Prevention: Health Promotion and Lifestyle Modification
Cardiovascular health promotion strategies are key to prevent hypertension in Black women. The primary approach of any antihypertensive treatment plan is education about lifestyle modifications. These modifications include managing weight, exercising, limiting alcohol intake, and adopting a DASH diet, which restricts sodium intake, enhances potassium intake, and increases intake of fruits, vegetables, and low-fat dairy products.23
However, adherence to lifestyle modification and antihypertensive treatment is problematic within this population, according to a number of published studies.24-26 Black women who were prescribed a low-salt diet were less successful than black men in adhering to the diet, and it has been suggested that factors such as poor social support and lack of education influence the lack of adherence.26,27
Healthcare providers need to educate themselves about cultural aspects of the Black community to help enact preventive health strategies. Social factors can act as barriers to health promotion and medication adherence. Enhanced patient education about cardiovascular health and continual patient support to promote adherence to treatment are healthcare strategies needed within the Black community.
Nonadherence to medication is a major problem in the Black community.28 Lack of health insurance, low income, and an inability to pay for medications prevent some patients from consistently adhering to their treatment regimens.29 Lack of access to healthy food, fruits, and vegetables in Black communities diminishes a patient’s ability to adhere to the DASH diet.30
It is important for healthcare providers to be aware of the phenomenon of minority stress and how it negatively affects cardiovascular health in Black individuals.20,22 Clinicians should be cautious not to perpetuate the factors that cause minority stress. Unconscious and implicit bias among clinicians contributes to the discrimination experienced by persons of color and incites distrust in the healthcare system. Self-examination and dialogue are needed among healthcare providers to improve cultural sensitivity and recognize factors in the healthcare system that may be perpetuating minority stress.31-33
It is imperative for healthcare providers to make efforts to reach Black patients in their communities to teach and support lifestyle modifications.28 In 2019, Brewer et al used a community-based approach to cardiovascular health promotion for Black patients.34 In the study, community churches participated in the design and development of a culturally relevant, cardiovascular health and wellness digital application. The team created an educational mobile app that used evidence-based, simple health information, and social networking to reach Black people in the community. They engaged the community in all phases of the process, which allowed them to better understand the population’s mobile technology preferences and experiences. This model resulted in a culturally tailored cardiovascular health and wellness app prototype (FAITH! App) developed with input from the community.34
In 2019, Dutta et al developed a culture-centered patient education campaign about cardiovascular disease prevention designed by community members in 2 counties in Indiana.35 The campaign was carried out through radio and television advertisements, face-to-face peer leaders, and local networks such as Black churches, health fairs, and barbershops. Community-wide presentations were held during health fairs, postcard mailings were sent, and peer leaders handed out patient education materials. Their campaign successfully reached more than 300,000 residents.35
Among rural Black communities, Abbott et al developed a cardiovascular health promotion campaign entitled “With Every Heartbeat Is Life,” designed to reach Black congregants of 12 rural churches in northern Florida.36 Nurses delivered weekly cardiovascular health education seminars to groups in community church settings over 6 weeks. The 90-minute intervention sessions included a lecture, discussion, and multimedia visual aids, such as pictures, videos, and handouts. There also were interactive activities such as role-playing, problem-solving scenarios, and interpreting nutrition information on food labels. The campaign had a positive influence on the intentions, attitudes, norms, and self-efficacy of rural Black patients to increase produce consumption and reduce saturated fat intake. The intervention also enhanced participants’ attitudes and self-efficacy about exercise.36
Such innovative health promotion strategies are needed to enhance lifestyle modifications and patient education about cardiovascular risk factors within the Black community. Nurse-led community health education programs, peer-led health campaigns within the community, and development of programs using digital technology are examples of effective strategies.
Medication for Black Patients
When patients cannot obtain blood pressure control with lifestyle modifications alone, antihypertensive agents should be prescribed. Generally, a single agent is prescribed initially, but commonly combination antihypertensive drug treatment is needed. Using drugs from different classes in combination has a significantly greater effect in lowering blood pressure than doubling the dose of a single drug.23
In a review of best medications for Black patients, Egan et al recommended a dihydropyridine calcium channel blocker or a thiazide-like diuretic (such as chlorthalidone) as initial drug treatment.37 If monotherapy is insufficient, a dihydropyridine calcium channel blocker combined with either an angiotensin-converting enzyme (ACE) inhibitor or angiotensin II receptor blocker (ARB) is recommended.37
For Black patients, ACE inhibitors or ARBs are not recommended as monotherapy but should be combined with calcium channel blockers or thiazide diuretics to obtain optimal control of hypertension.38 However, a high number of Black women have been prone to the side effect of cough when treated with an ACE inhibitor. Therefore, agents other than ACE inhibitors may be preferable for Black women.39
Black patients are at greater risk for treatment-resistant hypertension than White patients; thus, addition of another agent often may be required. In such patients, a potassium-sparing diuretic (in particular, a mineralocorticoid receptor antagonist such as spironolactone or eplerenone) is recommended.37 However, patients who have moderate to advanced chronic kidney disease or a baseline serum potassium level greater than 4.6 mEq/L have an increased risk of hyperkalemia with these agents. Serum potassium levels should be monitored in all patients treated with potassium-sparing diuretics or mineralocorticoid receptor antagonists.37
Black women are affected disproportionately by hypertension. The high rate of hypertension in Black women stems from biological, genetic, and social factors that are more common within the Black population. Cardiovascular health promotion strategies that include education and social support are key for prevention of hypertension in Black women. Healthcare providers need to reach out to the community to support Black patients. Healthcare providers should understand the unique risk factor of minority stress and deliver culturally competent care. Innovative health promotion strategies are needed to enhance lifestyle modification, patient education, and adherence to antihypertensive drug therapy within this population.
Theresa Capriotti, DO, MSN, CRNP, RN, is clinical professor at Villanova University M. Louise Fitzpatrick College of Nursing, in Villanova, Pennsylvania. Alaina Roman, BSN, and Molliana Schwarz, BSN, are honor students at Villanova University M. Louise Fitzpatrick College of Nursing in Villanova, Pennsylvania.
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