Co-Created Health Education Intervention (Co-CHIN) among Older African American Women Living with Hypertension

Abstract

Introduction:

African Americans over the age of 60 years face disproportionate risk of developing hypertension, which can be mitigated with lifestyle changes. This study examines the acceptability and cost of a patient-centered, co-created health education intervention with older African Americans living with hypertension.

Methods:

Twenty women participated in this study that included four weekly, two-hour group sessions centered on hypertension knowledge and calibration of home blood pressure monitors, stress and interpersonal relationship management, sleep and pain management, and healthy eating. The study took place in the Midwest United States.

Results:

Descriptive statistics were used to analyze acceptability data that included attendance and a brief investigator-generated questionnaire. Twenty women were enrolled. Sixteen participants attended all four sessions, all reported they intended to continue using the intervention and felt it fit within their culture, routine, and self-care practices. The estimated cost of conducting the intervention was $227.00 (U.S. dollars) per participant.

Conclusions:

The co-created health education intervention was acceptable. Given the dire need for cost-effective interventions to improve the adoption of health promoting self-care management behavior, to reduce the prevalence of hypertension in older African Americans, the results of this study have implications for future research and practice.

INTRODUCTION

Disparities in the prevalence of hypertension are a persistent challenge for African Americans as compared to their White counterparts— resulting in more complications (cardiovascular disease) and reduced quality of life.[1] There is thus a significant need for risk reduction measures, and evidence suggests that healthy diet, physical activity, and stress management could prevent 80% of cardiovascular disease.[2] However, research shows that both Black and Hispanic people are less likely to engage in healthy lifestyle behavior than Whites.[3] Likewise, research shows the limitations of some existing approaches to promoting self-care; for example, although dietary advice to reduce sodium is often provided in the clinical setting, it is not a sufficient motivator to change behaviors.[4] Multiple strategies are needed to promote the adoption self-care behaviors to prevent hypertension in African American older adults.

There are a range of barriers that hinder the adoption of healthy self-care behaviors in African American older adults.[2] Low self-efficacy (the confidence that is required to carry out a self-care goals) limits ones’ ability to manage hypertension. In addition, the lack of support from family and friends to engage in healthy eating—a particular challenge in the African American community since church and family gatherings center around traditional foods that are high in fat, sugar, and salt.[2] Some studies show that lack of access to healthy foods (e.g., travel out of the local neighborhood to a grocery store) and the time to prepare meals pose significant barriers for African Americans and hinder self-care practices.[3, 4] While a vast body of literature has addressed community-based interventions including Stanford Chronic Disease Self-Management [5, 6] and hypertension in African American men at barbershops [7] that focus on healthy self-care behaviors, comparatively fewer studies focus on the acceptability of co-creating health education interventions to promote hypertension self-care among older African American women.[8–12]

African American women face a lifetime risk of higher blood pressure than White Women. For example, African American women are twice more likely to suffer from the high blood pressure than their white counterparts.[1] Research shows African American women are less likely to engage in self-care (such as diet and exercise behaviors) if they believe their hypertension is caused by stress. Although lifestyle changes are effective, they will not make a difference in controlling hypertension in patients are not participating in these behaviors.[13, 14] Our own research to date has found that stressful interpersonal communication problems, sleep disturbance, chronic pain, blood pressure knowledge deficits, and complex diet information all interfered with older African American women’s blood pressure self-care.[15, 16] The barriers to hypertension self-care require a multi-component approach, [17] to develop culturally conscious patient-centered self-management interventions for African American women. As a result, the barriers to hypertension self-care can be overcome by empowering patients to engage in the process of creating interventions and promoting self-efficacy.[2]

Information Motivation Behavioral Model

Through an iterative design and analysis process, we used qualitative data to co-create a hypertension health education intervention tailored to the needs of older African American women. The paradigm for the co-created health education intervention was based on the Information-Motivation-Behavioral (IMB) model.[15, 16, 18, 19] The model requires implementation of a program by a health professional and a systematic review of studies of the IMB model suggests this feature may contribute to positive outcomes. As compared to peer-led interventions [5, 8], the health professional delivers the intervention. The rationale is that the health professional can address the questions of participants that may not be answerable by a lay-leader. Additionally, the presence of the health professional demonstrates a commitment to the older adult that lends credibility to the delivery of the intervention.[2, 18]

The three components of the IMB model are basic information regarding an illness/disease, motivation through learning in a socially supportive environment, and behavioral skills acquired to manage a chronic illness through improving self-efficacy. In this case, the disease is hypertension, the socially supportive environment is forged through a co-created intervention, and the skills acquired are designed to give participants confidence (self-efficacy) in the management of their conditions. The IMB model provides the basis to develop, test, and evaluate the adoption of healthy self-care behaviors in persons with chronic conditions, such as hypertension.

Studies have shown the use of the IMB model to be effective in managing multiple chronic conditions including diabetes, human immunodeficiency virus, and cardiovascular disease.[18, 20–23] For example, a structural equation analysis of the IMB model in persons with diabetes found that participants had more knowledge about diabetes, social support, and self-efficacy after participating in an intervention using the IMB model. It also enhances the development of trust between health care professionals and patients.[18]

A key element to developing non-pharmacological interventions among older African American women are “two-way communication and trusting, and collaborative relationships with active involvement in the treatment regimen” through social supports.[24] Having the co-created intervention with participants and health professionals, the group-based environment allowed for social exchange among and was conducive to learning and boosted confidence.

The aim of this study was to examine the acceptability and cost of the co-created intervention in older African American women living with hypertension. To our knowledge, it is the first study utilizing a hypertension education intervention that employed the IMB approach targeting African American women living with this disease. This study contributes to the field of health promoting self-care intervention research by developing and testing strategies, co-created health education intervention with African American female nurse scientists and older adults, to reduce blood pressure in African American women. It also adds to the field by offering a template for creating an intervention to address an important threat to longevity and quality of life in African American women.

METHODS

Design

This study consisted of a focus group of African American older adults between the ages of 60 and 90 years.[16] The co-creation methodology and qualitative analysis of the focus group that was used to develop the intervention are detailed elsewhere.[15, 16] The materials and methods for the study are described below. All methods were approved by the Institutional Review Board (IRB# 12–16-43).

Sample and Setting

African American women from low-income communities, age 60 years and older with a diagnosis of hypertension, were included in this study. The four weekly group co-created intervention sessions (2 hours per session) were held in the activity room of an urban senior center.

Materials

Two automatic blood pressure monitors were used to demonstrate how to self-monitor blood pressure and calibrate home monitors. The co-created intervention included educational materials from the National Heart, Lung and Blood Institute and the American Heart Association. These free content materials were the Dietary Approaches to Stop Hypertension,[25] Understanding Blood Pressure Reading,[26] Healthy Food Under $1.00,[27] Heart Healthy Soul Food,[28] and Managing Stress to Control Your Blood Pressure.[29] Other educational materials included a 2-day food journal,[30] Ten Tips on Being Assertive-Better Health Channel,[31] and the National Sleep Foundation 7-night Sleep Diary.[32] Paper, three-ring binders, and pens were provided to the participants to store educational materials and homework assignments.

Participant Incentives

A taxicab provided transportation for those who could not drive to the sessions. Those who drove to the sessions received a $10.00 U.S. dollars gas card after each session to ensure attendance would not be costly. We provided a laptop computer to deliver a slide presentation which was projected on a large screen to ensure easy legibility. Healthy snacks consisting of fresh fruit and bottled water were provided for participants. Participants were compensated with a one-time $50 U.S. dollars retail gift card for being in the study. During the final session, the participants selected a wrapped “mystery” gift, either a scented candle or a picture frame that cost less than $5.00 U.S. dollars to celebrate the completion of the study.

Interventionists

The co-created health education intervention was delivered by a Registered Nurse who was accompanied by two graduate nursing students, who were all African American women, and one non-African American Licensed Dietitian.

Co-Created Health Education Intervention

Topics covered in the group sessions were: (a) learning more about hypertension, (b) interpersonal communication stress, (c) sleep and pain, and (d) healthy eating. The elements of the IMB model were included hypertension education (information) delivered by a Registered Nurse and Licensed Dietitian, group discussions and sharing (motivation), and practice of behavioral skills (e.g. blood pressure self-monitoring, modification of “soul food” recipes, and homework).[16, 19]

The assignments over the course of the sessions focused on content to try at home such as, keeping a food and sleep diary, practicing interpersonal communication skills, and setting health related goals.[16] The first three sessions were led by one Registered Nurse and supported by graduate nursing students. The last session was led by the Licensed Dietitian accompanied by graduate nursing students. Each session was 120 minutes in duration.

Co-Created Health Education Intervention Weekly Topics

Week 1.

In session one, topics such as diagnosis, causes, risk factors, symptoms, interventions, and how to self-monitor blood pressure were delivered by the Registered Nurse. This included an interactive didactic lecture and slide presentation and practice using and calibrating their home arm-automatic blood pressure monitors. The Registered Nurse and graduate students worked with participants and demonstrated use of the home blood pressure monitor. At the end of session one, participants received a homework assignment to record at least one day of food intake and complete a sleep diary.[16]

Week 2.

In session 2, topics covered included effective communication (verbal and nonverbal), thinking, listening, and speaking—delivered by the Registered Nurse. Participants learned about communication and the effects of stressful interpersonal communication on the body’s physiological responses. They were encouraged to talk about their positive and negative experiences communicating with family and friends in the context of the African American culture (e.g., family support, spirituality, and reverence for elders). Participants learned problem-solving skills to address communication breakdown and role play what they have learned. At the end of the session, participants were given the opportunity to review their food and sleep diaries with the Registered Nurse and graduate students.[15, 16]

Week 3.

Session 3 was dedicated to sleep and pain management. The Registered Nurse reviewed barriers and facilitators to pain management, sleep management practices, and relaxation before bedtime. Participants practiced a 10-minute mindfulness body scan (progressive relaxation). Throughout the session, the Registered Nurse reinforced collaboration with participants’ healthcare providers to seek treatment for sleep problems. In small groups, participants reviewed sleep diary entries that they completed the previous week and shared strategies. In preparation for session four, participants were given a food diary to fill out two days of eating, and a www.choosemyplate.gov sheet that visually depicts a healthy plate.

Week 4.

The Licensed Dietitian delivered the fourth and last session. This included educational materials from the American Heart Association and National Heart, Lung, and Blood Institute on lowering blood pressure with the Dietary Approaches to Stop Hypertension, portion sizes, and ingredient substitutions to add flavor without salt.[33] The dietitian led the group in completing a salt quiz that compares sodium in common foods like milk, breads, and pasta. She used a PowerPoint presentation to deliver a lecture on Portion Distortion II Interactive Quiz from the National Heart, Lung, and Blood Institute that demonstrated changes in serving sizes over the past 20 years.[34] This slide presentation also included examples of the amount of physical exercise needed to burn the extra calories contained in supersized portions. At the end of the session, participants could volunteer to have their food diary reviewed by the dietitian and the group. Together they identified healthy substitutes for cooking favorite ethnic meals (soul food), such as using olive oil, celery, and spices to season collard greens instead of cured fatty cuts of pork.

Acceptability Measures

Acceptability was measured by recording weekly participant attendance and an investigator-generated questionnaire adapted from previous studies.[10, 35] The investigator-generated questionnaire had a list of nine items on a visual analog scale of 1–10 with one being very poor and 10 being excellent.[35] An emoji of a sad face was positioned at one, neutral face at five and happy face at 10. The minimum score was nine and the maximum was 90. The form contained acceptability related questions and were focused on the participant’s satisfaction with the intervention, intent to continue using the intervention, perceived appropriateness of the intervention and the fit of the intervention within their routine and culture. Specifically, the extent to which the participant perceived that co-created health education intervention can be used in day-to-day life in the context of the African American culture (e.g., flavorful adaption of traditional soul foods to reduce salt and fat). To assure anonymity, participants’ unique identification number was not linked to their responses. Participants completed questionnaires at the end of session two and session four.

Cost Measures

The estimated costs for the intervention included participant incentives, transportation, and Licensed Dietitian. For our study, LMJ, KOM, and CHS (all registered nurses) delivered week 1–3 of the intervention in-kind as part of their research responsibilities, avoiding the need to pay a Registered Nurse. Therefore cost for the Registered Nurse was estimated from the 2018 U.S. Bureau of Labor Statistics for the State of Ohio.[36] Participant compensation data and Licensed Dietitian charges were obtained from the study budget and materials (paper, folders, and pens) were estimated by using a Google search of retail prices.

Statistical Analysis

Descriptive statistics, including means, standard deviations, and range were used to display the results of the investigator-generated acceptability questionnaire, attendance, and cost data. A 95% confidence interval was used to determine the true mean for the range of values of the investigator generated acceptability questionnaire. All statistical analyses were conducted using statistical software package SPSS 25.[37]

RESULTS

Thirty-one participants from the focus groups were invited to participate in this study to try the co-created intervention; 20 accepted and were re-consented for this study. All participants were African American women and the mean age was 71.55 (SD = 8.3; Range = 62–91 years). Sixteen of the participants attended all four sessions, four people attended three sessions, and one person attended only two sessions. See Table 1 for attendance per session.

Table 1:

Participant attendance for the weekly 2-hour sessions

Topic	Week	Attendance (Percentage)
Hypertension and self-monitoring of blood pressure	One	19 (95%)
Interpersonal communication stress	Two	19 (95%)
Sleep and pain	Three	18 (90%)
Healthy eating	Four	19 (95%)

Descriptive statistics of items from the investigator-generated acceptability questionnaire are presented in Table 2. Twenty-eight questionnaires were completed that included the Interpersonal Communication Stress session two (11 completed; eight not completed) and the Healthy Eating session four (17 completed; two not completed) sessions. The mean score was 80.46 (SD = 8.80) with a range of 62–90 (95% CI = 77.05, 83.87). Cronbach’s alpha, measure of internal consistency, was acceptable (nine items; α = .88).

Table 2:

Investigator generated feasibility and acceptability questionnaire

Item	Mean (Standard Deviation)	Median	Range
Satisfaction with the intervention	9.53 (.62)	10	8–10
Intent to continue using the intervention	9.39 (.90)	10	7–10
Perceived appropriateness of the intervention	9.25 (1.17)	10	6–10
Fit of the intervention within your routine and culture	9.1 (1.17)	9	7–10
Actual intervention use	8.8 (1.07)	9	7–10
Expressed interest or intention to use the intervention	9.21 (1.16)	10	6–10
Degree of execution or how much of the intervention have you done	8.92 (.96)	9	7–10
Efficiency, speed, or quality of the implementation of the intervention	8.74 (.97)	9	6–10
Ability of participants to carry out intervention activities	9.96 (.98)	9	7–10

The cost estimates for the delivery of the intervention are listed in Table 3. The total cost was $4,543 U.S. dollars ($227 per participant). Most participants lived within a 5–10 mile radius of the community center; parking was available at no cost and the gas cards fully covered the cost. Participant compensation was $55.00 per person. Study participants incurred no cost for the intervention.

Table 3:

Estimation of costs of the co-created intervention

Item	U.S. Dollars
Participant incentives ($50/person and $5.00 mystery gift)	$1155
Transportation
Taxi cab	1440
Gas card	600
Healthy snacks ($6.00/person)	$120
Registered Nurse ($34.48/hour for 8 hours)	$267
Registered Dietitian ($200/hour for 2 hours)	$200
Graduate nursing students (research practicum-no cost)	$0
Automatic blood pressure monitors	$100
Room rental ($50.00/ session for 4 sessions)	$200
Laptop computer (PowerPoint presentations)	$800
Ink pens, binders and paper	$128
Educational handouts (free content)	$0
Total cost	$4,543
*Cost per participant	$227

^*Denominator was the number of participants (N=20). The one male participant is not included in this table. +Rounded up to the nearest dollar

DISCUSSION

The purpose of this study was to describe the acceptability and cost of a co-created health education intervention for African American women living with hypertension. Novel to co-created intervention is the use of the IMB health behavior model to structure the delivery of the intervention. We successfully incorporated all of the elements of the model within co-created intervention, incorporating education (information), peer sharing through small groups (motivation), and learning to monitor blood pressure (behavior).

Acceptability

The intervention was acceptable and cost-effective. The attendance rates exceed the average for chronic disease management interventions, with 90% attendance, significantly higher than 74.9% in other studies.[38, 39] Evidence from other large cross-sectional studies indicate that interpersonal communication stress is a barrier to engagement in healthy behaviors and, thus, may contribute to poor hypertension control.[5, 14]

Our co-created intervention health education intervention is unique. The participants led the researchers in tailoring an intervention that included interpersonal communication skills training to navigate life chaos−a risk factor for African American women living with hypertension—a critical factor to promote the adoption of healthy lifestyles in African American women living with hypertension.[40] Although trust itself was not measured in the present study, we believe that its development may have contributed to the acceptability of the intervention. If a patient does not trust their provider, they are unlikely to implement their providers’ recommendations.[2] Likewise, a study of interventions serving low-income African American women found that this group has greater trust in research when it is delivered by nurses.[41] Moreover, while leading the educational sessions, the participants engaged in self-disclosure, which contributes to trust.[14]

Cost

The cost of our non-pharmacological co-created intervention is minimal, particularly in comparison to the cost of treating uncontrolled hypertension and the renal failure (dialysis), strokes (rehabilitation), heart failure, and mental health issues (anxiety and depression – related to inadequate stress management) hypertension can cause. Success in our co-created health education intervention could potentially save money. According to the Centers for Medicare and Medicaid, the yearly costs to treat multiple chronic conditions average $30,000 per capita across U.S. states .[42] Likewise, cardiovascular disease cost nearly $131 billion a year between 2003 and 2014.[43]

The potential cost-related challenges in the delivery of the co-created health education intervention include the use of graduate students, free content (health education materials) that may not always be accessible, and available to health professionals willing to lead the sessions. In instances where funding is limited, using a video of the expert or video conference may make it possible to deliver the intervention in rural counties where getting the expert to be available for four sessions may be difficult. To generalize the intervention, the budget may need to include the costs of student assistants, as other sites that may want to replicate this may not have this free assistance as a resource.

Limitations

A limitation was that the co-created intervention was tested in the same group that designed it – while there are benefits to this model, it may mean that the intervention would be less effective with a group who did not have such involvement. Future research should test the efficacy of the intervention in a randomized controlled trial among groups of older African American women in various settings (urban vs rural).

CONCLUSIONS

The IMB skills model served as a guide for the examination of the acceptability and cost of this new intervention. The intervention has the potential to improve the adoption of health promoting self-care behaviors to reduce blood pressure among older African American women living with hypertension, with significant benefit to them, their families, and society. Additionally, the intervention could also be adjusted for use to serve other cultural underrepresented groups.

Highlights.

• African American women need a voice in the designing of co-created health education interventions to improve blood pressure.

• Participants reported that they intended to continue using the co-created intervention and felt that the intervention fit within their culture, routine, and self-care practices.

• Co-created culturally tailored interventions may be the key to improving blood pressure self-care.