May is National High Blood Pressure Education Month, and nurses know the urgent need of giving accurate information to help patients. If left untreated or improperly treated, this condition can have devastating, long-term impacts on cardiovascular health and throughout the body—that’s why it’s often called the “silent killer.” It’s also the reason many people don’t see it as the serious health threat it is.
Here are four ways you can help your patients comprehend the risks.
Understand Why High Blood Pressure Is Serious
Many patients, particularly those who are fairly symptom free, often don’t pay attention to their numbers. But they also often don’t realize how untreated high blood pressure can wreak havoc on the human body. According to the American Heart Association, blood pressure impacts everything from your heart health to your vision. One of the biggest struggles nurses have with prevention behaviors is getting people to understand that maintaining a normal blood pressure is critically important to overall health.
Realize It’s Manageable
Thankfully, the condition can be treated with effective and available treatments including medications. Generally, patients are put on a dose of blood pressure medication that helps keep their numbers in the right range. Lifestyle changes are even more manageable and sustainable for some patients. While not everyone can reduce their blood pressure with lifestyle changes, many people can reduce it so they require less medical intervention. Losing weight helps reduce the workload of the systems in the body and therefore can help reduce blood pressure. Eating healthier foods, getting exercise, reducing stress, and getting enough good-quality sleep also helps.
Accept It’s Sometimes Genetic
Plenty of exceptionally healthy people still have high blood pressure. As a disease with a genetic component, high blood pressure often runs in families. For some people, doing everything you’re supposed to do to reduce blood pressure still doesn’t work. The important thing is to make sure you get it treated. Help patients understand that if what they’re doing isn’t working, they still have to get those numbers in a good zone.
Be Alert for Red Flags
Lots of people can check their blood pressure at home or in the local drug store and that’s a great additional tool. But patients who do that should understand that that’s not all they have to do. Increasing blood pressure sometimes indicates something else is going on. If blood pressure suddenly spikes or drops or if symptoms start to resurface, make sure patients know they need to check in with you.
With education, interventions, and modifications, most people can successfully control their blood pressure. The biggest factor is making sure patients understand why it’s so essential to treat the condition before it escalates into something worse.
The Johns Hopkins Bloomberg School of Public Health has led a study displaying a relation between demographic health issues and mobility limitation. Researchers found that depressed African American women had almost three times the odds of mobility limitations than those who are not depressed. Additionally, African Americans reporting multiple medical conditions tended to have a higher risk of mobility limitations than those with fewer medical conditions. The study can be found in a 2011 issue of the Journal of Gerontology.
The study was conducted with 602 African Americans, made up of men and women between the ages of 48 and 92. The participants previously reported having difficulties walking and climbing stairs. The researchers used logistic regression to measure how demographics and health independently affected mobility. Results proved that pre-existing medical conditions in African Americans were associated with mobility limitations; however, African American women with lower incomes were affected the most.
Roland Thorpe, assistant scientist with the Bloomberg School’s Department of Health Policy and Management, says depressive symptoms have not been labeled as a mobility limitation factor in the past, but the studies have begun to prove otherwise. Thorpe says the problem might have been a lack of motivation rather than a mobility limitation; therefore, in order to repair mobility, African Americans must tend to medical conditions right away and control their depressive symptoms.
Rosemarie Jeanpierre remembers the cruel comments as if she heard them yesterday. She was riding a crowded bus to work in Los Angeles when a perfect stranger got on and said, “move over, fatso,” as they all jostled for more standing room. Feeling ashamed, she wanted to get off the bus immediately, but kept riding, all the way to her job as a treatment nurse at Western Convalescent Hospital.
At the time, Jeanpierre weighed 220 pounds, and at 5’2″, she was considered obese. In 2003, her doctor told her she had pre-diabetes, a condition of elevated blood sugar and a harbinger for a diabetes diagnosis down the road. She had been overweight her whole life. As a girl in the Philippines, she learned the habit of overeating for emotional comfort. She had the classic symptoms: her blood sugar was “out of control,” yet she felt hungry all the time. She felt short of breath, propping up pillows at night to breathe while sleeping. And her co-workers told her she looked stressed.
“My doctor got upset with me,” Jeanpierre, L.V.N., recalls. “She said, ‘You’re only 39 and you’re a nurse!'” Being scolded by her physician was upsetting, but not nearly as traumatic as dealing with her father’s death of a massive heart attack a few years before. He had been a diabetic and suffered from high cholesterol and high blood pressure as well.,
“That gave me a big realization that I needed to do something about my health,” Jeanpierre says. “I said to myself, ‘I’m a nurse, and I want to set a good example for my patients.'”
In a dramatic reversal of fate, Jeanpierre lost half her body weight in 18 months through a disciplined regimen of exercise and dietary changes. She forced herself to reduce her daily caloric intake from 6,000 to 1,800. The trips to McDonald’s and a local bakery stopped. What began with 45-minute walks on the treadmill gradually morphed into an abiding passion for running. Jeanpierre ran her first marathon in 2005 at the urging of her nephew. Now, she routinely wins shorter distance races in her age division and plans to run the Nanny Goat 100-mile race this year.
Jeanpierre’s story is exceptional, yet could have turned out much differently if she hadn’t found the willpower to change her behavior. Diabetes, heart disease, and hypertension are chronic diseases and are among the leading causes of death in all populations, but more acutely strike minority groups: African Americans, Latinos, Native Americans, and certain Asian ethnicities. They also happen to be diseases where behavioral changes can reverse—or at least mitigate— their impact.
Nurses possess greater knowledge of these illnesses than the average person, but are no exception. In addition, researchers have recently discovered nurses may be particularly vulnerable to developing key risk factors.
Diabetes: bad for our blood vessels
If not properly managed, diabetes sets the stage for poor heart health. Grim statistics prove cardiovascular disease is the leading cause of death among people with diabetes. Two out of three people with diabetes die of heart disease or stroke; a middle-aged person with type 2 diabetes has as much of a chance of having a heart attack as someone without diabetes who has already had one heart attack, according to the National Institute of Diabetes and Digestive and Kidney Diseases.
“Diabetes is a risk factor for cardiovascular disease, and any diabetes education program must include information about heart disease,” says Cristina Rabadán-Diehl, Ph.D., M.P.H., Deputy Director of the Office of Global Health at the National Heart, Lung, and Blood Institute.
In fact, researchers have come up with a special name for the cluster of traits that make a person prone to both diabetes and heart disease: metabolic syndrome, meaning he or she has three out of the following five conditions.
Excessive abdominal fat
High levels of triglycerides
Low amounts of HDL, or “good,” cholesterol
Fasting blood sugar level of 100 milligrams per deciliter
So how exactly does diabetes compromise cardiovascular health? By adding stress to our circulatory system, which carries blood and oxygen to vital organs and tissues.
In type 2 diabetes, cells become resistant to insulin, the hormone needed to extract sugar from the blood and metabolize it into energy. Having excess sugar, or glucose, in the blood contributes to the deterioration of blood vessels, but researchers have yet to pin down glucose’s specific role in this process.
“Glucose exacerbates the action of other risk factors, [and] the process of atherosclerosis gets accelerated,” says Rabadán-Diehl. Atherosclerosis is the process by which arteries become clogged and hardened by plaque, a waxy substance made of cholesterol, fat, calcium, and cellular waste, thereby narrowing the channel through which blood can flow.
According to Rabadán-Diehl, excess blood sugar could also “stimulate the production of fatty acids, and makes plaque a bit vulnerable.” By producing fatty acids, glucose potentially destabilizes pieces of plaque, moving them through our arteries to potentially form blood clots.
“Glucose likely contributes to the formation of plaque and might also contribute to the instability of plaque, causing particles to drift,” she says.
The narrowing and blockage of blood vessels is the root cause of all major cardiovascular problems, from stroke (caused by blockage of arteries leading to the brain) to coronary heart disease (blockage of arteries leading to the heart) to peripheral arterial disease (blockage of arteries leading to the legs). In addition, more pressure is felt by the arterial walls because of the constricted space through which blood can flow, giving rise to hypertension.
Why nurses are vulnerable
Nurses shoulder a unique burden among health care providers. Not only are they the primary caregivers and conveyers of health information to their patients, but they are often expected to be role models of healthy behaviors. Among nurses who care for diabetic or cardiac patients, the burden is greater since risks for both can be mitigated by behavioral changes like weight loss, dietary modifications, and exercise.
Key Statistics 18.8 million people have been diagnosed with diabetes.* A 2007–2009 survey showed among people 20 years or older, 7.1% of whites, 8.4% of Asian Americans, 11.8% of Hispanics/Latinos, and 12.6% of African Americans/blacks were diagnosed with diabetes. Compared to whites, the risk for a diabetes diagnosis was 18% higher for Asian Americans, 66% higher for Hispanics/Latinos, and 77% higher for African Americans/blacks. * Among Latinos, Mexican Americans and Puerto Ricans run the highest risk of developing diabetes. * 26.7% of African American women are overweight, and another 51% of African American women are obese; 64% of African American women are sedentary and get no leisure time for exercise. ** Latina women suffer from heart disease 10 years earlier than other ethnic groups. *** Sources * National Diabetes Fact Sheet 2011, published by the Centers for Disease Control and the U.S. Department of Health and Human Services ** The National Coalition for Women and Heart Disease *** Interview with Marleny Ramirez-Wood, communications manager, Go Red Por Tu Corazón, American Heart Association
Sally K. Miller, Ph.D., F.N.P.-B.C., and clinical professor of nursing at Drexel University, has studied obesity rates among nurses and their ability to provide weight management counseling to their patients. She links a nurse’s own health status to her credibility among those in her care: “‘Do as I say and not as I do’ is not very effective. People in general put more weight on advice from someone who is modeling that behavior and has been successful in that behavior.”
Yet how easy is it for nurses to maintain a healthy weight and avoid chronic metabolic disorders? Not terribly, according to two studies published last year.
At the University of Maryland School of Nursing, postdoctoral fellow Kihye Han, Ph.D., R.N., and professor Alison M. Trinkoff, Sc.D., M.P., B.S.N., R.N., F.A.A.N., found that nurses who worked long shifts were more likely to be obese than underweight or at a normal weight. Their results, published in the November 2011 issue of Journal of Nursing Administration, show that among the 2,103 female nurses surveyed, 55% were obese and reported less physical exertion and movement in their jobs.
“Long hours affect circadian rhythms,” Han and Trinkoff wrote in an e-mail interview. “Disrupted day/night cycles have detrimental effects on sleep quality and quantity, which are important independent risk factors for obesity, more important than even physical inactivity and high fat intake.”
Han and Trinkoff conclude that nurses who work long shifts might not have the time and energy to participate in regular exercise and that sleep deprivation also stimulates the appetite, forcing nurses to snack during shifts when healthy food choices might not be available.
Nutrition researcher An Pan, Ph.D., goes a step further by solidifying the connection between nurse’s shift work, obesity, and a dispensation towards type 2 diabetes in a study published in the December 2011 issue of PLoS (Public Library of Science) Medicine.
Pan and his colleagues at the Harvard School of Public Health analyzed responses from 177,184 nurses surveyed over a span of two decades. They discovered that a nurse’s risk of developing type 2 diabetes grew in direct proportion to the number of years she worked night shifts. A nurse working night shifts for three to nine years had a 20% chance of becoming diabetic, while that risk jumped to 58% if a nurse worked night shifts for over 20 years.
Weight gain became inevitable after years of working nights, says Pan in an interview: “Women who worked rotating night shifts gained more weight and were more likely to become obese during the follow-up.”
Nurses also say they have a tendency to turn a deaf ear to warnings about their own health, opting to take care of everyone else—patients, spouses, children—first. Eva Gómez, M.S.N., R.N., C.P.N., and a staff development specialist at Children’s Hospital in Boston, waited 13 years before following up on a diagnosis of a heart murmur she received in her 20s. In 2010, she found out she had a misshapen aortic valve, causing her aorta to bulge with backed-up blood. She scheduled valve replacement surgery for later that year and says if she had waited any longer, her aorta could have burst.
“At one point, I said, ‘That cannot be me; that’s something that happens to patients. I take care of people who have this,'” says Gómez, a national spokeswoman for the American Heart Association’s Go Red Por Tu Corazón campaign. “It never occurs to you that it could happen to me.”
Why certain races and ethnicities are at risk
Nurses face serious occupational challenges when it comes to managing their weight and stress level, and those who belong to certain racial and ethnic groups face even steeper barriers.
Latinos, African Americans, and Native Americans are at particular risk for becoming diabetic, while cardiovascular disease remains the #1 killer of all populations, despite race. While genes play a role that researchers are only beginning to understand, lifestyle, socioeconomic, and environmental factors have been the focus of most public health campaigns.
Relying on staples like rice, beans, and bread products and cooking techniques like deep frying, many Latin American cultures eat “diets that are richer in carbs and fats,” says Maria Koen, F.N.P., C.D.E., a bilingual nurse practitioner and diabetes educator at the Joslin Diabetes Latino Initiative in Boston. In addition, “they’re not necessarily having regular exercise as part of their lifestyle [or] making it a priority.”
Getting patients to eat more fruits and non-starchy vegetables remains a challenge, and fast food is perceived as a reward in certain communities. “Going to a fast food restaurant is considered to be aspirational; it’s a treat” among Latinos, says Marleny Ramirez-Wood, Communication Manager of the AHA’s Go Red Por Tu Corazón campaign. “We want to focus our message…in terms of cooking traditional meals, how they can make them healthier, [and] how they can incorporate physical activity into what they’re doing.”
For many ethnic groups, questions about access and affordability arise in conversations about eating healthier, since the corner markets in their neighborhoods may offer nothing more than liquor, cigarettes, and lottery tickets.
“Access to fresh fruits and vegetables is not available in certain communities we’re talking about,” says Lurelean B. Gaines, R.N., M.S.N., Chair of the Department of Nursing at East Los Angeles College and President-elect, Health Care & Education, of the American Diabetes Association. “If it’s not there and you don’t have the means, and with gas prices what they are, you’re not going to drive out of your community to get better food.”
A diabetes educator at the Mattapan Community Health clinic in Boston, Sharon Jackson counsels Haitian immigrants and African Americans from the neighborhood, many of whom work multiple jobs, have no time for exercise, and struggle to manage their disease.
“There isn’t a two-hour stretch where a person who is conscientious isn’t trying to take care of their diabetes,” says Jackson, M.S., R.D., C.D.E., a clinical research program manager at the Joslin Diabetes Center. “Taking care of diabetes is a full-time task…[it] becomes a luxury when you’re in a lower socioeconomic level.”
Managing the deadly three
A nurse’s hectic schedule is often beyond his or her control, especially early on in the career. Scarfing down meals on the go, never getting a decent night’s sleep, working crazy hours to make ends meet, and juggling the demands of work and family life is the norm for many.
These habits take their toll, yet are not simply a matter of individual nurses making bad choices. Institutions play their part in either discouraging or promoting a culture of health for nurses.
One hospital is taking an aggressive approach in helping nurses and other hospital staff get control over chronic diseases like diabetes, heart disease, and hypertension. For the past decade, the Cleveland Clinic has offered its staff disease management programs as part of its employee health plan. Employees are assigned case managers who help them set and reach specific goals related to their condition, says Patricia Zirm, B.S.N., R.N., M.P.H., Senior Director of Employee Health Plans at the clinic.
The clinic is known for its culture of wellness, with nine different fitness areas scattered among its 12 hospitals, reimbursement of gym memberships, a ban on regular soda in vending machines, and healthy food choices in its cafeterias.
Of more than 30,000 employees enrolled in the health plan, approximately 18,000 have one of the diagnoses for which the clinic has a disease management program, and roughly 8,000 are already enrolled in a disease management program.
In 2010, the clinic started to incentivize employee health through a program called Healthy Choice, which ties participation in one of six disease management programs to lower monthly premiums. The six programs are focused on diseases, including diabetes and hypertension, where behavioral changes in diet and exercise deliver a huge impact.
Healthy Choice is a three-tiered system of insurance premiums where the highest level of discount (gold) is awarded to employees who are complying with their disease management goals. In the case of a diabetic, one goal is to maintain a blood sugar level of less than 7%. The silver rate is for employees participating in disease management, but aren’t completely meeting their goals; the bronze rate is the standard rate, where an employee is insured but not enrolled in disease management.
Attaching health outcomes to an employee’s paycheck seems to be a smart strategy. Since 2010, Healthy Choice participation among the staff has tripled. Over the past year, 17% of clinic employees went from the standard rate to the gold rate, and employees are making fewer trips to the ER and are being admitted less frequently to inpatient care, says Zirm. These are all signs of progress, yet work remains to be done.
“Anybody who is doing shift work is more prone to stress, diabetes, and heart disease,” says Zirm. “The clinic tries to do a [favor] of addressing these issues related to shift work…we’re trying to remove barriers, but the fact remains, because of the nature of the job, we can’t fix it for everybody.”
Last issue, Minority Nurse addressed infant mortality in minority communities, discussing some of the disparities, research, and solutions surrounding the issue. This piece was submitted as a supplement to “A Quiet Crisis: Racial Disparities and Infant Mortality”
Aim for a healthy weight. Get enough folic acid in your diet. Find effective ways to manage stress. Talk to your doctor about your family history. All very important information to maintain good preconception health, but as nurses know all too well, people don’t always follow good advice. But how about when the message is coming from someone you can relate to and trust—like a peer?
The U.S. Health and Human Services Office of Minority Health’s Preconception Peer Educator (PPE) program taps into the power young people have to positively influence each other’s behavior, by enlisting and training college students to become health ambassadors. PPEs—many of them nursing, public health, and social work students—organize events at college campuses, K–12 schools, and in the wider community to educate teens and fellow 20-somethings about infant mortality and to deliver the simple message that now is the time to take care of your health…for life.
Born out of OMH’s A Healthy Baby Begins With You campaign, launched in 2007 with the aim of raising awareness about infant mortality in minority populations, who suffer some of the highest rates, the PPE program highlights preconception health as the less-emphasized factor to influence birth outcome and maternal and child health. Science shows that in communities of color, health disparities begin early in life, so PPEs serve as messengers—drawing attention to the critical link between healthy behaviors in youth and improved maternal and overall health in adulthood.
The information is important for other reasons too. While many adolescents and young adults may be a long way from thinking about starting a family, about half of pregnancies are unplanned, which makes preconception health all the more pertinent. Poor health in the early years can also lead to chronic disease later in life, and learning about the long-term payoff of preconception health is not only a way to catch problems early but to curb health disparities in communities as a whole.
The pilot program started in 2008 with Morgan State University, Spellman College, Fisk University, Meharry Medical College, and University of Pennsylvania School of Nursing. The general objective was to tackle the high rates of infant mortality in the African American community by addressing the root causes much earlier in life.
Today, around 90 schools and almost 1,000 students have participated in preconception health trainings. PPEs who have completed the program say their efforts are making a difference in young lives, and the program has grown in popularity mostly through word of mouth.
“We’ve always been taught in the black community that when you get married and decide to have kids—that’s when you should start thinking about your body,” says 20-year-old PPE Atalie Ashley-Gordon, a University of South Florida student in public health. “But I learned that we were very wrong.
“Peers make a big difference in driving this message home,” she adds, because “I’m just old enough to be influential but just young enough to be credible. That’s what makes peer education so important.”
For the past five years, cardiovascular disease (CVD) has been the leading cause of death for all racial and ethnic groups in the United States. Approximately 61 million Americans suffer from some form of cardiovascular disease. Every year, CVD is responsible for 6 million hospitalizations and approximately 950,000 deaths.In 2003, the financial burden of CVD on the nation’s health care system was estimated at $351 billion.
Forms of cardiovascular disease include high blood pressure, stroke, rheumatic heart disease, coronary heart disease and valvular disease. Approximately 70% of deaths from heart disease and 48% of deaths from stroke occur before arrival to a hospital or the arrival of medical emergency personnel. According to the American Heart Association (AHA), stroke is a leading cause of serious, long-term disability in the United States, while coronary heart disease can result in permanent disability at a young age.
African Americans have the highest mortality rate from heart-related diseases than any other racial/ethnic group. According to the Centers for Disease Control and Prevention (CDC), in 2000 cardiovascular disease accounted for 40% of deaths in the nation, of which 29% were African American adults and approximately 45,000 were African Americans under the age of 18.1 The CDC also reports that in 2002, age-adjusted heart disease death rates were 30% higher among African Americans than for non-Hispanic whites.
Prevention of heart disease and stroke is one of the 28 key focus areas of the U.S. Department of Health and Human Services’ Healthy People 2010 initiative. Healthy People 2010’s two goals are to:
Increase quality and years of healthy life
Eliminate health disparities.
These goals can only be accomplished through the collaborative efforts of health care professionals, educators, government officials, public health departments and local communities—including faith-based organizations, community organizations, local businesses, community leaders and individual community members. Nurses can play a substantial leadership role in these efforts, on multiple fronts: as care providers, health educators, patient advocates and through community outreach.
Factors Behind CVD Disparities
To understand the reasons why cardiovascular disease mortality rates are disproportionately high in the African American population, we must first look at the factors that contribute to the development of CVD. These include uncontrolled high blood pressure, smoking, coronary artery disease, diabetes, obesity, family history of heart disease, hyperlipidemia and high blood cholesterol.
The AHA states that African Americans develop hypertension more often than whites, and it tends to occur earlier and be more severe. Other studies have found that 70% of all hypertensive patients do not have their blood pressure under control. Uncontrolled hypertension can lead to stroke and heart attack, as well as kidney damage and blindness. Persons with uncontrolled high blood pressure are seven times more likely to have a stroke, six times more likely to develop congestive heart failure and three times more likely to have a heart attack.2
According to the CDC, in 2000 smoking contributed to an estimated 438,000 deaths in the U.S., a financial burden of $75 billion in medical costs, $82 billion in lost productivity and 8.6 million illnesses, including chronic bronchitis, emphysema, lung cancer and heart attack. Smoking contributes to elevated blood pressure and heart rate and decreased coronary and cardiac output. A number of studies have shown that tobacco companies have aggressively targeted African Americans in their marketing efforts. Ninety percent of tobacco billboards are located in African American communities, portraying an African American as the central character, while three major African American publications—Ebony, Jet and Essence—received proportionately higher revenues from cigarette advertisements than did other magazines.3
People with diabetes are at a higher risk of developing cardiovascular disease than non-diabetics. Recent studies from the American Heart Association show that approximately 60-65% of people with diabetes have hypertension, lower levels of HDL (good cholesterol), higher levels of LDL (bad cholesterol) and are overweight. AHA researchers also found that nerve damage caused by diabetes can prevent patients from recognizing symptoms of heart attack when they occur, directly contributing to CVD-related mortality among diabetics. In fact, over 55% of diabetes-related deaths are due to cardiovascular disease.4
Statistics from the American Diabetes Association show that African Americans are 1.8 times more likely to have diabetes than non-Hispanic whites. Another recent study found that complications from diabetes are more likely to develop in African Americans, even if the disease is caught early.5
CVD Prevention through Community Education
Health education is one of the areas where nurses can make a real difference in preventing cardiovascular disease disparities in African American communities. All too often, physicians and hospitals spend more time on curative than preventive health matters during the delivery of health care services. Preventive care is one of the core needs of every community, and it must be emphasized in nurses’ training. The nurse’s role in CVD preventive education should be to teach the importance of a healthy diet, exercise, stress reduction, smoking cessation and other health behaviors that can reduce African Americans’ disproportionately high risk of developing heart-related disease.
Studies show that African Americans often have limited knowledge about hypertension and stroke.6 In some cases, cultural barriers may contribute to these knowledge gaps. Some African Americans, especially those from older generations, continue to resist health education because of long-standing distrust of the medical system resulting from the Tuskegee Syphilis Study of 1932-1972.7 Undocumented immigrants may not trust health care personnel for fear of being reported to immigration officials.
Nurses as health educators must build trust in the African American community in order to educate people about cardiovascular disease prevention. The health educator must understand the community’s dynamics and develop preventive education strategies that are culturally relevant, easily understood, affordable and appropriate.
For example, the nurse must know what kinds of foods are culturally acceptable, affordable and easily available in the community, rather than assuming that everyone will be able to obtain items like tofu and turkey. Health education about sources of protein must include a wide variety of food options, such as eggs, beans, peanuts, meat, chicken, turkey, fish and more.
Nurses must build rapport with community members to gain their attention and loyalty. Clear, effective, culturally sensitive communication is key. Health education information, both oral and written, should be presented in simple language that is commonly understood in the community, rather than nursing/medical jargon such as LDL, HDL, PRN, qid, BP and so on.
When establishing contact with individuals in the community, the nurse must know whether, for example, eye contact or a firm handshake is acceptable in the culture or not. The nurse must introduce himself or herself clearly and explain the importance and benefits of the health education topic being presented. For cardiovascular disease education to be effective, the audience must clearly understand the reason for the lesson and why they should be concerned about preventing CVD.
Forming partnerships with key stakeholders in the community—such as community leaders, churches and other faith-based groups, youth groups, YMCAs, local health care providers, legislators, school officials and local businesses—can also maximize the effectiveness of a preventive education program. It is important to include these stakeholders in the planning process. People are more likely to participate in a program when they are involved in planning and implementing that program. Nurses should motivate community members to form health promotion coalitions, such as youth groups, adult groups, women’s groups and more.
Teaching Heart-Healthy Behaviors
To design health education programs that will affect behavior change in African American communities, nurses must turn to the literature and study various theories of health behavior. Behaviors such as smoking and consuming foods high in saturated fat, for example, contribute to negative health outcomes such as cardiovascular disease.
In particular, nurses should study theories that address health behavior as learned routines of an individual, such as the Social Cognitive Theory (Bandura, 1986), the Protection Motivation Theory (Rogers, 1983) and the Health Belief Model (Rosenstock, 1974). These three theories are essential resources for developing health education and intervention programs because they address individual motives for health behavior maintenance and change.
Unless a person understands the consequences of a behavior such as smoking or consuming a high-fat/high-cholesterol diet, he or she will not understand why the habit is bad. The nurse educator must bear in mind that lifestyle and habit changes can only occur if the person is motivated to make those changes. The individual must desire to achieve a goal—such as reduction in body weight, quitting smoking or a reduction in fat and cholesterol intake—to prevent cardiovascular disease.
In creating culturally sensitive behavior-change interventions for African American communities, nurses must understand that socioeconomic factors such as poverty, unemployment, illiteracy and lack of social support can contribute to high levels of stress, depression and other conditions that may negatively impact health behaviors. For example, some people cope with stress by smoking or overeating. Recent studies have found that there is a link between these types of socioeconomic issues and negative health behaviors that can increase a person’s risk of developing cardiovascular disease, such as smoking, eating an unhealthy diet and lack of exercise.8
Teaching heart-healthy behaviors must start early, and children are at an ideal period for learning. When planning community health education on CVD prevention, nurses must partner with local schools, youth organizations, parents, grandparents and others to reach this important audience, so that future generations of African Americans can grow up knowing how to reduce their risk of developing cardiovascular disease.
Sample CVD Prevention Messages for Health Educators
Rheumatic Heart Disease
Rheumatic heart disease accounts for approximately 1.8 million deaths per year in the United States.2 It sometimes leads to congestive heart failure. Rheumatic heart disease develops when streptococcal throat infection progresses into rheumatic fever, eventually leading to permanent damage to the heart valves. Community education on the importance of getting early treatment for strep throat with antibiotics has proven to be helpful in preventing rheumatic fever and rheumatic heart disease.
High Blood Pressure
Health education should focus on the risks, causes and consequences of high blood pressure, and on teaching health behaviors that can help prevent it. Patients who are already hypertensive must be educated about strategies for controlling their high blood pressure, such as regular checkups, medication, stress reduction interventions and lifestyle changes like weight reduction, getting more exercise and eating a more heart-healthy diet.
Physical activity such as moderate exercise for 30 minutes a day, five times a week, can go a long way toward reducing the risk of developing high blood pressure, stroke and other forms of cardiovascular disease. Brisk walking and exercise programs must be encouraged. Education on the importance of moving to keep healthy should present a variety of options, such as doing household chores (vacuuming, mowing the lawn, etc.), walking, aerobic exercises, jumping rope, bicycling, swimming, dancing and jogging.
Decreased intake of salt, saturated fat, trans fat, and cholesterol, along with increased intake of fiber, fruit, vegetables, grain products, fish and lean meat products can reduce the risk of developing high blood pressure and cardiovascular disease. Health educators should teach community members about recommended dietary guidelines, such as eating four to five servings of fruit and vegetables a day, two servings of protein a day, baking rather than frying foods, etc. It is important to emphasize that heart-healthy eating does not have to be expensive or require “special” foods. It can simply be a regular diet based on affordable, nutritious food groups that are readily available in the community.
Coronary Heart Disease
Coronary heart disease occurs when there is hardening and narrowing of the coronary arteries that supply the heart with oxygen and nutrients (atherosclerosis). One of the major contributors to atherosclerosis is high blood cholesterol. The nurse educator should teach simple preventive strategies such as the importance of having one’s cholesterol checked regularly, consumption of a low-fat/low-cholesterol diet, body weight reduction and regular exercise.
Stroke is a condition in which a blood vessel that supplies the brain with oxygen and nutrients is clogged by a blood clot, resulting in the death of cells in the affected part of the brain within minutes. This may lead to dysfunction such as paralysis or weakness of the side of the body controlled by the affected nerve cells in the brain. Stroke affects different people in different parts of the body, depending on the type of stroke. Brain injury-related stroke, for example, often affects speech, behavior, motor activity and the senses. Because dead brain cells are not replaced, the effects of stroke are often permanent.
Preventive strategies that nurses should cover during community health education include stress reduction, blood pressure control, brisk walking or other physical activity for 30 minutes or more several times a week, and reducing fat and cholesterol in the diet. Patients with surgical wounds or fractures should be treated with blood thinners to reduce their risk for formation of blood clots in the circulatory system.
To counter tobacco companies’ racially targeted advertising messages, nurses must educate African American communities by presenting the facts about the health risks of smoking, along with effective strategies for quitting the habit. It is especially critical to bring this information into the schools, from elementary to university levels. Studies have found that every day, approximately 5,000 young people ages 11 to 17 smoke a cigarette for the first time and 2,000 of them will continue to smoke in adulthood.
The following is an example of a brief smoking cessation message for health educators:
Smoking can cause illnesses such as cancer, emphysema and heart disease—and even death.
Admit to yourself that you have a problem.
Determine to quit the habit, not just reduce it.
Seek help from health professionals.
Determine to leave the old habit and move forward with a new, revitalizing healthy lifestyle.
Your decision to quit can promote healing of damaged lung tissue.
Quitting the habit of smoking decreases the smoker’s risk of heart attack and premature death by 50%.
Centers for Disease Control and Prevention (2005). “Cardiovascular Disease in the United States.” Retrieved from http://www.cdc.gov.
The Health Authority (2006). “Cardiovascular Risk Factors.” Retrieved from http://www.healthauthority.com/cardio.htm.
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