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1Running head: HIGH BLOOD PRESSURE PREVENTION

Prevention Strategies for High Blood Pressure:

A Rural Community Approach

Jasmine Wagner

University of Hawai’i at Hilo

Committee Chair:

Dr. Katharyn Daub

Committee Member:

Dr. Jeanette Ayers-Kawakami

2HIGH BLOOD PRESSURE PREVENTION

Acknowledgements

There are many people that have guided and supported me to make this Practice Inquiry Project

(PIP) possible. I would like to send a big mahalo nui loa the Wai’anae community for being

open to learning on the prevention strategies for high blood pressure and sharing feedback on the

topics.

I would like to thank the University of Hawai’i at Hilo School of Nursing for allowing me to be

part of the Doctor of Nursing Practice (DNP) Program and encouraging future nurse practitioners

to educate communities in Hawai’i.

I want to thank Dr. Katharyn Daub for being my PIP chair and mentor. Thank you for inspiring

me. Your guidance has allowed me to successfully deliver this project. Thank you for

supporting me and taking time to guide me through this project. You are truly phenomenal!

I would also like to thank Dr. Jeanette Ayers-Kawakami for being my committee member. You

have helped steer my project in the right direction. Your advice was much appreciated.

A special thanks to Bobbie Elisala, MSN, FNP. Thank you for all your support and

encouragement! I am fortunate to have had you throughout my journey.

Many thanks to the Honolulu Community Action Program and Leeward District Service Center

Manager, Val Tavai for supporting this project.

A big thanks to my family who showered me with unconditional love and support. To my

children, Skylee, Shayla, Scarlett, Jordan, Jacob, Arthur, and Colt, I love you all! To my mother,

Helena, thank you for always being there for me and supporting me through my endeavors. To

my father-in-law, Dale, and mother-in-law, Teresa, thank you for your tremendous support,

perseverance, and encouragement.


Lastly, I would like to acknowledge and thank my husband, Carlos. Mahalo nui loa for your

unconditional love and support. You are my world.


Abstract

High blood pressure (HBP) increases the risk for dangerous and potentially fatal health

conditions. HBP is a leading cause for heart disease and stroke in the United States (U.S.).

Heart disease and stroke are among the top causes of mortality in the U.S. HBP is known as the

“silent killer” because signs and symptoms are not always apparent. Individuals who live in

rural communities and lack education and access to medical services are at a higher risk for

developing HBP and are more likely to die from heart related complications compared to

individuals living in suburban or urban communities. According to literature, 15% of the

American population lives in rural areas. There are modifiable risk factors, which can lower the

risk of HBP. The outcome of this project is to increase awareness of HBP and identify

modifiable risk factors to reduce the incidence of HBP among rural community members.

Evidence-based education was provided to the community to improve outcomes. The project

setting was held at Honolulu Community Action Program (HCAP) on the Leeward Coast of

Oahu. A convenience sample was used for this project. A quantitative research design was used

to gather data. Materials used included a pre-questionnaire, a post-questionnaire, and an open-

ended questionnaire. Data was analyzed and organized in an Excel spreadsheet. This project

was also evaluated for validity and accuracy. The goal of this Practice Inquiry Project (PIP) was

to identify risk factors for HBP among community members, and to use this evidence-based

information to educate on effective strategies to reduce the risk of HBP.


Table of Contents

Acknowledgements………………………………………………………………………………..2

Abstract……………………………………………………………………………………....……4

Chapter 1…………………………………………………………………………………………8

Introduction and Background……………………………………………………………………..8

Risk factors………………………………………………………………………………8

Cost of Managing High Blood Pressure…………………………………………………10

Problem Statement…………………….…………..……………………………………..10

Significance of the Problem……………………………...………………………………11

Expected Outcomes….………………………………………………………………..…11

Chapter 2………………………………………………………………………………………..12

Background and Project Description…………………………………………………………….12

Comprehensive and Focused Review of the Literature…………...…………………..…12

Background and Significance of Community…...……………………………………….13

Goal of the Project…..…………………………..……………………………………….14

Specific Aim 1…………………………………………………...………………………14

Specific Aim 2…………………………………………………...………………………14

Specific Aim 3………………………………………………...…………………………14

Chapter 3……………………………………………………………………………..…………..15

Project Design and Evaluation Plan……………………………………………………………...15

Research design…………...…..…………………………………………………………15

Framework…………………………...…………………………………………………..15

Project Setting……………………...…………………………………………………….16


Target Population………………………………………………...................................…16

Recruitment.…….………………………………………………………………………..16

Timeline and Steps for Project Implementation…………………………………………17

Methods…………………………………………………………………………………..18

Data Analysis Methods………………………………………………………….……….18

Human Subject Protection……………………………………………………………….18

Chapter 4…………………………………………………………………………………..……..19

Results…………………………………………………………………………………...……….19

Background characteristics……………………………………………………...……….19

Pre-overall & Post-overall questionnaire………………………………………………..19

Pre-questionnaire & Post-questionnaire……………………………………………..….20

Week 1………………………………………………………………………………..…20

Week 2………………………………………………………………………………..….21

Week 3………………………………………………………………………………..….21

Week 4………………………………………………………………………………..….21

Project Evaluation…………………………………………………………………….….22

Chapter 5………………………………………………………………………………………....23

Discussion and Conclusion….…………………………………………………………………...23

Project Limitations……………………………………………………………………….23

Implications for Practice…………………………………………………………………24

Conclusion……………………………………………………………………………….24

References……………………………………………………………………………………......25

Appendix A………………………………………………………………………………………28


Appendix B………………………………………………………………………………………29

Appendix C………………………………………………………………………………………30

Appendix D………………………………………………………………………………………31

Appendix E………………………………………………………………………………………32

Appendix F………………………………………………………………………………………33

Appendix G………………………………………………………………………………………34

Appendix H………………………………………………………………………………………35

Appendix I…………………………………………………………………………….…………36

Appendix J…………………………………………………………………………….…………38

Appendix K………………………………………………………………………………………39


Chapter 1

Statement of the Problem

Introduction and Background

High blood pressure (HBP) or hypertension increases the risk for dangerous and

potentially fatal health conditions. HBP is a leading risk factor for heart disease in the United

States, and heart disease is the leading cause of mortality. HBP affects both men and women

equally. However, more men, under the age of 45, are affected more than women of the same

age. In contrast, more women, over the age of 65, are affected more than men of the same age.

African Americans develop HBP more than any other ethnic background (American Heart

Association, 2019). The American Heart Association (2018) estimates 103 million adults living

in the United States have HBP. Nearly half of individuals with HBP do not have their blood

pressure under control (Center for Disease Control, 2018). The normal, elevated, and HBP

readings from American Heart Association (2019) can be found in appendix H.

High blood pressure is known as the “silent killer” because signs and symptoms are not

always apparent. One in five adults with HBP are unaware they have it (CDC, 2018). In 2014,

more than 410,000 Americans died from HBP related deaths, which equates to more than 1,100

deaths each day (CDC, 2018). According to the American Heart Association (2018), death rates

caused by HBP increased by 38% from 2005 to 2015. The elimination of HBP can reduce

cardiovascular deaths by 30.4% among males and 38.0% among females (AHA, 2018). There

are modifiable risk factors to help reduce the incidence of HBP.

Risk Factors

There are two major risk factor groups for HBP. The first is modifiable risk factors,

which are factors that can be changed. Some modifiable risk factors include: physical activity,


diet, maintaining a healthy BMI, limiting alcohol intake, controlling high cholesterol, diabetes,

smoking and tobacco use, and stress. The second is non-modifiable or fixed risk factors, which

are factors that cannot be changed. Some non-modifiable risk factors include: family history of

HBP, advanced age, race, and having chronic kidney disease. The Data from the Nurses’ Health

Study report that diet and lifestyle changes are main factors that can prevent HBP among females

(AHA, 2018).

Consuming a heart healthy diet can prevent and help manage HBP. The Dietary

Approaches to Stop Hypertension “DASH” diet is a heart healthy plan to lower blood pressure.

The DASH diet includes eating foods rich in fruits and vegetables, whole-grains, low fat daily

products, skinless poultry and fish, nuts and legumes, and non-tropical vegetable oils. In

addition, limiting saturated and trans fat, sodium, red meat, sweets and sugar-sweetened

beverages can help lower blood pressure. The World Health Organization (WHO) recommends

a low sodium diet to reduce HBP, cardiovascular disease and stroke. A study conducted by Ha

(2014), found the DASH significantly lowered systolic and diastolic blood pressure among

individuals with hypertension. The DASH diet had a greater effect on systolic BP. The study

found a decrease in systolic blood pressure of 11.5mmHg in participates with hypertension.

Dietary guidelines suggest no more than 1,500mg of sodium per day for individuals with

hypertension. People should be aware of hidden sources of salt in foods and condiments.

Incorporating the DASH diet and low sodium diet can significantly reduce blood pressure. In

addition, a healthy diet can improve weight management, which is crucial for a healthy lifestyle

and prevention of HBP.

The prevalence of overweight and obesity is on the rise. Between 1980 and 2013, adults

who are overweight and obese rose by 27.5% (AHA, 2018). In 2008, 1.46 billion adults were


estimated to be overweight or obese. Education on diet and exercise can significantly reduce the

risk of developing HBP.

Lack of physical activity can lead to multiple health issues, with one major issue being

HBP. Physical activity can help to lower blood pressure. The American Heart Association

(2018) recommends 150 minutes per week of moderate to vigorous physical activity. These

activities include but not limited to brisk walking, hiking, jogging, running, bicycling,

swimming, or dancing. Tobacco use also increases the risk for HBP. Tobacco use is the leading

cause of preventable deaths, and nearly half a million Americans die each year from tobacco use

(American Heart Association, 2018).

Cost of Managing High Blood Pressure

The cost to treat HBP is also on the rise. Managing HBP cost the nation $48.6 billion

annually (CDC, 2018). These costs include heath care related services; medications to treat

HBP, and absence from work. The American Heart Association predicts by 2035 a total direct

cost of HBP will be estimated at $220.9 billion. In addition, pharmacological intervention costs

are also increasing. According to IMS Health National Prescription Audit, the number of

prescriptions for antihypertensive medications increased from 613.7 million to 653 million

between 2010 and 2014 (AHA, 2018). The cost to fill the 653 antihypertensive medications in

2014 was $28.81 billion.

Problem Statement

High blood pressure increases the risk for dangerous and potentially fatal health

conditions. HBP is an ongoing chronic condition that affects many people in the Wai’anae

community of O’ahu. Wai’anae has an estimated population of 13,000 individuals (U.S. Census

Bureau, 2010). Most of the population is mature adults, and according to the CDC (2017),


33.5% of adults over the age of 20 have HBP. Native Hawaiians and Pacific Islanders make up a

large percentage of the Wai’anae community who are at a higher risk for developing HBP

compared to other ethnicities. Education on HBP prevention strategies is vital for the Wai’anae

community to decrease the risk of developing HBP.

Significance of the Problem

In 2016, heart disease and stroke were the first and fourth cause of death in Hawai’i.

Lack of awareness and lack of education are major factors for developing HBP among rural

communities. Those who live in rural communities are at a higher risk for developing HBP

compared to individuals who live in the suburban or urban communities. There are modifiable

risk factors that can decrease the risk of developing HBP for rural communities.

Expected outcomes

The outcome of the project is to increase awareness of HBP and identify modifiable risk

factors to reduce the risk of HBP among rural community members. Evidence based education

is provided to further improve outcomes.


Chapter 2

Background and Project Description

Comprehensive and Focused Review of the Literature

The clinical question that drove this literature review was, “For rural community

members at risk for increased blood pressure, what are modifiable risk factors to prevent high

blood pressure?” Several database searches were conducted for literature review which include:

American Heart Association, Centers for Disease Control and Prevention, CINAHL, Conchrane

Library, EBSCOhost, Google, and Pub Med. The time frame was limited to 2014-2019. Key

words used included: “high blood pressure,” “hypertension,” “high blood pressure in adults,”

“risk factors for high blood pressure,” “rural community,” “low socioeconomic status,” “DASH

diet,” “high salt diet,” and “community level intervention.” The literature search provided

evidence on HBP among rural community members.

High blood pressure is a leading cause of death around the world. Understanding what

can cause HBP and being aware of ways to prevent this disease is crucial to prevent health

complications. The prevalence of hypertension in 2025 is projected to increase by 60% (Diaz &

Shimbo, 2013). Currently, 33% of the world’s population has hypertension. According to the

CDC (2017), American’s living in rural areas has a higher risk of developing blood pressure than

their urban counterparts.

There are ways to prevent hypertension, such as increasing physical activity and

consuming a healthy diet. Activities that can help prevent hypertension include aerobic exercise,

resistance training, high intensity, interval training, accumulated exercise, and walking.

Interventions can benefit the communities’ knowledge and understating of hypertension. In

addition, primary prevention can decrease the risk for hypertension and is one way to increase


awareness on hypertension and promote health to the community. Lifestyle modification, such

as a well balanced diet, reducing sodium, smoking cessation, regular physical activity, and

avoiding excessive alcohol consumption is recommended to reduce hypertension (Aronow

2017).

Background and Significance of Community

The Wai’anae community is located on the Leeward side of Oahu, which is about an hour

drive from downtown. The land in Wai’anae is 5.4 square miles. The Wai’anae coast is

considered rural with some farmlands in the valleys but predominately residential. Wai’anae

does not get much rain and is considered a dry and desolate area. However, during the summer

months, Wai’anae will get more rainfall than any part of the island due to humid sea breezes that

blow against the Wai’anae mountain range. This leaves the mountains with lush green

vegetation. Wai’anae has a hidden homeless camp, which is 19 acres, and is located in the

Wai’anae Boat Harbor. There are more than 240 adults and children who reside in the Wai’anae

Boat Harbor area.

The United States Census is updated every 10 years. The most recent census count was

in April of 2010 with an estimate of 13,000 individuals residing in Wai’anae (U.S. Census

Bureau, 2010). Most of the population is adults. Persons under the age of 18 are 32.5% of the

population (U.S. Census Bureau, 2010). There is less than 1% variation between the male and

female population with females being 0.6% higher than males in numbers. Mixed race is the

predominant race of Wai’anae at 44.8%. Native Hawaiians or other pacific islander is second at

30.6%. The third greatest race of the population is Hispanic at 15%.


Goal of the Project

The goal of this PIP is to identify risk factors for HBP among rural community members,

and use evidence based information to educate regarding effective strategies to reduce the risk of

HBP.

Specific Aim 1

Assess the level of awareness that contribute to HBP among rural community members.

Objective 1. Determine baseline understanding by administering a pre-overall

questionnaire consisting of 5 questions.

Objective 2. Administer a pre-questionnaire consisting of 5 questions related to the

educational session provided.

Specific Aim 2

Provide evidence-based education.

Objective 1. Identify modifiable and non-modifiable risk factors for HBP.

Objective 2. Use American Heart Association Five Simple Steps to Control Blood

Pressure.

Specific Aim 3

Evaluate the project for validity and accuracy to decrease HBP risks.

Objective 1. Determine if awareness on HBP was effective by administering a post-

questionnaire and post-assessment questionnaire.

Objective 2. Evaluate participants’ individual thoughts regarding the project using an

open-ended questionnaire.


Chapter 3

Project Design and Evaluation Plan

Research Design

The project design was a practice intervention design. The implementation of the project

was done over four weeks. Each week offered an educational session on ways to reduce the risk

of HBP using American Heart Association’s Five Simple Steps to Control Blood Pressure. An

overall pre-questionnaire was administered prior to the start of the first week to determine a

baseline understanding. Prior to each educational session, a pre-questionnaire was administered

and after the educational session, a post-questionnaire was administered. A post-overall

questionnaire was administered at the conclusion of the project.

Framework

The Iowa Model: Evidence Based Practice to Promote Excellence in Health Care was

selected as the theoretical framework to guide this practice inquiry project (Appendix K). The

Iowa Model was developed to help identify issues, find solutions, and implement changes while

using evidence based methods. The Iowa Model was chosen for this project because of the

importance of using evidence-based practice to guide research. Permission to use the Iowa

Model was approved by the University of Iowa Hospital and Clinics.

There are several steps within the Iowa Model.

1. Step 1 includes identifying triggering issues where evidence base practice change is

needed.

2. Step 2 is stating the question or purpose for the project.

3. Step 3 requires an interdisciplinary team to be formed.


4. Step 4 is assembling and synthesizing the body of evidence. This also includes

conducting a related literature search. If there is sufficient evidence and research the

model suggest conducting and implementing research. The next step is to integrate and

sustain the practice change. The final step is to disseminate results. The Iowa Model fit

this project well because of the focus on evidence-based methods to improve patient care

(Iowa Model Collaborative, 2017).

Project Setting

Project setting took place at The Honolulu Community Action Program (HCAP) in

Wai’anae, which is located on the Leeward Coast of Oahu. HCAP is a private, non-profit

organization that offers many programs and services on Oahu to economically challenged

communities since 1965. HCAP’s mission statement is, “POI: Providing Opportunities and

Inspiration to enable low-income individuals or families to achieve self-reliance.” Most of

HCAP members are predominately Native Hawaiian and reside in Wai’anae. Community

members gathered at HCAP once a week for this project.

Target Population

The target population included adult participants that reside in the Wai’anae community.

Eligibility criteria for participants include adults, male and female, over the age of 18, who live

in the Wai’anae community and are able to read, write and speak English, and have an interest in

prevention strategies for HBP. Community members were included or excluded based on the

recruitment statement prior to implementing the project.

Recruitment

Participants were recruited from the Wai’anae community. A convenience sampling

method was used to recruit participants. The sample size goal was 10-15 participants. Before


the start of the project, a recruitment statement was verbally delivered in person to members who

attend HCAP in Wai’anae. Each member was informed about the project, the four-week

timeline, educational sessions, and questionnaire surveys that were part of the project. In

addition, every member was informed regarding the eligibly criteria and voluntary participation.

Timeline and Steps for Project Implementation

The Wai’anae community was the starting point for this project. Participation subjects

came from the targeted community. Assessment of HBP was obtained by pre-questionnaire and

data was collected. Education on HBP was conducted over the course of four weeks and

consisted of American Heart Association (2019) Five Simple Steps to Control Your Blood

Pressure. The five steps include:

1. Knowing your numbers

2. Working with your doctor

3. Make a few lifestyle changes

o Maintain a healthy weight

o Eat healthier

o Reduce sodium

o Get active

o Limit alcohol

4. Check your blood pressure at home

5. Take you medication.

A post-questionnaire was administered after the educational teaching and the data was collected.

An evaluation on the project was administered and collected after the four weeks. All data was

analyzed appropriately and put into a Word spreadsheet.


Methods

The methods for this project follow the same outline found under specific aims and

objects on 14.

Data Analysis Methods

A quantitative study was done for data analysis. Data was collected using structured

multiple-choice questionnaires. An information sheet was used to obtain information on risk

factors for HBP. In addition, an open-ended questionnaire was administered after the project.

Data was analyzed using pie charts and frequency distribution graphs.

Human Subject Protection

The University of Hawai’i at Hilo School Nursing Department approved this project to

proceed. Application for this practice inquiry project was submitted to the Institutional Review

Board (IRB) and approved to conduct this study. The population consisted of community

members in a rural setting. Each participant was informed of voluntary participation and the

option to opt out at anytime. Each participant, who voluntarily wanted to participate, was

provided with an informed consent prior to the start of the project (Appendix I). All information

remained confidential and names were never collected.


Chapter 4

Results

Background Characteristics

All the participants were above 50 years old. There were a total of 17 participants that

filled out the information sheet (Appendix A). The participant age range of 50-59 years old

accounted for 18%, and participants age 60 years and older accounted for 82%. Majority of the

participants were female (88%). The participants self-identified as either American Indian or

Alaska Native, Asian, Black, Native Hawaiian or Other Pacific Islander, White, or Other. The

sample had a high number of Native Hawaiian or Other Pacific Islander (71%), and lower

numbers of White (18%), American Indian or Alaska Native (6%), and Other (6%). Highest

level of education completed was somewhat distributed evenly, with the exception of no post

college graduates. Thirty-five percent of the participants had some college, 29% graduated high

school, 18% graduated from college, and 18% had less than a high school diploma. Ninety-four

percent of the participants had health insurance and 6% had no health insurance. Eighty-two

percent of the participants said they smoked tobacco. Fifty-three percent of the participants said

they have HBP. When asked about following a health diet, 53% of the participants said most of

the time, 24% said sometimes, 12% said always, and 12% said never.

Pre-Overall Questionnaire & Post-Overall Questionnaire

During week one, prior to the start of the project, a pre-overall questionnaire was

administered to determine a baseline understanding for HBP (Appendix B). There were 16

participants that filled out the pre-overall questionnaire. During week four, after the end of the

project, the same overall questionnaire was administered to determine if the educational teaching

sessions were effective. There were 15 participants that filled out the post-overall questionnaire.


Results for the over-all questionnaire show a significant increase between pre-overall and post-

overall scores. There was a 12% increase in knowledge for question one. There was a 30%

increase in knowledge for question two. Question three depicted a 43% increase in knowledge.

Question 4 demonstrated a 42% increase in knowledge, and question 5 showed a 79% change in

knowledge (Table 1).

Table 1.

Pre-Questionnaire and Post-Questionnaire

In total, there were four pre-questionnaires and four post-questionnaires administered

over the course of the four-week implementation portion of the project. The pre-questionnaire

was completed before the start of the educational session and the post-questionnaire was

completed after the educational session. The cumulative results were compared to observe

changes.

Week 1

The topics covered in week one were Risk Factors for HBP, Check your Blood Pressure

at Home, and Know Your Numbers (Appendix C). There were 15 participants during week one.

The pre-score cumulative determined 81% of participants felt they were educated about the topic

of HBP. After the educational session, the post-score demonstrated that 95% of participants felt


they were much more educated on the topic of HBP. There was a 14% increase in pre-post test

scores.

Week 2

The topics covered in week two were the life style changes: Maintain a Healthy Weight

and Get Active (Appendix D). During week two, there were 13 participants. The pre-score

cumulative determined 72% of participant felt they were educated about the topic of HBP. After

the educational session, the post-score demonstrated that 95% of participants felt they were much

more educated on the topic of HBP. There was a 23% increase in pre-post test scores.

Week 3

Week three covered the lifestyle changes: Eat Healthier, Reduce Sodium, and Limit

Alcohol (Appendix E). There were 15 participants during week three. The pre-score cumulative

determined 72% of participants felt they were educated about the topic of HBP. The post-score

demonstrated that 96% of participants felt they were much more educated on the topic of HBP.

There was a 24% increase in pre-post test scores.

Week 4

The topics during week four included: Working with your Doctor and The Importance of

Taking your Blood Pressure Medication (Appendix F). During week four, there were 13

participants. The pre-score cumulative determined 82% of participants felt they were educated

about the topic of HBP. After the educational session, the post-score demonstrated that 97% of

participants felt they were much more educated on the topic of HBP. There was a 15% increase

in pre-post test scores.


Project Evaluation

There were two multiple-choice questions and four open ended questions for the project

evaluation (Appendix G). The first question, “I enjoyed the presentation,” 100% of the

participants responded “very much.” The second question, “I will benefit from this

presentation,” 100% of the participants responded “very much.” The remaining four questions

were open-ended questions. The participants had various answers for the first question, “What

modifiable risk factors have you learned that can decrease the risk of high blood pressure,”

included responses were avoiding salty foods, looking for foods to eat with low salt, exercising,

and taking medication as prescribed by your doctor. The most common response for the

question, “What part of the project did you like the best,” included topics such as diet and

exercise, managing your medication and working with your doctor. For the question, “What part

of the project did you like the least,” the majority of the participants responded “none” or “I liked

it all.” The last open-ended question was “additional comments,” and responses included, “thank

you,” “very informative,” “N/A,” and some were left blank.


Chapter 5

Discussion and Conclusion

Studies show there is a link between lack of education and increased HBP. One aim of

this project was to use evidence based information to educate on prevention strategies. This aim

was met by providing evidence-based education over the course of four weeks. Another aim for

this project was to increase awareness of HBP and identify modifiable risk factors. The findings

from this project concluded that this aim was met by the increase in post-questionnaire scores.

Education and health promotion is necessary to improve population health. The patient

education was delivered successfully within this project. It is important to target and educate

high-risk communities, such as the rural population, to improve their health. There is an

abundance of information on how to control BP, and the results discussed from this project is

consistent with the information found in the literature. This PIP demonstrates that providing

education to rural community members increases awareness on the topic.

Project Limitations

There were some limitations with this project. The use of a convenience sample may

have been a limiting factor. This project obtained a small sample size of less than 20 participants

per day. Another limiting factor may have been the fact that all participants were collected from

HCAP in Wai’anae. Other limitations include the participants that were interested in the topic

and met the requirements to participate. However, this project was to target Wai’anae

community members who met the requirements of the study. There are not many studies on how

prevention strategies for HBP affect rural communities and their awareness on HBP. More

studies should be done to lower the risk of HBP and increase knowledge on the subject.


Implications for Practice

Education is key to increase awareness and decrease the risk of hypertension. Nurse

practitioners should advocate for those in the community in making preventive programs

accessible. Nurse practitioners can provide education on preventive strategies to empower the

community to make healthier choices. This project aids DNP practitioners in providing

education programs to improve health outcomes and awareness of hypertension in rural

populations. The findings for this project can help DNP practitioners who seek to improve

awareness for their patients about HBP. DNP practitioners can contribute by discussing the five

simple steps to lower the risk of HBP. Due to the small sample size of this project, more studies

on prevention strategies for HBP are needed in a larger population target.

Conclusion

High blood pressure remains a leading risk factor for heart disease. The prevention of

HBP is a public health challenge, but education on prevention strategies can help decrease the

incident of HBP for this rural community. Educating the public on American Heart Association

Five Simple Steps to Control Blood Pressure is an effective way to increase awareness on HBP

and decrease the modifiable risk factors. This project on the five simple steps to control blood

pressure can aid DNP practitioners or other healthcare professionals in providing education

programs to improve health outcomes and increase awareness of HBP in rural populations. DNP

practitioners can contribute by discussing the five simple steps to lower the risk of HBP. Future

research can use this project as a baseline to increase awareness on HBP.


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https://www.cdc.gov/bloodpressure/facts.htm

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https://www.cdc.gov/nchs/fastats/hypertension.htm

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https://www.cdc.gov/bloodpressure/measure.htm

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from five leading causes. Retrieved from

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https://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/index.htm

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Current Hypertension Reports, 15(6), 659–668.

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12(1), 7–18.


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https://www.census.gov/quickfacts/table/BZA010213/1574450/accessible#footnotes.


Appendix A

Let’s Prevent High Blood Pressure

INFORMATION SHEET

1. What age group do you fall into?a. 18-29b. 30-39c. 40-49d. 50-59e. 60 and over

⮚ Which gender do you most identify?a. Maleb. Femalec. Other

⮚ Which race do you most identify?a. American Indian or Alaska Nativeb. Asianc. Blackd. Native Hawaiian or Other Pacific Islandere. Whitef. Other

⮚ What is the highest grade you completed?a. Less than high schoolb. High school graduatec. Some colleged. College graduatee. Post-college graduate

⮚ Do you have health insurance?a. Yesb. Noc. Not sure

⮚ How often do you eat fast food or processed foods?a. Neverb. Rarelyc. Oftend. Always


Appendix B

High Blood Pressure Overall Pre & Post Questionnaire

PLEASE CIRCLE ONE

⮚ High blood pressure leads to the number one cause of death in the United States. What is the leading cause of death in the United States?

a. Cancerb. Diabetesc. Heart diseased. Stroke

⮚ Which of the following is considered a normal blood pressure?

a. 142/90 mmHgb. 118/78 mmHgc. 139/80 mmHgd. 152/110 mmHg

⮚ What do you think are risk factors for high blood pressure?

a. Smokingb. Lack of physical exercisec. Diet high in saltd. Overweighte. Stressf. All of the above

⮚ What is the maximum amount of salt consumption recommended per day?

a. 1,150 mg (1/2 teaspoon)b. 2,300 mg (1 teaspoon)c. 3,450 mg (1 ½ teaspoons)d. 4,600 mg (2 teaspoons)

⮚ How much exercise is recommended weekly for adults (such as brisk walking, dancing, gardening)?


a. 1 hourb. 2.5 hoursc. 4 hoursd. 5 hours or more

Appendix C

Health Topic:Risk Factors for High Blood Pressure

Check Your Blood Pressure at Home and Know Your Numbers

PLEASE CIRCLE ONE

1. What are non-modifiable risk factors for high blood pressure?

a) Family historyb) Agec) Genderd) Racee) All of the above

2. What are modifiable risk factors for high blood pressure?

a) Unhealthy dietb) Lack of physical activityc) Drinking too much alcohold) Smokinge) All of the above

3. Which of the following is important when taking your blood pressure at home?

a) Be stillb) Sit correctlyc) Measure at the same time every dayd) Take multiple readings and record the resultse) All of the above

4. A normal blood pressure is considered:

a) Less than 120/80b) 130/89c) 149/95d) Above 140/90

5. There are steps you can take to keep your blood pressure in a healthy range.


a) Trueb) False

Appendix D

Health Topic:Maintain a Healthy Weight, Get Active

PLEASE CIRCLE ONE

1. What is body mass index (BMI)?

a) Diagnostic tool of body fatb) A screening tool that determines if you are at a healthy weight based on your

height and weightc) Interpreted the same for adults, teens, and childrend) Not important

2. What are ways to maintain a healthy weight?

a) Reduce screen timeb) Exercise regularlyc) Follow a healthy dietd) Eat fruits and veggies dailye) All of the above

3. What is an example of moderate to intense aerobic activity?

a) Brisk walkingb) Water aerobicsc) Gardeningd) Dancinge) All of the above

4. How much moderate to intense physical activity should you aim for each week?

a) 1 hourb) 2.5 hoursc) 4 hoursd) 5 hours

5. Benefits to being more active include:


a) Lower risk of high blood pressureb) Better sleepc) Less weight gain and obesityd) Better quality of lifee) All of the above

Appendix E

Health Topic:Eat Healthier, Reduce Sodium, Limit Alcohol

PLEASE CIRCLE ONE

6. According to the Dietary Guidelines, what is a healthy eating pattern?

e) A variety of vegetablesf) Whole fruitsg) Whole grainsh) Fat-free or low fat dailyi) Variety of protein foodsj) All of the above

7. According to the Dietary Guidelines, what does a healthy eating pattern limit?

f) Saturated fatsg) Tans fatsh) Added sugarsi) Sodiumj) All of the above

8. How much salt does the Dietary Guidelines for Americans and American Heart Association recommend a day for adults?

f) Less than 1,150 mg (1/2 teaspoon)g) Less than 2,300 mg (1 teaspoon)h) More than 3,450 mg (1 ½ teaspoons)i) More than 4,600 mg (2 teaspoons)

9. What is excessive alcohol use?

e) Binge drinkingf) Heavy drinkingg) Alcohol use by anyone under 21 years oldh) All of the above

10. The Dietary Guidelines for Americans defines moderate alcohol consumption as:


f) 1 drink for women and 2 drinks for men per dayg) 2 drinks for women and 4 drinks for men per dayh) 4 drinks for women and 4 drinks for men per dayi) 6 drinks for women and 6 drinks for men per day

Appendix F

Health Topic:Work with Your Doctor

Importance of Taking Blood Pressure Medication

PLEASE CIRCLE ONE

11. Having a good doctor-patient partnership is important to control your blood pressure and reach your treatment goals.

k) Truel) False

12. It is important to ask your doctor about your blood pressure at your checkups.

k) Truel) False

13. Which of the following are substitutes for blood pressure medications?

j) Naturopathic approachesk) Waterl) Over the counter medicationsm) There is no substitute for blood pressure medications

14. High blood pressure cannot be cured, but it can be managed with:

i) Life style changes j) Medication when neededk) A and Bl) High blood pressure cannot be managed

15. Taking blood pressure medication as directed by your doctor is ______ important.

j) Sometimesk) Alwaysl) Never


Appendix G

Project Evaluation

1. I enjoyed the presentation

a) Very muchb) Somewhatc) Not reallyd) Not at all

2. I will benefit from this presentation

a) Very muchb) Somewhatc) Not reallyd) Not at all

3. What modifiable risk factors have you learned that can prevent high blood pressure?

4. What part of the project did you like the best?

5. What part of the project did you like the least?

6. Additional comments:


Mahalo Nui Loa for your participation!

Appendix H


Appendix I

University of Hawai'iConsent to Participate in a Research Project

Jasmine Wagner, Student InvestigatorProject title: Strategies to Prevent High Blood Pressure: A Rural Community Approach

Aloha! My name is Jasmine Wagner and you are invited to take part in a research study. I am a graduate student at the University of Hawai'i at Hilo in the Department of Nursing. As part of the requirements for earning my graduate degree, I am doing a research project.

What am I being asked to do? If you participate in this project, you will be asked to fill out a survey.

Taking part in this study is your choice. Your participation in this project is completely voluntary. You may stop participating at any time. If you stop being in the study, there will be no penalty or loss to you.

Why is this study being done?The purpose of my project is to evaluate the effectiveness of education on prevention strategies for high blood pressure in a rural community. I am asking you to participate because you live in a rural community area.

What will happen if I decide to take part in this study?You will fill out surveys that consist of multiple choice and open-ended questions. It will take 5-10 minutes per survey. The survey questions will include questions like, “A normal blood pressure is considered?” “What are ways to maintain a healthy weight?” “What are modifiable risk factors for high blood pressure?” You will receive education on a blood pressure health topic then take a survey based on the health topic information. The surveys will be paper format and provided to you in person.

What are the risks and benefits of taking part in this study?I believe there is little risk to you for participating in this research project. You may become stressed or uncomfortable answering any of the survey questions. If you do become stressed or uncomfortable, you can skip the question or take a break. You can also stop taking the survey or you can withdraw from the project altogether.

There will be no direct benefit to you for participating in this survey. The results of this project may help improve if education on prevention strategies for high blood pressure is effective.


Privacy and Confidentiality: I will not ask you for any personal information, such as your name or address. Please do not include any personal information in your survey responses. I will keep all study data secure in a locked filing cabinet in a locked office/encrypted on a password protected computer. Only my University of Hawai'i advisor and I will have access to the information. Other agencies that have legal permission have the right to review research records. The University of Hawai'i Human Studies Program has the right to review research records for this study.

Compensation:There is no compensation for participating in this research project.

Future Research Studies:After removing identifiers, the data from this study collected will not be used or distributed for future research studies.

Questions: If you have any questions about this study, please email me at [email protected]. You may also contact my faculty advisor, Dr. Katharyn Daub, at 808-932-7067 or email at [email protected]. You may contact the UH Human Studies Program at 808.956.5007 or [email protected] to discuss problems, concerns and questions, obtain information, or offer input with an informed individual who is unaffiliated with the specific research protocol. Please visit http://go.hawaii.edu/jRd for more information on your rights as a research participant.

Filling out the survey will be considered your consent to participate in this study.

Please keep a copy of the consent form for your records.

Mahalo!


Appendix J


Appendix K

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