to be diagnosed with hypertension. In addition, the women with elevated blood pressures were older (59 years) than the women with controlled blood pressure (52 years), t (135.17) = -3.60, p <. 001.

Table I. Sample Characteristics (N = 151).

SBP<140 (n = 96) SBP 140+ (n = 55)
% (n) % (n) χ2 (df) value p value
Income χ2 (10) = 10.64 .39
30,000 – 59,999 29.2% (28) 36.4% (20)
Greater than 60,000 37.5% (36) 29.6% (11)
Relationship status χ2 (6) = 6.54 .37
Married or partner 44.8% (43) 41.8% (23)
Education χ2 (7) = 9.29 .23
College graduate 32.2% (31) 27.3% (15)
Advanced Degree 30.3% (29) 32.7% (18)
Occupational Status χ2 (1) = .26 .61
Full-time 45.8% (44) 40.0% (22)
Diagnosis of hypertension χ2 (1) = 10.44 .001
Yes 52.1% (50) 80.0% (44)
No 47.9% (46) 20.0% (11)
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Note: SBP – systolic blood pressure

Blood pressure

The average blood pressure reading for the overall sample was 136/82 mmHg (which is elevated and categorized as prehypertension). The average blood pressure reading for women diagnosed with hypertension was 143/84 mmHg. Eighteen of the women (14%) had a systolic reading of greater than 160 mmHg. Sixteen of these women had been diagnosed with hypertension, while two had not been diagnosed. Most of the women (55%) had their blood pressure measured within the past two months.

Hypertension knowledge scores

The majority of the sample (97%) answered at least seven of the 12 questions correctly (Table II). The average score for hypertension knowledge was 8.76 (SD = 1.00), which was a score of 73%. The scores ranged from 6 to 11, or 50% to 92%. The effects of age, income, education, diagnosis of hypertension, and employment status on hypertension knowledge were examined. Each variable was entered into a separate regression analysis in order to determine its independent influence on hypertension knowledge scores. Each model was examined and none of the demographic characteristics had a statistically significant effect on hypertension knowledge scores.

Table II. Hypertension Knowledge Characteristics.

Correct Answer Overall sample (N = 151)
Incorrect % (n) Correct % (n)
1. There is nothing you can do to prevent HBP. False 3.9% (6) 96.0% (145)
2. If your mother or father has HBP, you'll get it. False 3.5% (26) 96.5% (124)
3. Young adults don't get HBP. False 1.8% (2) 98.2% (148)
4. HBP has no symptoms. True 86.8% (131) 12.6% (19)
5. Stress causes HBP. False 88.7% (134) 10.6% (16)
6. HBP is not life threatening. False 2.6% (4) 96.6% (146)
7. BP is high when it is over 140/90 mmHg. True 9.9% (15) 89.4% (135)
8. If you are overweight, you are 2 to 6 times more likely to develop HBP. True 4.6% (7) 95.3% (144)
9. You have to vigorously exercise every day to improve your BP and health. False 53.6% (81) 46.4% (70)
10. Americans eat 2 to 3 times more salt and sodium than they need. True n/a 100% (151)
11. Drinking alcohol lowers BP. False 1.3% (2) 98.6% (149)
12. HBP has no cure. True 72.1% (109) 27.8% (42)
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Note: BP – blood pressure, HBP – high blood pressure, HTN – hypertension, n/a – not applicable

Overall, there were eight statements to which the majority of the sample selected the correct response. As shown in Table II, there were three statements to which the majority of the participants responded incorrectly. In response to the first statement, “Stress causes high blood pressure,” 89% of the participants incorrectly responded “true”. In response to the next statement, “High blood pressure has no symptoms,” 87% of the sample incorrectly responded “false”. In response to the third statement, “High blood pressure has no cure,” 72% of the participants responded incorrectly, “false”. Also noteworthy, 54% of the sample incorrectly responded “true” to the statement, “You have to vigorously exercise every day to improve your blood pressure and health.”

There was no association between systolic blood pressure and hypertension knowledge r (-.05), p = .52. In addition, there was no association between blood pressure control status and hypertension knowledge r (-.06), p = .90. As shown in Table III, women who were normotensive were compared to women with elevated blood pressures, to examine differences in each hypertension knowledge survey question. No statistical differences were identified between the groups, meaning that women with elevated blood pressures answered the questions in the same manner as the women who were normotensive.

Table III. Hypertension Knowledge by Group.

SBP<140 (n = 96) SBP 140+ (n = 55) χ2 (df) value p value
Incorrect Correct Incorrect Correct
% (n) % (n) % (n) % (n)
There is nothing you can do to prevent HBP. 4.2% (4) 95.8% (92) 1.8% (1) 96.4% (53) χ2 (1) = 10.64 .78
If your mother or father has HBP, you'll get it. 16.7% (16) 83.3% (80) 14.5% (8) 80% (44) χ2 (1) = .00 1
Young adults don't get HBP. 1.0% (1) 99.0% (95) 1.8% (1) 96.4% (53) χ2 (1) = .00 1
HBP has no symptoms. 90.6% (87) 9.4% (9) 80.0% (44) 18.2% (10) χ2 (1) = 1.85 .17
Stress causes HBP. 89.6% (86) 10.4% (10) 87.3% (48) 9.1% (5) χ2 (1) = .00 1
HBP is not life threatening. 2.1% (2) 97.9% (94) 3.6% (2) 92.7% (51) χ2 (1) = .01 .94
BP is high when it is at or over 140/90 mmHg. 9.4% (9) 87.5% (84) 10.9% (6) 87.3% (48) χ2 (1) = .00 1
If you are overweight, you are 2 to 6 times more likely to develop HBP. 3.1% (3) 96.9% (93) 7.3% (4) 92.7% (51) χ2 (1) = .58 .45
You have to vigorously exercise every day to improve your BP and health. 33.3% (32) 66.7% (64) 36.4% (20) 61.8% (34) χ2 (1) = .08 .78
Americans eat 2 to 3 times more salt and sodium than they need. 100% (96) 100% (55) n/a
Drinking alcohol lowers BP. 99% (95) 98.2% (54) n/a
HBP has no cure. 76.0% (73) 24.0% (23) 65.5% (36) 34.5% (19) χ2 (1) = 1.46 .23
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Note: BP – blood pressure, HBP – high blood pressure, SBP – systolic blood pressure, n/a – not applicable

Discussion

This study addresses the need for evidence related to hypertension knowledge specifically among at-risk women.12 The overall average hypertension knowledge score in this sample was 73%, suggesting that, in general, this group of African American women were knowledgeable about the condition. This is comparable to reports that participants were generally knowledgeable about hypertension in a sample of primarily European women diagnosed with hypertension.36 Although their overall knowledge was above average, the women in this study could benefit from additional education on the cause, lack of symptoms, and options for the management of hypertension. In fact, when comparing women who were normotensive to women with elevated blood pressures, there were no differences in the way that they responded to the statements. Also, none of the demographics variables (age, income, education, diagnosis of hypertension, employment status) explained any of the variance in hypertension knowledge scores. This suggests that despite varying demographics and blood pressure status, the women in the sample had the same cultural misconceptions about specific characteristics of hypertension (cause, symptoms, and management).

There were three statements to which the majority of the participants responded incorrectly which may have been influenced by cultural misconceptions. The first statement concerned hypertension symptoms. Although studies have shown an association between hypertension and late-occurring symptoms, such as headache and nosebleeds, self-management of hypertension is not based on response to symptoms. It is based on daily eating and exercise patterns, and adherence to medications.9 Basing treatment on symptoms might lead to inconsistencies in a patients' regimen, such as not taking medications as directed or only reducing sodium in response to a headache.

The next statement that the women had difficulty answering was related to stress as a cause of high blood pressure. There are debates about the role of stress and poor health outcomes including elevated blood pressure. Chronic stressors relating to social constructs such as race, socioeconomic status, immigration status and experiences, stressful work environment, and history of trauma have been shown to have a direct correlation with high blood pressure.37-40 However, among this group of study participants, it was noted that their conceptualizing episodic stress as a cause lends to the belief that hypertension is not a chronic disease, supporting the notion that stress reduction would lead to remediation of hypertension. Previous studies have also reported on beliefs that hypertension is a result of stress and is a curable disease.41-43 The fact that the women believed hypertension could be cured showed that they did not view hypertension as a chronic disease. This finding is disconcerting given that individuals must have accurate knowledge in understanding hypertension is manageable, not curable.9 Patients also must understand the purpose of following a regimen (dietary changes, exercise plans, and medication adherence) in order to effectively self-manage their blood pressure.9,16 It is within the advanced practice nurse's scope of practice to identify gaps in the patient's knowledge of hypertension and provide education that meets their needs.18 Understanding the basis for these misconceptions will help the advanced practice nurse tailor culturally competent health education messaging to African American women with hypertension.

Finally, 35% of the sample incorrectly answered the question regarding the use of vigorous exercise to lower blood pressure. This relates to previous studies that found overweight and obese African American women were not participating in weight loss efforts due concerns surrounding the misconceived intensity of exercise required to reduce weight.24-26 Perhaps the women felt if they were not able to exercise vigorously, their weight loss efforts would be in vain. Advance practice nurses play a role in delivering evidence-based education to address this misconception by promoting the benefits of light and moderate exercise to reduce blood pressure.

Comprehensive interventions (that also account for stressors such as race, and socioeconomic status) that address such cultural misconceptions will improve self-management routines, helping ensure that they are successful and consistent across the lifetime. Nurse administered interventions have been successful in assisting patients to self-manage their blood pressure through making these lifestyle changes.21,44,45 Advanced practice nurses can help to mitigate these problems in two ways. First, they must remain current in evidence-based practice and cognizant of differences among groups, especially nurses who are prescribing anti-hypertensive medications.20 In addition, frequent patient-nurse interactions can lead to increased medication adherence among hypertensive patients. 21,44,46,47 While interacting with patients, nurses can assess patients for side effects and suggest modifications to their treatment plan.20 Advanced practice nurses can also help patients to self-manage side effects while adhering to their current treatment plan.44,48

As expected, there was no correlation between hypertension knowledge and systolic blood pressure. Studies continue to show that knowledge does not necessarily translate to changes in behavior.9,41,49,50 This finding is consistent with other studies, as fewer than half of the women with hypertension who were on medication had their blood pressure under control.3,51 The mean systolic blood pressure of women diagnosed with hypertension was greater than 140 mmHg. Therefore, there are opportunities to improve knowledge of hypertension and promote self-management strategies to improve blood pressure control, particularly among the women in the sample who had been diagnosed with hypertension and were already receiving treatment.

There are health disparities among those with hypertension and nursing has been challenged to find methods to reduce those differences.9,52,53 The advance practice nurse has highly developed skills that can make significant contributions towards helping patients to successfully self-manage their blood pressure. Through implementing evidence-based practices, nurse-directed care will continue to decrease morbidity and mortality related to hypertension.19,20,54 However, to further enhance care provided by the advance practice nurse, we must develop and test new intervention methods, especially those that can be tailored to meet the needs of vulnerable populations in order to continue to reduce the health disparity gap.

Limitations

These findings should be interpreted within the limitations of the study. One limitation is that data collection took place at a regional church conference, where the women were culturally similar and it is probable they had shared belief systems. Also, the sample obtained was a convenience sample, which limits the generalizability of these findings. Additional studies are needed to examine hypertension knowledge and blood pressure status among women in other church settings, outside of the church setting and among women from other regions of the United States, to determine if they have the same misconceptions about hypertension self-management. The study participants were highly educated women, as over 85% of the sample had attended college. Studies are needed among women with fewer years of education to determine if their perceptions and knowledge differ. Another limitation is that this was a cross-sectional study and blood pressure was measured at one time point. There are multiple factors that could have affected the women's blood pressure readings – normal blood pressure variation, as well as physical (arterial stiffness), emotional (anxiety), and behavioral (sleep) influences.55 Finally, there was limited information on the validity and reliability of the hypertension knowledge survey, although this survey has been used in similar samples.33 Despite these limitations, this study provided an opportunity to capture specific views of women within a community and highlights knowledge deficits that must be addressed in order to improve self-management and blood pressure control.

Conclusion

This study examined hypertension knowledge and blood pressure in a sample of African American women. The findings of this study show that there are opportunities for the advanced practice nurse to improve knowledge among the women in this sample, particularly among women diagnosed with hypertension. Despite the high prevalence of hypertension in the sample, the women had a moderate level of knowledge of the condition. The knowledge deficits identified could affect blood pressure self-management. Women in this study could benefit from additional education on the cause, lack of symptoms, curability, and options for management of hypertension. The lack of an association between one's blood pressure and one's hypertension knowledge suggests that women may require additional support to translate hypertension knowledge into self-management behaviors. Additional studies are needed to better understand the role and influence of the advanced practice nurse in translating hypertension education into health information, diet, exercise, and medication adherence behaviors among African American women improve their blood pressure control.

Acknowledgments

Research reported in this publication was supported by the National Institute of Nursing Research of the National Institutes of Health under Award Numbers T32-NR-007073 and P30NR015326-02S1. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Contributor Information

Lenette M. Jones, Department of Health Behavior and Biological Sciences, University of Michigan School of Nursing, Room 2180, 400 N. Ingalls, Ann Arbor, MI 48109, phone: 734-763-1371.

Marie-Anne S. Rosemberg, Department of Systems, Populations and Leadership, University of Michigan, School of Nursing.

Kathy D. Wright, The Ohio State University College of Nursing, 1585 Neil Avenue, Columbus, Ohio 43210, phone: 614-292-0309.

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