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Spring 2020
The Effect of Hypertension Education on Knowledge, Lifestyle The Effect of Hypertension Education on Knowledge, Lifestyle
Behaviors and Blood Pressure Management Among Parishioners Behaviors and Blood Pressure Management Among Parishioners
in a Faith-Based Setting in a Faith-Based Setting
Lynda N. Goodfriend, MSN, RN
George Washington University
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Behaviors and Blood Pressure Management Among Parishioners in a Faith-Based Setting.
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Running head: HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 1
A DNP PROJECT
The Effect of Hypertension Education on Knowledge,
Lifestyle Behaviors and Blood Pressure Management
Among Parishioners in a Faith-Based Setting
Student Name:
Lynda N. Goodfriend, MSN, RN
DNP Program Primary Advisor & DNP Team Member(s):
Quiping Pearl Zhou, Ph.D., RN
Mary-Michael Brown, DNP, RN, CENP
Date of Degree: Spring, 2020
The George Washington University
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 2
DNP Project Approval Signature Sheet
The Effect of Hypertension Education on Knowledge, Lifestyle Behaviors
and Blood Pressure Management Among Parishioners in Faith-Based Setting
A Project Presented to the Faculty of the School of Nursing
The George Washington University
In partial fulfillment of the requirements
For the Degree of Doctor of Nursing Practice
By
Lynda N. Goodfriend, MSN, RN, Electronically signed: 4/24/2020
DNP Student
Approved: Quiping Pearl Zhou, PhD., RN, Electronically Signed: 4/17/2020
DNP Primary Advisor
Approved: Mary-Michael Brown, DNP, RN, CENP, Electronically Signed: 4/19/2020
DNP Secondary Advisor
Approval Acknowledged:
Director DNP Scholarly Projects
Approval Acknowledged:
Assistant Dean for DNP Program
Date: April 27, 2020
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 3
Abstract
Background: Hypertension (HTN) is a major risk factor for life threatening events. Although
evidence supports using faith-based settings to provide health education to better manage chronic
conditions and prevent complications, HTN education is underutilized in this setting.
Aims/Objectives: This project aimed to assess the effectiveness of HTN education on
knowledge, self-reported lifestyle behaviors and blood pressure (BP) management among
parishioners in a suburban church.
Method: A pre-post educational intervention was used in this evidence-based project. BP
screening identified 56 eligible adults and a convenience sample of 44 parishioners with HTN
were enrolled. Participants received two 45-minutes educational sessions. Pre- and post-
intervention HTN knowledge scores and lifestyle behavior were compared using paired t-test.
The differences in pre-, post-, and 2-week post-intervention systolic blood pressure (SBP) and
diastolic blood pressure (DBP) were compared using a repeated measure ANOVA.
Results: 36 participants completed the study. There was an increase in HTN knowledge scores
(9.31 to 13.6, p<0.001), increase in number of minutes participants exercised (123.23 minutes to
167.1 minutes, p=0.023), increase in number of participants watching their salt/sodium intake
(57.6% to 84.8%, p=0.012), and decrease in SBP (139.11 mmHG to 132.4 mmHG, p=0.016).
BP changes sustained to 2-weeks post intervention.
Conclusion: Providing HTN education in a faith-based setting is effective to favorably impact
disease risk factors in the short term, fosters an environment of sustained support to engage
parishioners, and can serve as a catalyst for spread into the community. Further study is
recommended to evaluate longer term impact on disease management.
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 4
Table of Contents
Abstract .......................................................................................................................................... 3
Introduction ................................................................................................................................... 6
Background and Significance ...................................................................................................... 8
Needs Assessment ........................................................................................................................ 10
Problem Statement...................................................................................................................... 12
Purpose Statement ...................................................................................................................... 12
Aims .............................................................................................................................................. 13
Objectives..................................................................................................................................... 13
Study Question ............................................................................................................................ 13
Review of Literature and PICOT .............................................................................................. 14
Evidence Based Translational Models ...................................................................................... 21
Methodology ................................................................................................................................ 23
Study Design ............................................................................................................................ 23
Study Setting ............................................................................................................................ 23
Study Population ..................................................................................................................... 24
Subject Recruitment ............................................................................................................... 25
Ethical Considerations ............................................................................................................ 25
Outcomes .................................................................................................................................. 26
Study Tools .............................................................................................................................. 27
Project Timeline ...................................................................................................................... 29
Resources Needed/Study Expenses ........................................................................................ 29
Evaluation Plan ........................................................................................................................... 30
Data Analysis ............................................................................................................................... 31
Results .......................................................................................................................................... 31
Discussion..................................................................................................................................... 34
Study Limitations ........................................................................................................................ 35
Implications/Recommendations for Practice, Policy and Research ....................................... 36
Plans for Sustainability and Future Scholarship ..................................................................... 38
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 5
Conclusion ................................................................................................................................... 39
References .................................................................................................................................... 41
Results Tables and Charts ......................................................................................................... 49
Appendices ................................................................................................................................... 53
Appendix A - SWOT Analysis ............................................................................................... 53
Appendix B - Literature Review Table ................................................................................. 54
Appendix C – Evidence-Based Theoretical Models ............................................................. 63
Appendix D - Advertisement Flyer ........................................................................................ 64
Appendix E - Agreement with Project Site ........................................................................... 65
Appendix F – Blood Pressure Measurement Competency .................................................. 66
Appendix G - Permission to use HELM Knowledge Scale .................................................. 68
Appendix H - Survey Tools .................................................................................................... 69
Appendix I – Project Timeline ............................................................................................... 74
Appendix J - Evaluation Planning Matrix ............................................................................ 75
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 6
Introduction
High blood pressure (HBP) also called Hypertension (HTN) happens when the force of
your blood pushing against the walls of your blood vessels is consistency too high. HTN is
defined by the American College of Cardiology (ACC) and the American Heart Association
(AHA) as an abnormally high arterial blood pressure (BP) in adults when the systolic blood
pressure (SBP) is 130 mmHg or greater or the diastolic blood pressure (DBP) is 80 mmHg or
greater (Whelton, et al., 2018). The AHA, ACC, Centers for Disease Control and Prevention
(CDC) and the World Health Organization (WHO) all state that HTN is a leading independent
risk factor for cardiovascular disease, cerebrovascular accidents (strokes), heart disease and
failure, and chronic kidney disease and failure (AHA, 2016; Cifu & Davis, 2017; Merai, et al.,
2016; WHO, 2020). It is a significant health problem not just globally but for millions of
Americans as well. It is estimated that half of adults in the United States have HTN and only one
in four of these adults have their BP under control (CDC, 2020). Uncontrolled HTN is defined in
accordance with BP treatment targets recommended by the Eight Joint National Committee
Criteria (2018) of a SBP equal to or greater than 30 mmHg and a DBP of equal to or greater than
80 mmHg (Whelton, et al, 2018). Given the trends and increasing prevalence rates of HTN with
increasing age, limited access to care, and increased co-morbidity, the consequences of HTN are
expected to increase (CDC, 2016; Whelton, et al., 2018). Recommended non-pharmacological
evidence-based interventions including education, lifestyle behavior modification, and
medication adherence to manage HTN have been shown to decrease BP and reduce the incidents
of heart disease, strokes, and kidney failure (Cifu & Davis, 2017). However, underutilization of
these evidence-based approaches to HTN management has been identified as the biggest risk
factor for uncontrolled HTN (Fitzgerald, 2011, Sessoms, et al., 2015). Despite the benefits of
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 7
these interventions to control HTN, it remains an important public health challenge in the United
States (CDC, 2017; Sessoms, et al., 2015).
Evidence-based education and self-management support for HTN and other chronic
diseases are two integral components of the chronic care model with strong evidence showing a
link to positive health outcomes, including lowering BP, improving HTN-related knowledge, and
enhancing competence in self-management behavior (CDC, 2017). Additionally, these
interventions are widely supported by federal and nonfederal initiatives, including CDC’s
Million Heart Initiative, Healthy People 2020, and the Triple Aim (Beigi, et al., 2014; CDC,
2017; Cooper & Zimmerman, 2017). Lack of HTN knowledge and awareness is identified in the
literature as a barrier to management and an underlying cause of uncontrolled HTN (Khatib et al,
2014; Heinert et al. 2020). There is strong evidence supporting evidence-based educational
interventions designed to improve management of HTN in community settings which has shown
to improve knowledge and self-management (Abu et al., 2018; Beigi, et al., 2014; Darrat, et al.,
2018; Lu, et al., 2015). Health promotion interventions delivered in faith communities can reach
broad populations, have great potential for reducing health disparities, and has proven to produce
significant impacts on a variety of health behaviors (Campbell, et al., 2007). Further, HTN
education for parishioners in faith communities with keen collaboration across healthcare and
faith leaders are supported and recommended in the literature (Bangura et al., 2017; Cooper &
Zimmerman, 2017; Schoenthaler, et al., 2018).
This DNP project focused on an interactive and tailored educational intervention aimed at
improving HTN knowledge to increase awareness and modify lifestyle behaviors to better
manage BP among hypertensive parishioners in a suburban community church. Faith-based
settings can be successful vehicles for disseminating health information and promoting healthy
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 8
behaviors as faith leaders have a positive influence on parishioners (Heward-Mills, et al., 2018;
Levin, 2014). Hence, there is a need for healthcare professionals to collaborate with these
community leaders to enhance the health of their communities and support transition of care for
patients beyond the clinical setting.
Background and Significance
HTN is a serious medical condition that significantly increases the risks for heart disease,
strokes and kidney disease and failure (WHO, 2020). However, despite evidence-based
approaches in place to manage this chronic condition, the rates for mortality and disability keeps
rising. Recent guidelines published by the ACC and AHA in 2017 redefined the criteria for
HTN as a SBP of 130 mmHg or greater and a DBP of 80 mmHg or greater (Dorans, et al., 2018;
Whelton, et al., 2018). In 2017, there were108 million adults in the United States who have
HTN, which is nearly half of all adults (45%) in the United States (CDC, 2020). Further, only
one in four (24%) of these adults with HTN have their condition under control (CDC, 2020;
Million Hearts, 2020). In 2017, HTN was a primary or contributing cause of death for over
472,000 Americans accounting for more than 1,300 deaths each day (CDC, 2020). Additionally,
the economic burden of this disease on the United States is an average of $131 billion each year
and includes cost of health care services, medications, and missed work days (CDC, 2020). The
prevalence of HTN increases with age and accounts for 33.2% among those aged 40–59 years
old and 63.1% among those aged 60 years old and over, and estimates showing a greater percent
of men (47%) have high BP than women (43%) (CDC, 2020).
HTN is often a modifiable risk factor for the majority of patients but given the persistent
high rates of uncontrolled HTN, the ACC and AHA published new guidelines in 2017
recommending non-pharmacologic interventions for better management of HTN which include
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 9
weight loss, a healthy diet, reduced intake of dietary sodium, enhanced intake of potassium,
increased physical activity, and moderation in alcohol (Whelton, et al., 2018). Lack of
knowledge regarding the importance of HTN and BP screening appears to be the most common
barrier to HTN awareness and must be addressed in any intervention aimed to improve BP
control (Heinert, et al., 2020; Khatib et al., 2014; Morgado, et al., 2010; Sa'adeh, et al., 2018).
Several studies done to educate people in the community settings about HTN have shown to
improve knowledge, lifestyle behaviors and BP control (Abu, et al., 2018; Beigi, et al, 2014;
Darrat, et al., 2018; Park, et al., 2011; Schapira, et al, 2012).
With the 2017 ACC/ACA updated guidelines redefining HTN as 130/80 mmHg or
greater, which is a change from 140/90 mmHg or greater, a larger population is now considered
potential candidates for monitoring and treatment (AHA, 2018). Healthy People 2020 goals are
to reduce the number of adults with HTN from 29.9% to 26.9%, increase the proportion of adults
with controlled HTN from 43.7% to 61.2%, and increase the number of adults with HTN
controlled with prescribed medications from 63.2% to 69.5% (Healthy People 2020, 2019).
Additionally, controlling HTN is a priority for the AHA as it recognizes the urgent need to
address inadequate control and has a goal to improve cardiovascular health by 20% and reduce
mortality rate by 20% by the year 2020 (Go, et al., 2014). These goals are similar to the goals
for HTN control established by the Million Hearts Initiative, the WHO, and the Institutes of
Medicine (IHI) Triple Aims and highlight the critical need for healthcare professionals to
increase their efforts with providing evidence-based interventions to help patients prevent and
better manage their HTN (Million Hearts, 2020; IHI, 2019; WHO, 2020).
To achieve these objectives, addressing the barriers to HTN control by providing
recommended evidence-based interventions such as HTN education to increase knowledge about
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 10
awareness and lifestyle behavior modifications to control BP are warranted. Faith-based settings
offer a safe, trusted and spiritual environment for many individuals where positive influence and
behavioral changes are likely to happen (Baruth et al., 2015). There is also strong evidence
suggesting that faith leaders have an immense influence on parishioners’ health behavior and, as
a community resource, could better be positioned to organize and foster community participation
in health matters (Baruth et al, 2015; Dodani et al., 2011; Heward-Mills et al., 2018). Multiple
community educational programs have been successfully implemented in faith-based and other
community settings to promote healthy behaviors and proven effective (Bangurah et al., 2017;
Cooper & Zimmerman, 2017; Schoenthaler, et al., 2018). Thus, healthcare providers should
consider collaborating with faith leaders to enhance the health of their communities.
This DNP project is significant because it engages healthcare, individuals and faith
community leaders in a health promotion effort to improve disease management and health
outcomes, provides opportunities for collaboration across healthcare and communities, has the
potential to inform nurse leaders, and can serve as a catalyst for community spread to manage
chronic diseases outside of the clinical setting. Importantly, it supports the goals of the CDC,
AHA, ACC, IOM, Million Hearts Initiative, Health People 2020, and WHO to prevent and
control HTN in community settings, improve population health outcomes and reduce healthcare
costs.
Needs Assessment
A needs assessment of the church was conducted to establish internal elements of
strengths, weaknesses and external elements of opportunities and threats (SWOT). These are
summarized in a SWOT analysis in Appendix A. The greatest strength of this church is that it
has an effective leadership structure which is comprised of six pastors, several ministry leaders
and a parish nurse who are the decision makers for different church activities. This effective
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 11
structure enhances communication between the church, its parishioners, and the community to
ensure that they deliver the services that are meeting the needs of those they serve. The
leadership team offers strong support for providing social and health benefits to its community.
The mission and values of this organization are to glorify God and make disciples for Jesus while
serving and growing God’s people to bring hope and healing through worship, community
outreach and health promotion. Leaders are knowledgeable about the health needs of their
congregation which can help with the successful implementation of a health promotion program.
The church has an active and updated website in addition to a Facebook page on which it shares
information and advertises church activities to members and the community in general. Other
strengths include modern large facilities, advanced technology such as big screens and
computers, administrative staff onsite every weekday and ample parking for events.
The church’s greatest weakness is that the current parish nurse serves in a part time
volunteer position which can impact the sustainability of a health promotion program.
Additionally, there are limitations relating to when the program can be offered as educational
sessions cannot be offered during Sunday worship times or small group ministries such as bible
studies. The church’s greatest opportunity is that this project can lay the groundwork for a
tailored, interactive and community engaged approach to successfully implement evidence-based
interventions within a health promotion program at this project site. The leadership team
expressed the need to provide more health-related activities for its parishioners. Partnering with
the local hospital, health department and other community stakeholders and seeking out
opportunities for grant funding for health promotion activities can provide the opportunity for
increased community engagement and strategies for sustainability of this program. The greatest
threat of this program is if the parish nurse can no longer volunteer in this role, there will be no
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 12
health expert to oversee the program. The affluent nature of this community may be viewed as a
threat as well since many may not be interested in community education because they may
receive this education directly from their personal health providers.
Problem Statement
HTN control is of critical importance in the prevention strategies of cardiovascular
disease. According to CDC (2020), 45% of Americans adults have HTN and only 24% of them
having their BP under control, with the risks for the disease increasing with age. Effective BP
management has been shown to decrease the incidence of stroke, heart attack, and heart failure
(Ambrosius, 2014; Zanchetti et al., 2015). However, despite all efforts, BP control remains
below expectations. Among all factors affecting BP control, lack of knowledge has been
identified as one of the most common barriers to HTN awareness and control (Khatib, et al.,
2014; Heinert, et al., 2020).
Use of faith-based organizations to reach a wider population to impact health outcomes
for community residents is supported in the literature. Churches and other faith-based
organizations have become increasingly popular settings in which to conduct health promotion
programs and research studies (Dodani, 2011). While educational interventions in the
community-based settings have been shown effective in improving HTN awareness and
knowledge, lifestyle behaviors, and improve BP control for hypertensive study participants, this
evidence has not been translated into practice in this suburban community church.
Purpose Statement
The purpose of the project was to determine if an HTN educational intervention will
improve HTN knowledge, modify lifestyle behaviors and decrease BP among parishioners ages
40 and over with a self-reported HTN diagnosis, a BP reading of 130/80 and over or currently
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 13
taking BP medications at a suburban community church. This project layed the groundwork for a
tailored, interactive and community engaged approach to implementation of an evidence-based
intervention within a faith-based health promotion program. Engaging and educating patients
beyond the clinical settings and in places where they feel comfortable is critical for primary
prevention of chronic diseases such as HTN (Dodani, 2011).
Aims
This evidence-based project aimed to evaluate the effectiveness of an HTN educational
on HTN knowledge, lifestyle behavior changes, and BP management among parishioners in a
suburban community church.
Objectives
• Implementation: Delivered two interactive 45-minute AHA guided educational sessions
on HTN management to include elements of risk factors, diet, exercise, sodium intake,
and medication adherence.
• Improve HTN knowledge scores: Compared pre and post intervention knowledge of
parishioners using the Hypertension Evaluation and Lifestyle Management (HELM) tool.
• Change Lifestyle Behaviors: Compared pre and post lifestyle behavioral changes.
• Lower BP measurements: Compared pre, post and 2 weeks follow-up average SBP and
DBP measurements.
Study Question
What is the effect of an educational intervention, compared to the baseline, on HTN
knowledge, lifestyle behavior modifications and BP control, among parishioners ages 40 and
older at a suburban community church?
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 14
Review of Literature and PICOT
The aim of conducting this literature review was to examine the study question stated
above. PICOT is an acronym that assists in assuring that key components of a study are
evaluated and includes: P = Patient population; I = Intervention or issue of interest; C =
Comparison intervention or issue of interest; O = Outcome; and, T = Time frame (Stillwell, et
al., 2010). The PICOT for this study included: P – Adult parishioners in a faith community; I -
Education session guided by a theoretical framework and is tailored and interactive; C – Baseline
knowledge score, lifestyle behavior and BP; O – Increase knowledge score, change in lifestyle
behavior and decrease in SBP and DBP; and, T – Baseline, immediate post- and two-week post
intervention.
Synthesizing the Body of Evidence
The search for this literature review was completed between April 2019 to March 2020
by the DNP student. Evidence was gathered from PubMed, CINAHL, Scopus, and Google
Scholar using several different search terms “hypertension, education, knowledge, BP control,
barriers and facilitators, and faith community.” Results produced 442 articles which were
assessed for eligibility and 399 were eliminated based on titles. Of the remaining 73 articles
reviewed, 13 were deemed appropriate to answer the research question and were included in this
literature review. Data was extracted independently and the quality of studies was evaluated
using the Johns Hopkins Quality Appraisal tool (Dearholt &Dang, 2018). The expertise of a
research librarian from The George Washington University (GWU) was utilized in this search.
Inferences made from the literature aided in identification of gaps in practice, supported the
effectiveness and practicality of providing education to improve HTN knowledge and lifestyle
behaviors to improve BP control in a faith community and collaboration of health care and faith
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 15
communities in the management of chronic disease. A table summary of this literature review is
presented in Appendix B.
Lack of HTN education – a gap in practice
Two studies have identified lack of HTN education and awareness as the most common
barrier to HTN management. Khatib et al. (2014) conducted a systematic review and meta-
analysis of qualitative and quantitative studies to examine patient and healthcare barriers to HTN
awareness, treatment and follow-up. Findings revealed several barriers which included
disagreement with clinical recommendations as the most common barrier among health care
providers while lack of knowledge was the most common barrier to HTN awareness and
management for patients. Both findings suggest a need for targeted-multifaceted interventions to
improve awareness and management of HTN. Similarly, a second study by Heinert et al. (2020)
was conducted in four community churches to assess barriers and facilitators to HTN control.
This Community Targeting of Uncontrolled HTN (CTOUCH) study used focus groups to gain
feedback on barriers and facilitators to HTN control. While social support, knowing how to
control HTN and community resources were facilitators of HTN control, lack of both HTN
knowledge and disease awareness were two areas identified as barriers. The authors of both
studies concluded that knowledge of these barriers and facilitators can inform opportunities for
successfully improving community-based HTN programs.
Support for HTN education intervention
Six studies provided strong evidence supporting education programs as an effective
intervention to improve HTN knowledge, awareness, and lifestyle behaviors to better manage BP
in community settings. Park, et al. (2011) examined the effectiveness of an integrated health
education and exercise program in community-dwelling older adults with HTN in a randomized
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 16
controlled trial. The experimental group received health education, individual counseling, and
tailor exercised program for 12 weeks while the control group received no care. SBP was
significantly decreased and scores for exercise, self-efficacy and general health were
significantly increased compared to that of the control group, indicating that an education
program was effective in controlling SBP and improving-self efficacy for exercise and health-
related quality of life. Similarly, Beigi, et al. (2014) conducted a quasi-experimental study of 112
hypertensive patients selected via systematic random sampling to determine the effectiveness of
a short-term educational program on knowledge level, lifestyle changes, and BP control. The
intervention was delivered in two one-hour training sessions per month over a three-month
period on 100 patients. Results show that mean knowledge scores and lifestyle scores improved
statistically and BP decreased. These findings indicated that a HTN educational program was
effective in increasing HTN knowledge, improving self-management, and controlling BP.
Similarly, in another observational, prospective cohort designed study conducted in a
community-based setting, Darrat et al. (2018) explored the impact of a structured HTN
educational intervention on patient knowledge, lifestyle behaviors and BP control. Participants
were recruited through a BP screening and were randomly assigned to either a control group or
an intervention group and data was collected over a 4-month period. The intervention group
received a HTN educational intervention while the control group received usual care. While
there were no significant differences between the two groups at baseline, there were significant
improvements in HTN knowledge and awareness, exercise levels, and weight as well as greater
reduction in both SBP and DBP in the intervention group. Additionally, Ozoemena, et al. (2019)
conducted a quasi-experimental study on 400 retires in two cities to determine the effectiveness
of a health education intervention in improving HTN knowledge and self-care practices and
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 17
found that HTN knowledge score as well as self-care activities significantly increased from
baseline to one month follow up than those in the control group. Findings in Ozoemena et al.
(2019), Darrat, et al, (2018) and Beigi, et al., 2014) studies strongly suggest that providing
tailored educational intervention can positively impact HTN knowledge, lifestyle behavior
changes and control within a community setting.
In an effort to examine patients’ knowledge about HTN and its association with heart
healthy lifestyle practices and medication adherence, Abu et al. (2018) conducted a cross
sectional survey of 385 adults in two primary care clinics using an 11-item measure to assess
HTN knowledge and obtain self-reports on dietary changes, engagement in physical activity and
medication adherence. Results indicated that while 85% of patients were properly identified as
having HBP, more than two-thirds were unaware that HTN is a lifetime diagnosis, and one-third
were unaware that HTN could lead to renal disease and failure. Additionally, patients with low
HTN knowledge were less likely to reduce their salt intake and eat less to decrease their weight
than patients with high HTN knowledge. The authors concluded that increased HTN knowledge
was associated with healthy lifestyle practices and intensifying educational strategies may
engage patients and optimize BP control.
Lu, et al. (2015) further looked at effective education strategies for health promotion
programs. In a randomized controlled, non-blinded study to evaluate three different HTN health
education strategies in the management of hypertensive patients in community health centers in
China, Lu, et al. (2015) randomized participants in three groups for intervention over a 2-year
period. Group 1 received self-learning; group 2 received monthly didactic lecture; and group 3
received monthly interactive education workshop. Outcomes of changes in BP, HTN knowledge
score, adherence to BP medication, and lifestyle (salt intake and regular physical activity), body
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 18
mass index and serum lipids were evaluated. After 2 years, group 2 showed significant increase
in BP but group 3 showed a more substantial increase in BP. Group 1 did not change
significantly. Additionally, improvements in remaining outcomes were progressively greater
from group 1 to group 2 to group 3. These findings suggest that an interactive education
intervention may be the most effective strategy in community-based health promotion education
programs for hypertensive patients in improving their HTN knowledge and mitigating clinical
risk factors for preventing HTN-related complications.
Support for HTN education in faith communities
Faith-based settings offer a safe and trusted place for parishioners to improve their health.
Schoenthaler, et al. (2018) used a randomized control trial to assess the comparative
effectiveness of a therapeutic lifestyle changes (TLC) intervention plus motivational
interviewing (MINT) versus health education (HE) alone, on BP reduction among 373 black
participants with uncontrolled HTN in 32 New York City churches. The experimental group
received 11 sessions of TLC and 3 sessions of MINT while the control group received one
session of TLC plus 10 sessions of health topics delivered monthly by local experts. The
experimental group had a significantly greater systolic BP reduction than that control group at 6
months and at 9 months, however, the reduction at 9 months was not significant. Findings
suggested that a community-based lifestyle intervention delivered in churches led to significantly
greater reduction in systolic BP in hypertensive blacks compared with HE alone which were
similar to Lu, et al., (2015) findings. In another pre-post intervention study done in a faith
community, Bangurah, et al. (2017) aimed to measure BP readings, dietary sodium intake
behaviors and physical activity levels of 16 parishioners before and after a tailored educational
intervention with data collected over a 4-week period. Results indicated that a nurse-led diet and
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 19
exercise teaching intervention led to lower BP readings over the 4-week period and highlights
the importance and practicality of using faith-based settings to provide education to better
manage HTN and prevent complications. However, further studies are needed to determine long
term impact.
Collaboration across healthcare and faith communities
BP control is one of the measures of the national Million Hearts’ initiative and its focus
on prevention and community-clinical collaboration was a call to action for nurses in the
community to collaborate with community and acute care leaders to better coordinate care and
implement innovative measures to identify undiagnosed and uncontrolled HTN and improve
management (Cooper & Zimmerman, 2017; Merai, 201) Collaborating with faith-based leaders
to empower parishioners through knowledge, coaching and other effective measures is effective
and feasible in reaching this population. Cooper & Zimmerman (2017) conducted a one group
pre-post designed study to measure BP and lifestyle satisfaction scores. The study was conducted
by 39 trained parish nurses who offered a 3-month BP self-monitoring and coaching intervention
over a 2-year period to 119 hypertensive or at-risk parishioners. Results showed decreased BP
readings and improved lifestyle satisfaction scores in six out of the seven targeted areas across
the program period. These findings indicated that coaching by nurses on disease management in
faith settings and in collaboration with and support from faith leaders can create an environment
of sustained support that can promote improved lifestyle behaviors and BP changes over time
(Cooper & Zimmerman, 2017). These findings echoed similar findings in the Bangurah, et al.
(2017) study.
Validity and reliability of the HELM scale
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 20
Ikwanudin, et al. (2015) utilized the HELM scale successfully and supported its validity
and reliability in a quasi-experimental two-group study. Pre and post-test data were collected
from 68 elderly patients selected from two Primary Health Centers in Indonesia and the study
aimed to evaluate the effectiveness of the lifestyle modification program with objectives to
provide HTN knowledge to improve lifestyle behaviors and decrease BP. Results showed that
the mean score of knowledge were significantly higher while BP measurements were decreased
between the intervention group and comparison group indicating a positive effect on improving
hypertensive elders’ knowledge and maintaining their BP. The authors also conducted a sample
study to test the HELM tool on 30 hypertensive elders and found that the instrument had good
internal reliability with Chronbach’s alpha .89. These findings concur with those of Schapira, et
al. (2012) who developed and tested the scale and found that HELM demonstrates content and
construct validity in measuring the knowledge required for patients to take an active role in the
chronic disease management of HTN.
Influence of faith leaders on the health of parishioners
Faith-based settings are increasing becoming popular in which to deliver health
promotion programs since many Americans attend religious services one or more times a week
and therefore, it is important to understand how to effectively capitalize on the strengths of faith
leaders and engage them in promotion efforts (Baruth, et al., 2015). Baruth et al. (2015)
conducted a qualitative study to explore the influence of faith leaders on health-related issues
within their congregation through semi-structured interviews of 24 faith leaders and found that
chronic conditions and poor health behaviors were the top health-related challenges facing their
congregation. A majority mentioned current health-related activities in the churches, and
believed they had influence on their congregation for issues related to health and wellness in the
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 21
form of raising awareness and being a role model. These findings were able to identify the role
and influence of these leaders on health-related issues and programs in their congregation.
Recommendation
The evidence gleaned from this literature review was deemed good and consistent in
considering a health promotion program that addressed disease management at the project site.
A tailored and interactive educational intervention coupled with lifestyle behavior changes to
better manage BP were considered an evidence-based practice for disease management in a
community setting. The evidence addressed the gaps in practice and was consistent with current
barriers for HTN management and the church’s needs and priorities. Additionally, the evidence
supported the feasibility of sustainability. With stakeholder support and approval from senior
leaders within the church, this study can be successfully implemented into the project site.
Evidence Based Translational Models
The WHO has emphasized patient education as an important strategy to improve the
active participation of patients in their disease management process given that there is strong
evidence revealing that HTN control reduces the risk factors for mortality and inabilities
resulting from heart and kidney diseases (Javadzade, et al, 2018). A theoretical framework is
critical to describe how the educational emphasis on social, psychological, and cognitive
variables can affect selfcare behaviors (Khorsandi et al., 2017). One such framework that is used
frequently is the Health Care Belief Model (HBM). The HBM constructs are among the most
crucial and effective factors in selfcare behaviors which are rooted in the individuals’ health
beliefs (Javadzade et al., 2018). In two studies, one randomized control trial and one quasi-
experimental, done to assess the effect of HTN education that is grounded on the HBM theory,
researchers found that the intervention increased the performance and enhanced the HTN health
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 22
beliefs in hypertensive people, and therefore, was recommended to consider the HBM to enhance
self-care behaviors in hypertensive individuals (Javadzade, et al., 2018; Khorsandi, et al., 2017).
The HBM was utilized in the development of this educational intervention (see Appendix
C1). The HBM posits that in order for participants to adopt selfcare and controlling behaviors,
they must understand that they are susceptible to the disease (perceived susceptibility), that they
may suffer the consequences and side effects of uncontrolled HTN (perceived severity), that
controlling their lifestyle behaviors have some benefits for them (perceived benefits), that there
are a few barriers against controlling behaviors (perceived barriers), that there are several ways
to (for example, health ministry health promotion program) encourage them to adopt controlling
behaviors (cues to action), and finally, they should feel that they are able to control HTN through
correct behaviors (self-efficacy) (Khorsandi, et al., 2017). These constructs were included in the
development of this study’s educational module.
To guide the planning, implementation and evaluation of this evidence-based DNP
project, a logic model was developed for by the DNP student. An effective logic model makes a
detailed visual roadmap of the activities that are simple, engaging and will bring about change as
well as results expected for the targeted community (CDC, 2011). It links several concepts:
inputs which are resources acquired or necessary for program implementation; activities which is
the actual intervention that will achieve project outcomes; outputs which are outcomes achieved
as a result of activities implemented; outcomes which addressed the changes, impacts and
results over time; and environmental factors which addresses any challenges faced during
implementation (CDC, 2011). The Logic Model is a proven best practice model design and is
critical to the overall success of future program planning and evaluation with multiple
approaches (Ferdinand, 2012). One of the advantages in utilizing this approach was the effective
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 23
understanding of how the activities can impact outcomes to improve health status of
communities and individuals and avoid unnecessary spending of human resources and finances
that can restrict sustainability of healthcare (Ferdinand, 2012). The Logic Model design used to
guide this DNP project’s implementation, evaluation and dissemination is depicted in Appendix
C2.
Methodology
Study Design
We used a pretest-posttest design. The intervention included two tailored face-to-face 45-
minute interactive sessions on HTN education and management. The sessions were delivered to
participants via a power point presentation by the DNP student in a classroom setting. The two-
module educational curriculum was tailored to follow ACC and AHA guidelines found on their
websites (Whelton, et al. 2018 & AHA, 2017). The first module focused on general HTN
knowledge and risk factors associated with uncontrolled BP while the second module focused on
how to modify diet, exercise, salt and sodium intake, and medication adherence to impact BP
management.
The pre HTN knowledge test was administered prior to the first education session and a
post-test was administered after the second education session in week two. Participants also
received printed informational material to take home. The materials, available on the AHA
website and some purchased, focused on healthy lifestyle behaviors to manage BP and aligned
with the educational modules to further enhance parishioners’ knowledge.
Study Setting
A large suburban Lutheran church was selected to implement this evidence-based project.
The church currently has over 600 members, sees about 20-30 visitors a month, and serves a
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 24
predominantly white population. It is located in an affluent neighborhood that boasts many
healthy food stores, gyms, as well as walking and bike paths. A large number of parishioners are
over age 50 and many have chronic conditions, HTN being one of them. The church is a setting
where parishioners feel comfortable, is family oriented, and has 30 small group ministries that
brings together about 200 members for routine gatherings which involve prayers, meal sharing,
and other fun activities, thus, this setting was ideal to evaluate the effectiveness of an education
intervention to improve knowledge, modify lifestyle behaviors and decreased BP among
parishioners.
Study Population
Participants were recruited from the congregation through a three-week
screening/enrollment process after GWU’s Institutional Review Board (IRB) determination. The
population selected for this study included English speaking adults ages 40 years and older with
a self-report diagnosis of HTN, or a BP of 130/80 or greater at screening, or currently taking BP
medication(s). A diagnosis of HTN was defined by the following criteria: (1) a history of being
told by their physician that they have HTN, (2) currently taking medications to treat HTN, or (3)
documentation of BP reading of 130/80 or greater by study staff using standardized methods of
BP measurement (Shapira, et al., 2012). Adults whose BP could not be measured in either arm
using standardized methods of BP measurement due to a medical contraindication such as
bilateral lymphoedema were excluded (Darrat, et al, 2018). Adults with cognitive impairments
were also excluded. A convenience sample of participants was used for this project. Assuming a
moderate effect determined by statistical power analysis, with a power of 80% and alpha of 0.05,
a sample size of 31 participants was targeted. Assuming a dropout rate of 20% at follow-up, a
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 25
minimum of 39 participants was needed. 44 parishioners were recruited, 8 dropped out and 36
completed the study.
Subject Recruitment
After IRB determination was obtained, advertisement and recruitment of subjects took
place over a three-week period. An informational flyer was created by the DNP student and was
posted on bulletins boards around the church, in the associated Kindergarten school attached to
the church, and on the church’s website and social media platforms. A copy of this flyer is
presented in Appendix D. Additionally, announcements were made by the Senior Pastors at all
three worship services on Sundays and by small group ministry leaders at their gatherings or by
email during the recruitment period. Screening sessions and enrollment were held mostly on
Sundays but also at small groups during the week to accommodate as many parishioners as
possible. Once screened, those that were eligible and willing to participate in the program were
asked to fill out a demographic survey and had their baseline BP measured.
Ethical Considerations
This educational intervention sought the approval of the GWU’s IRB. Additionally, since
the project site does not have its own IRB, an agreement with the project site to conduct the
study was obtained and is presented in Appendix E. Participation was strictly voluntary and
participants were able drop out anytime they wished to without being pressured or penalty from
the church. Consent was assumed with participation in the program. Privacy was provided for the
participants at all times during recruitment and data collection. There were no anticipated risks or
harm to participants in this study. No participants experienced any emotional discomfort if their
BP was high. There were no cost or compensation to study participants. Participants were given
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 26
the DNP student’s contact information (phone number and email) in case they had questions or
concerns.
The study utilized surveys and BP measurements to collect participants’ data. To protect
the confidentiality and identification of participants, each participant was assigned a participant
code which was written on a card and given to the participant to keep, and was instructed to
write the code on all data collection surveys. When collecting BP data, the study staff asked the
participant for their study code and it was entered with their data collection sheets. On a separate
document, with access restricted only to the DNP student, each participants’ names, phone
numbers, and emails and unique study codes were listed and stored separately from data
documents in the DNP’s student’s password protected personal computer at home. Data was
cleaned, verified for accuracy and entered into Excel and SPSS for storage and data analysis. All
de-identified data will be stored for six years as required by the study requirements.
Outcomes
HTN knowledge: Defined as scores obtained on a HTN knowledge test which was
measured using a self -administered modified HELM questionnaire containing 14 items (Shapira,
et al., 2012). This tool has been shown to be valid and reliable in assessing participants’
knowledge of HTN to manage their chronic disease (Ihwanudin, et al., (2015); Shapira, et al.,
2012). An increase in HTN knowledge score from baseline to post intervention was an
anticipated finding for this study.
Lifestyle Behavior Change: Weigh gain, physical inactivity, and high salt intake are
associated with inadequate BP control according to a retrospective study on hypertensive patients
(Yang, et al., 2017). Physical activity level (walking, running, strength training, and/or
gardening) watching or reducing salt and sodium were the two lifestyle behavior changes
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 27
selected as outcomes measured in this study. Weight gain was not measured given the short
duration time of our study. An increase in number of minutes parishioners exercised per week
from baseline and increase in number of days parishioners reduce their salt/sodium intake from
baseline were anticipated findings. These lifestyle behaviors were measured using self-reported
data.
BP: As described by the AHA and ACC, normal BP is defined as a SBP of 120 mmHg
and a DBP of 80 mmHg while HTN is defined as a SBP of 130 mmHg or higher and/or a DBP
80 mmHg or higher (Whelton, et al., 2018). BP was measured in both arms using a standardized
method with an automated BP monitor and the average of the two readings was documented
(Darrat, et al., 2018). A decrease in SBP and/or DBP from baseline to two-weeks post
intervention was an anticipated finding for this study. BP measurements data were obtained three
times during this study: pre intervention, post intervention, and two weeks post intervention
follow-up. The Omron 10 Series BP monitoring device was used to obtain BP data and
calibration was ensured prior to use according to the manufacture’s manual. To ensure inter-rater
reliability for obtaining BP measurements, study staff was required to attend a one-hour training
given by the DNP student and successfully completed a BP competency demonstration
(Williams, et al., 2009). Appendix F shows a copy of the BP Measurement Competency.
Study Tools
HTN knowledge is a vital part of the patient’s self-care model and is a critical preventive
strategy to help patients manage this chronic disease and a known barrier for HTN control. The
14 item HELM scale used in this study to assess HTN knowledge was developed by Schapira, et.
al., (2012) as part of a community-based study designed to improve self-management of HTN
addresses three domains of BP management understanding: monitoring and setting goals,
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 28
lifestyle and medication management, and general HTN knowledge and treatment goals
regarding HTN. It aimed to measure a patient’s readiness to begin self-management of their
HTN and to accurately measure knowledge of HTN, in the context of managing it as a chronic
disease (Schapira, et al., 2012). Validity of the HELM questionnaire “was assessed through
comparisons of performance with education, health numeracy, patient self-efficacy, and
hypertension control” and was successful in providing a valid measure of knowledge needed for
patients to proactively manage their HTN (Schapira, et al., 2012, p. 461). The instrument has
good internal reliability with Cronbach’s alpha .89 (Ikwanudin, et al., 2015). Darrat, et al.,
(2018) used the HELM tool in a prospective cohort randomized study to assess a patients’ HTN
educational intervention and BP control in a community setting. Results show that there were
significant improvements in HTN knowledge and BP measurements among participants in the
intervention group compared to control group (Darrat, et al., 2018). Thus, the HELM tool
appears to be a valid and reliable tool that can be used to measure knowledge of HTN in the
context of chronic disease management and is easily accessible for public use via the internet.
While the tool has no copyright because it was created with federally funded research,
permission for use in this project was still obtained from the authors. A copy of the permission
obtained is presented in Appendix G. Demographic and lifestyle behaviors questions were
extracted and modified for use in this study from the CDC’s 2015 Behavioral Risk Factor
Surveillance System Questionnaire (BRFSS) (CDC, 2014). A copy of all the HELM scale and
the BRFSS questionnaire study tools are presented in Appendix H as Study Tools.
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 29
Project Timeline
• Phase I (January, 2019): DNP student met with stakeholders from the project site to
assess needs of the organization and identified a topic for the DNP Project. Stakeholder
buy in was sought and a project team was formed.
• Phase II (February through May, 2019): A letter of agreement was obtained from study
site. The DNP student worked under the guidance of the project team which includes the
primary advisor to write the DNP proposal and obtained approval for the project. A
secondary advisor was also identified in this phase.
• Phase III (June-August, 2019): The proposal was submitted to GWU IRB for review and
approval was obtained. The DNP student worked to develop the educational intervention.
• Phase IV (September through December, 2019): Participants were recruited, the project
was implemented and results were analyzed.
• Phase V (January to March, 2020): Evaluation of the DNP project outcomes was
completed along with abstract writing and poster development.
• Phase VI (March through April, 2020): Final DNP report was completed and results were
disseminated to the project team.
Appendix I outlines these activities in a Gantt Chart as Project Timeline.
Resources Needed/Study Expenses
Strong leadership commitment, support and buy-in from the project site leaders were
critical to the successful implementation and completion of this evidence-based change project
(Moran, Burson & Conrad, 2017). Assistance from the project team was important for planning
and carrying out activities throughout the recruitment and implementation phases. Space for
educational sessions was also provided by the church. Advanced technology played a key role in
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 30
this project as educational sessions were conducted with a power point presentation, which
warrants a screen and laptop. The church’s IT specialist was responsible for setting up the
classroom with the necessary audiovisual equipment. Additionally, the DNP student utilized
software on her password protected computer such as Microsoft Word and Excel, SPSS for data
analysis and evaluation, and writing the final report of the project. Email was used to reach team
members and participants when necessary with the help of the church’s administrative assistant
and all participants were given the DNP student’s personal cell phone number to reach her in the
event that something comes up and they cannot attend a session. Healthy meals were offered to
participants and team members at each session. Four BP monitoring devises were purchased to
collect BP data. A $250 grant was provided by the Trivent Action Team via the project site, the
DNP student absorbed most of the cost incurred by this study which included BP monitoring
devises, take home materials, materials and supplies, heathy food and refreshments, and thank
you gift cards for study staff.
Evaluation Plan
Identifying the appropriate evaluation methodologies, techniques, and tools to
consistently measure the usefulness, effectiveness, and impact of an educational intervention to
improve HTN knowledge and BP control was a focus for this project. This one-year DNP project
set the following goals: increase HTN knowledge among participants, change lifestyle behaviors
to decrease salt intake and increase exercise, and improve BP control. The long-term impact is
expected to raise public awareness of strategies to control HTN, inform nurse leaders, and serve
as a catalyst for implementing health promotion programs within the faith communities to help
parishioners control detrimental lifestyle habits to manage their HTN and other chronic disease.
The intermediate impact is to modify lifestyle behaviors to better management of BP, and the
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 31
short-term impact is to increase knowledge and awareness of the risk factors associated with this
chronic disease and strategies to better manage it. The Logic Model as described earlier in this
paper guided the evaluation plan. The following questions were addressed in this evaluation:
• To what extent are the goals of the overall program being met?
• What resources and support are required at the organizational level in order to effectively
carry out this project and for it to be sustainable?
• Are stakeholders successfully involved?
• What are the identified barriers to implementation?
• Is the intervention successfully implemented as planned?
The evaluation matrix for this project is displayed in Appendix J. The results of this
evaluation identified lessons learned that can be applied to other educational intervention in
establishing a health promotion program within the faith-based setting.
Data Analysis
Data was analyzed using Microsoft Excel and Statistical Package for Social Sciences
(SPSS). Descriptive statistics were performed to examine participants’ characteristics and
distribution of study variables. Paired t-test and repeated measures analysis of variance (RM-
ANOVA) were used to address the three study questions: 1) Does providing education on HTN
increase HTN knowledge score among participants? 2) Does HTN knowledge aid in improving
lifestyle behaviors? and 3) Does increasing knowledge and changing lifestyle behaviors decrease
SBP and DBP? For all analysis, alpha is set at 0.05.
Results
A total of 87 participants were screened over a three-week period, 56 of whom met the
eligibility criteria for inclusion in the study, and 44 of these were enrolled. Of the 44 participants
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 32
enrolled in the study, 36 completed the study. Four participants changed their minds due to
personal and time-conflict, two participants could not make it on the day intervention was started
so did not receive any intervention, and two participants attended one class each and received
only partial intervention and were considered dropouts. Data was collected from the 36
participants who completed the study and were used in this data analysis.
Demographics and Characteristics of Study Population
The characteristics, average baseline BP pressure measurements and baseline lifestyle
behaviors of the study population are summarized in Table 1. Participants were 53% male; 33%
were below age 60, 25% ranged from ages 60-69, but most (42%) were ages 70 and over.
Participants were predominantly white, had college or higher education, and did not smoke. 75%
(27) of the participants reported a history of HBP, 9 of which reported having HBP for less than
5 years and 18 reported having HBP for 5 or more years, and 25 reported currently taking BP
medications. The other two had reported that they stopped using their medication. Less than half
of the participants (44%) reported that they exercised regularly. The 14 item HELM scale to
measure HTN knowledge was administered to all 36 participants prior to receiving the
intervention and showed a pre intervention mean score of 9.78. At baseline, participants had a
mean SBP was 139.1 and mean DBP of 84.25. Additionally, prior to receiving the intervention,
participants reported a mean average minutes exercised per week was 123.23 and more than half
of them (55.6%) reported that they were watching or reducing their also intake.
HTN Knowledge Score
Pre and post knowledge scores were computed using paired t-test. Before the
intervention, participants scored a mean average of 9.78 on the HELM scale while post
intervention, participants increased their mean score to 13.61. This increase in knowledge score
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 33
was statistically significant (t=11.15, p<0.001). These results are summarized in Table 2 and
charted in Figure1.
Lifestyle Behaviors
Two lifestyle behavior measures, exercise and salt/sodium intake, were chosen as a focus
for changing behaviors in this study and were analyzed using data from pre and post
intervention. Only 33 participants answered these questions. Results using paired t-test and
McNemar tests are summarized in Table 3 and charted in Figure 2.
Physical Activity: Prior to the intervention, 28 (77.8%) participants indicated that they had
exercised in the past two weeks compared to 34 (94.4%) post intervention, and 16 (44.4%) of
those participants reported that they exercised for 150 minutes or more per week compared 23
(68.9%). These differences were not statistically significant (p=0.07 and p=0.092 respectively).
However, the average number of minutes participants exercised per week pre and post
intervention increased from 123 minutes to 167 minutes, and was significant (t=2.40, p=0.023).
Salt Intake: Participants were asked whether they were watching or reducing their salt/sodium
intake, if so, how many days they were doing so. Prior to the intervention, 19 (57.6%)
participants stated they were currently watching or reducing their salt/sodium intake compared to
28 (84.8%) at post intervention. This comparison showed a significant increase from pre to post
intervention (p=0.012). We did not compare the number of days reducing salt/sodium intake
because at the screening, only 14 participants reported number of days, while after the
intervention, 28 participants reported on this variable.
BP Pressure Changes
To determine whether there was a difference in average SBP and average DBP of
participants before, immediately after, and at two weeks follow-up after the HTN educational
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 34
intervention, repeated measures analysis of variance (RM-ANOVA) were performed. The mean
average SBP decreased from baseline to follow-up which was statistically significant (m139.1 –
132.4 mmHg, F=4.37, p=0.016) while the mean DBP showed no difference. These results are
summarized in Table 4 and charted in Figure 3). Additionally, paired t-tests were performed to
further compare pre to post systolic BP, pre to 2-week follow-up, and then post to 2-week
follow-up and summarized in Table 5. There was significant decrease in average SBP from pre
to post and pre to 2-week follow-up. Post to follow-up average SBP did not show a significant
difference. All tables and figures are displayed in the Results Tables and Figures section of this
paper.
Discussion
The results of this study indicated that the educational intervention was highly effective
in helping to manage BP. We observed significant increase in HTN knowledge score and
physical activity level, reduction in salt/sodium intake, and decrease in SBP. The change in SBP
was not significant. Our findings are consistent with previous studies that reported increased
post-test scores for HTN knowledge from baseline scores with favorable impact on lifestyle
behaviors and BP control after a tailored HTN educational intervention (Abu et al., 2018; Beigi,
et al., 2014; Darrat et al., 2018; Park, et al., 2010). Further, the interactive nature in the delivery
of this intervention to participants is consistent with findings published by Lu, et al. (2015)
suggesting that interactive education intervention may be the most effective strategy in
community-based health promotion education programs for hypertensive patients in improving
their HTN knowledge and mitigating clinical risk factors for preventing HTN-related
complications.
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 35
Khatib et al. (2014) and Heinert et al. (2020) have found that lack of HTN education is
the most common barrier to HTN control. Our study findings reflected these findings and
suggested that providing an interactive educational intervention and engaging parishioners in
modifying their lifestyle behaviors to impact BP control is a multifaceted approach when
targeting the need of hypertensive patient and moves our progress in closing this gap in practice.
An additional finding that deserved mentioning is that during the recruitment phase of this
project, we found that 56 of the 87 (64%) participants screened met inclusion criteria for the
study, meaning that their either had HTN or was hypertensive at time of screening. This
“uncontrolled hypertension” for this congregation is almost consistent with CDC’s data that 76%
of American adults do not have their BP under controlled.
Our study findings gave insight into the practicality of healthcare professionals
collaborating with faith-based leaders to provide education in faith-based settings that would
impact lifestyle behavior changes which Cooper & Zimmerman (2017) and Schoenthaler, et al.
(2020) found to be key in controlling BP and achieving improved health outcomes for
parishioners in faith communities. It can also foster an environment of sustained support to
impact parishioners’ overall health. Buy-in and support from stakeholders as well as
empowerment through knowledge to improve disease management is fundamental for
sustainability of these health promotion programs, serves as a catalyst for spread into the
community to reduce risks of life-threatening conditions, decreases healthcare costs, and
supports population health beyond clinical walls.
Study Limitations
While this study produced some important results and met most of its objectives, there
were some potential limitations that must be considered. First, as the recruitment of this study
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 36
took place at screening events at a church, participants without a self-report HTN diagnosis were
recruited on the basis of having a HBP on that day which may have led to “white coat syndrome”
and overestimate the true prevalence of high BP (Darrat, et al. 2018). Second, information on
physical activity and salt/sodium intake were collected through participants’ self-reports which
could have resulted in potential recall bias and social desirability bias (Abu, 2018). Third, times
of data collection for BP measurements did not take into consideration parishioner’s times of
medication schedule. This could have potentially affected baseline BP readings and skew
comparison results with post intervention measurements. Fourth, the short study period of four
weeks made it difficult to determine whether the knowledge gained from the intervention was
consistent with lifestyle behaviors and BP changes, thus, longer term studies are needed. Fifth,
the two studies used in this project to support reliability and validity of the HELM scale targeted
low income and low literacy populations and may not be generalized to other populations such
our college educated population. Additionally, there may be some unmeasured confounding
factors not accounted for in this study. Participants’ motivation, either by faith leaders to help
with the study or simply to improve lifestyle practices, and the fact that our study population was
from a suburban high-income community and had access to healthy food stores, gyms, and
walking and biking trails may have influenced the association between HTN knowledge and
improved lifestyle behaviors and its impact on BP control.
Implications/Recommendations for Practice, Policy and Research
The prevalence of HTN in the United States is astounding with too many Americans
being affected. While recommended evidence-based interventions are in place to help manage
the disease, progress has been slow. Nurse leaders are well positioned to use evidence-based
interventions to help move the goals towards control and prevention. HTN education to improve
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 37
knowledge and lifestyle behaviors to help control BP has been identified in the literature as a
barrier to effective management of HTN. The results of this study have clinical implications for
hypertensive patient management and population health. Understanding this gap in practice with
disease management and recommended evidence-based interventions to help close these gaps
can inform areas of success for nurse leaders and the need to improve community-based HTN
programs including any future implementation of our HTN program in the faith community. We,
therefore, recommend providing well-designed educational programs that are interactive, tailored
and grounded in theory to the needs of parishioners to change lifestyle practices and improve
management of HTN and other chronic conditions on an ongoing basis in faith communities.
Effective HTN management also has significant financial implications. The ability to improve
the transition of care to the community settings as supported in the literature requires evidenced-
based interventions that will facilitate self-care for HTN management, reduction of risk factors
and morbidity and mortality HTN rates, all of which can favorably impact hospital re-admission
rates for uncontrolled HTN and thus, decrease health care expenses.
This project was conducted over a four-week period and, therefore, produced short-term
results. We recommend further research to determine any long-term impact of HTN education on
lifestyle behaviors and HTN management as this evidence-based intervention have massive
potential to serve as a catalyst for community spread.
Support for Health Ministries within faith-based settings to engage parishioners and
promote health is not only recommended but critical to reaching at-risk populations in this
community. Faith-based settings should develop a policy to support Parish Nurses in established
Faith Health Ministry Programs where they have a crucial role in the faith communities to make
key decisions and partner with community resources to improve the quality of life to facilitate
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 38
parishioners spiritual, emotional, and social health. An established Faith Health Ministry
Program overseen by a paid Parish Nurse in this setting can provide opportunities for
collaboration between faith communities, county health departments, hospitals and clinics to
provide preventive screenings on BP, diabetes, cholesterol, etc., as well as addressing issues with
disease management similar to this project. This keen collaboration is critical to engaging and
fostering faith community participation in HTN management to reduce HTN risk factors,
morbidity and mortality. Engaging high-risk populations in settings where they dwell and feel
comfortable can move our progress towards promoting healthier behaviors to better manage
uncontrolled HTN.
Plans for Sustainability and Future Scholarship
Too many parishioners at this project site are affected by HTN and an alarming number
of them do not have their BP under control which puts them at increased risk for life threatening
events. Our study found that utilizing a tailored and interactive educational intervention was
highly effective in increasing parishioners’ HTN knowledge, favorably changed their lifestyle
behaviors, and decrease their SBP. These results were disseminated to the DNP Project team at
both GWU and the project site with additional plans to disseminate at local, regional, and
national public health conferences. The faith leaders and the parishioners at this project site are
highly supportive of sustaining this program given our findings. This was the first time that this
kind of project was conducted there.
While further research is needed to examine long-term impact of education on lifestyle
behaviors and HTN management, the success of this DNP project helped lay the ground work for
sustainability of a Faith Health Ministry program in the church with oversight by a part-time
volunteer Parish Nurse. The Parish Nurse and lead project Pastor were both very involved with
the study and actually got good insight on the importance of sustainability. The program
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 39
evaluation conducted by the DNP student at the end of the project indicated that parishioners
want to see more projects like this conducted in the church with focus on health prevention,
screenings, and disease management. There are plans for collaboration with the local hospital
and health department to provide quarterly screenings at the church as well as inviting local
health experts to address chronic diseases and management via educational in-person sessions.
As a result of the study, parishioners are now more aware of their BP measurements and are
showing an increased interest in attending BP screenings. To stay on course with the plan for
quarterly BP screenings, another successful BP screening event was held at the church three
months post-intervention where 48 parishioners were screened, including a few of the
participants who wanted to get their BP rechecked. We are making progress already with this
health ministry in place. Importantly, additional finances were included in the church’s budget to
enhance health promotion activities and discussions regarding the recruitment of a paid full-time
Parish nurse to oversee this Ministry on a broader level will take place in the future. The success
of this program, enhanced with additional long-term studies, can serve as a catalyst for spread
into the community.
Conclusion
Overall, the study findings provided evidence for the effectiveness of providing an
evidence-based interactive educational intervention for adult parishioners in the faith-based
community and validated the importance of utilizing recommended best practices to help reduce
risk factors associated with uncontrolled HTN. Further research is needed to evaluate the long-
term impact of education on reducing risk factors, mortality and morbidity for the hypertensive
population.
BP control is critical to avoid the devastating risks of strokes, heart disease, and kidney
disease and failure. The increasing demand to provide education beyond the clinical wall and
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 40
into community settings is important for the management of BP and reducing its life-threatening
risks. Lack of HTN knowledge to promote and encourage lifestyle behavior change can
negatively impact the efforts of BP control and quality of life for parishioners and community
residents in general. Providing an interactive, tailored, and evidence-based educational program
that is grounded in theory is highly effective and recommended to target the needs of the faith
community. It changes lifestyle behaviors to favorably impact disease management, works to
help close the gap in practice, fosters an environment of sustained support to engage
parishioners, enhances collaboration across healthcare and community leaders, and can serve as a
catalyst for spread into the community.
Additionally, it provided an opportunity for a collaborative partnership across health care
and faith communities to improve health outcomes for the population which Campbell et al.
(2007) states is essential for program design, recruitment, and sustainability of church-based
health programs. Merai, et al, (2016) states that these collaborative and coordinated efforts are
required to leverage the strengths and resources of both public health and health care systems.
This evidence-based project also supported the goals of AHA, ACC, Healthy People 2020,
Million Hearts Initiative, the CDC, and the WHO and aligns with the Institute of Medicine’s
triple aim of improving patient care experience, improving health populations and reducing
health care costs. Effective HTN management in a faith community can help to improve
outcomes for individuals and populations and reducing healthcare costs.
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 41
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HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 49
Results Tables and Charts
Table 1: Demographics and Characteristics of the Study Population
Total Sample
(N=36)
Variable
Category
Frequency (%)
Gender
• Male
19 (52.8%)
• Female
17 (47.2%)
Age
• <60 years
12 (33.3%)
• 60 – 69 years
9 (25.0%)
• 70 plus years
15 (41.7%)
Race/Ethnicity
• White/European American
33 (91.7%)
• Other
3 (8.3%)
• High school or GED
4 (11.1%)
History of HBP
• Yes
27 (75.0%)
• No
9 (25.0%)
Length of HBP History
• < 5 years
9 (33.3%)
• > 5 years
18 (66.7%)
BP Medication
• Yes
25 (69.4%)
• No
11 (30.6%)
Smoke
• Yes
2 (5.6%)
• No
34 (94.4%)
Exercise Regularly
• Yes
16 (44.4%)
• No
20 (55.6%)
Pre-intervention HTN
Knowledge Mean Score
9.78 (SD 1.972)
Pre-intervention BP Mean
• Pre-Mean SBP
139.1 (SD 15.07)
• Pre-Mean DBP
84.25 (SD 11.89)
Pre- intervention Lifestyle
behavior
• Average minutes of exercise per
week
123.23
• Watching/reducing salt intake
- Yes
- No
- Don’t know/not sure
20 (55.6%)
15 (41.7%)
1 (2.8%)
Values are expressed as frequency and percentage, and means and SD are reported where
applicable.
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 50
Table 2: Knowledge Score (n=36)
Pre-intervention
M(SD)
Post-intervention
M(SD)
Statistics, p value
HTN Knowledge
9.78 (1.97)
13.61 (0.77)
t=11.15, p<0.001
Significant
Paired t-test was used to compute pre and post means. Significant results are bolded.
Table 3: Lifestyle behaviors pre and post the intervention (n=33)
Pre
Post
Statistics, p value
Have you exercised
• Yes
• No
28 (77.8%)
8 (22.2%)
34 (94.4%)
2 (5.6%)
p**=0.07
Not significant
Have you exercised
150+ minutes
• Yes
• No
16 (44.4%)
20 (55.6%)
23 (68.9%)
13 (36.1%)
P**=0.092
Not significant
Average number of
minutes exercised
per week
123.23(SD 125.11)
167.10 (SD 126.45)
t*=2.40, p**=0.023
Significant
Watching or
reducing sodium
• Yes
• No
19 (57.6%)
14 (42.4%)
28 (84.8%)
5 (15.2 %)
P**=0.012
Significant
Number of days
reducing sodium per
week
NA
t* paired t-test and P** McNemar tests were used to compare pre and post lifestyle behaviors.
Significant results are bolded.
Table 4: Changes in Blood Pressure Measurements (n=36)
Measure
Pre
Post
2-week Follow-up
Statistics, p value
SBP
139.11
133.35
132.40
F*=4.37, p=0.016
Significant
DBP
84.25
82.26
81.90
F*=1.55, p=0.220
Not Significant
Repeated measures ANOVA was used to compare the three BP measurements.
Significant results are bolded.
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 51
Table 5: Pairwise Comparison for SBP (n=36)
Variable
Statistics, p value
Pre vs. post
t=2.46, p=0.019 (significant)
Pre vs. 2-week follow-up
t=2.44, p=0.020 (significant)
Post vs. 2-week follow-up
t=0.42, p=0.678 (not significant)
Paired t-tests were used to compare BP measurements. Significant results are bolded.
Figure 1: Differences in Mean Hypertension Knowledge Score
Figure 2: Differences in Self-Reported Lifestyle Behaviors
9.78
13.61
0 2 4 6 8 10 12 14 16
Pre
Post
Differences in Mean
Hypertension Knowledge Score
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 52
Figure 3: Differences in Mean Systolic Blood Pressure Measurements
123.23
19
167.1
28
0
50
100
150
200
Average # of minutes participants
exercised per week
# of participants watching/reducing
their salt/sodium intake
Differences in Self-Reported Lifestyle Behaviors
Pre Post
139.11
133.35
132.4
128
130
132
134
136
138
140
Pre Post 2 Week Follow-up
Differences in Mean Systolic
Blood Pressure Measurements
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 53
Appendices
Appendix A - SWOT Analysis
Problem: Lack of a Health Promotion Program
Helpful
To achieving the objective
Harmful
To achieving the objective
Internal Origin
{Attributes of the organization}
Strengths
-Supportive leadership
-Parish nurse
-Large modern church facilities
-Advanced technology
-Administrative staff onsite
-Adequate parking
-Updated website
-Active engagement in community
Weaknesses
-Small groups offered at different times
-Pastors and Parish nurse do not have
set office hours
-Staff in volunteer positions
-Parish nurse is part time
External
Origin
{Attributes of the
organization}
Opportunities
-Collaboration with local hospital,
health department and other community
stakeholders
-Funding initiatives to develop
evidence-based faith-based or faith-
placed health interventions
Threats
-Affluent status of community so may
not be interested in community
education
-Lack of engagement of parishioners
-Parish nurse is part time volunteer
Running head: HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 54
Appendix B - Literature Review Table
PICO Question: What is the effect of an educational intervention, compared to the baseline, on HTN knowledge, lifestyle behavior
modifications and BP control among parishioners ages 40 and older at a suburban community church?
Article
#
Author &
Date
Evidence
Type
Sample,
Sample Size,
Setting
Study findings
that help answer
the EBP
Question
Observable
Measures
Limitations
Evidence
Level &
Quality
#1
Abu, et al.,
2018
Cross-
sectional
survey
385 adults with
HTN treated in
2 primary care
clinics
Increased HTN
knowledge was
associated with
healthy lifestyle
practices such as
dietary salt
intake and
eating less to
reduce weight.
Hypertension
knowledge and
self-reports on
dietary changes,
exercise, and
medication
adherence.
-Re-call bias and
social desirability
bias with self-
reports of lifestyle
practices
- Selection bias
with patients who
have seen their
doctors during
study period and
may be more
knowledge about
HTN.
Level III
Quality
A/B
#2
Bangurah, et
al., 2017
Pre-post
design
16 Black
adults 55 years
and older in a
faith-based
setting
Significant
decrease in
dietary sodium
and increase in
physical activity
level from pre to
post
intervention.
-Dietary sodium
intake and
physical activity
levels
- BP readings
-Sample size (16)
-Gender (75%
female) and racial
(100% Blacks) bias
limited
generalizability of
study
-Participant bias
due to self-reported
Level III
Quality B
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 55
-BP control
improved but
changes were
not significant.
data which can
threaten external
validity.
#3
Baruth, et al.,
2015
Qualitative
24 faith leaders
in 2
geographic
regions
Capitalizing on
the strengths of
and engaging
faith leaders in
health
promotion
efforts can be
beneficial to
improving
disease
management in
the faith
community.
- Perception
-Attitudes
- Beliefs
-Experiences
- Influence of
faith leaders on
their
congregation.
- Participant bias
with qualitative
study design
- Sample was from
2 specific
geographic areas
and does not
represent other
regions in county,
thus limiting
generalizability
Level III
Quality
A/B
#4
Beigi, et al.,
2014
Quasi-
experimental
110
hypertensive
patients in a
heart health
center.
A short-term
educational
HTN program
was effective in
increasing
knowledge,
- Knowledge
scores
- Lifestyle
behaviors
- Small sample size
- Short follow-up
Level II
Quality
A/B
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 56
improving self-
management,
and BP control
- BP control
-Lack of special
emphasis on
smoking
#5
Cooper &
Zimmerman,
2017
One group
pre-post study
109
hypertensive
parishioners in
a faith
community
39 faith nurses
offered 3-month
BP monitoring
and coaching
intervention
over a 2 -year
period.
Participants
showed
decreased BP
readings and
improved
lifestyle
satisfaction
scores in six out
of seven areas
across the 2-year
study period
- BP
measurements
-Lifestyle
satisfaction
scores (BP self-
monitoring,
healthy activity,
healthy weight,
managing
medications,
healthy eating,
managing stress,
tobacco use)
-No comparison
group which limits
generalizability
-Limited consistent
data showing effect
on participants
being referred to
provider.
-Demographic data
was severely under
collected since
gender was the only
demographic data
collected.
-The FCNs who
collected the data
were willing
volunteers.
Level III
Quality
A/B
#6
Darrat et al.,
2018
Quasi-
experimental
design with
two groups
with pre- and
post-test
118
hypertensive
participants
recruited from
a Stroke
center. 59
participants
were
randomized to
After a 4-week
study period,
significant
improvements in
HTN knowledge
and awareness,
exercise levels,
weight and
reduction in
- Hypertension
knowledge and
awareness
-Weight
-Exercise level
-BP
measurements
- Participants were
recruited on the
basis of having high
BP on that day
which may have led
to the recruitment
of participants with
“white coat
syndrome” and
Level II
Quality
A/B
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 57
intervention
group and
received a
HTN
educational
intervention
and 59 to
control group
received usual
care. The
response rate
was 69%.
both SBP and
DBP were
found,
indicating that
providing
tailored
educational
intervention can
positively
impact on HTN
knowledge, self-
care
management and
BP control in
within
community-
based settings.
could overestimate
the true prevalence
of high BP.
-Recall bias and
social desirability
bias with self-
reported data on
lifestyle behaviors
-Small sample size
-Short term
intervention and
follow-up phase
#7
Ihwanudin, et
al., 2015
Quasi-
experimental
with two
groups, pre
and post-test
design.
58 elderly
recruited
randomly from
two health care
center and
assigned to
two equal
groups.
Intervention
group received
a theory-based
lifestyle
medication
program while
control group
There was a
significant
difference in all
variable in the
intervention
group compared
to the control
group.
HELM scale
was tested and
found to have
good internal
reliability with
Chronbach’s
alpha .89
-Mean
knowledge score
-Situational
perception
-Blood pressure
-Cholesterol
-Given the
advanced ages of
participants,
continuous follow-
up may not be
sustainable.
-Gender bias since
most participants
were female.
Level II
Quality
A/B
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 58
received usual
care.
#8
Heinert, et al.,
2020
Qualitative
31 community
members were
recruited from
4 church-based
settings in
minority
neighborhoods.
4 focus groups
took place in
these 4
churches.
After receiving
screening, brief
intervention and
referral to
treatment
program for
hypertension,
participants
were able to
identify the most
common barriers
to HTN control
being lack of
HTN knowledge
and awareness,
and negative
primary care
experiences
while most
common
facilitators were
HTN control
with social
support,
knowing how to
control HTN,
and community
resources at 3
- Knowledge of
barriers to HTN
control
- Knowledge of
barriers and
facilitators for
HTN control
-Convenient sample
so maybe not
representative of
generalized
population.
-Intercoder
reliability was not
calculated so
cannot quantify
reliability of coding
across multiple
coders.
Level III
Quality
A/B
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 59
months post
intervention.
#9
Khatib, et al.,
2014
Systematic
Review and
Meta
Analysis
44 quantitative
and 25
qualitative
studies
Lack of
knowledge was
the most
common barrier
to HTN control
and awareness
and the need for
targeted multi-
faceted
interventions to
manage HTN.
- Barriers
reported by HTN
patients
-Barriers
reported by
population
groups at risk for
HTN.
- studies were
heterogeneous in
terms of study
population and
setting, and barrier
assessment methods
and tools.
-Modest
methodological
quality of both
quantitative and
qualitative studies.
-Majority of studies
conducted in higher
income countries,
mainly in the USA,
so not generalizable
to countries with
different
socioeconomic
status.
Level III
Quality
A/B
#10
Lu, et al.,
2015
Randomized,
non-blinded
trial
360
hypertensive
patients in a
community
heath service
center over a
2-year study
Interactive
education
workgroups was
the most
effective
strategy in
community-
- Hypertension
score
- Adherence to
medication
- Salt intake
- Trial was not
blinded to
participants
-Data on lifestyle
behaviors was self-
Level 1
Quality B
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 60
period.
Participants
were
randomized in
3 groups:
Group 1
received self-
learning
reading;
Group 2
received
monthly
regular
didactic
lectures; and
Group 3
received
monthly
interactive
education
workshops
based health
promotion
education
program for
HTN patients in
improving
patient’s
knowledge on
HTN and
reducing risk
factors.
- Physical
activity
- BMI
-Cholesterol
reported which
presents recall bias.
#11
Ozoemena, et
al., 2019
Quasi-
experimental
400
hypertensive
retires in 2
cities in
Nigeria
Intervention
group received
HTN health
education.
Mean HTN
knowledge score
and lifestyle
behaviors
significantly
increased in the
intervention
group compared
to the control
group between
baseline and
-HTN
knowledge score
-Prevention
-Self-care
practices
-External factors
unconnected to
interventions
-Small sample size
making
confounding factors
a bias
Level II
Quality
A/B
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 61
Control group
received health
talks without
intervention
one-month
follow-up.
#12
Park, et al.,
2010
Randomized
controlled
trial
Older
hypertensive
patients
18 allocated to
the
intervention
group to
receive health
education,
individual
counseling,
and tailored
exercise
program
22 allocated to
control group
and did not
receive any
intervention.
After the 12-
week study
period, systolic
BP in
intervention
group was
significantly
decreased, and
scores for
exercise, self-
efficacy and
behavior, and
health related
quality of life
were statistically
higher compared
to the control
group.
-self-behavior
-self-efficacy for
exercise
-physical activity
-health-related
quality of life
-BP readings
- short study period
of 12 weeks
-older adults who
had an interest in
the program were
included in the
study so motivation
level may have
been higher.
Level I
Quality B
#13
Schoenthaler,
et al., 2018
2-arm cluster
randomized
control trial
373 black
participants in
32 churches.
Intervention
group received
therapeutic
lifestyle
The
Motivational
interviewing
plus lifestyle
changes group
had a
significantly
greater systolic
- blood pressure
measurement at
6 months
(primary) and at
9 months
(secondary)
- duration of trial
was only 6 months
so difficult to
evaluate long-term
impact.
- Data collectors
were paid for their
Level I
Quality B
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 62
changes plus
motivational
interviewing.
Control group
received
general health
education
alone.
BP reduction at
6 months
compared to the
control health
education group
and persisted at
9 months.
time which makes
program
sustainability
difficult.
-30% attrition rate
-3:1 ratio of women
to men presented a
gender bias.
Running head: HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 63
Appendix C – Evidence-Based Theoretical Models
Figure C1: Health Believe Model
Source: University of Pennsylvania (n.d.)
Figure C2: The Logic Model
Source: Cooper & Zimmerman (2017)
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 64
Appendix D - Advertisement Flyer
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 65
Appendix E - Agreement with Project Site
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 66
Appendix F – Blood Pressure Measurement Competency
COMPETENCY: Blood Pressure Measurement
Hypertension Education Church Project Study Staff Nurse:_____________
Performance
Steps
Method of
Evaluation
Met
*Unmet
Evalu-
ator
Initials
and
Date
Study
Staff
Initials
and
Date
View video clip at:
http://www.nejm.org/doi/full/10.1056/n
ejmvcm08001 57.
View 100% of
video clip
Describe how to determine the correct
cuff size for the patient
• Identify rubber bladder in cuff
• Bladder covers 80%
circumference of arm
• Width of bladder 40%
circumference of arm
Return
Demonstration
Demonstrates correct patient
positioning
• Seated with feet flat on the floor
• Leaning against back of the chair
not on arm
• Arm fully supported,
brachial artery at heart level
• Upper arm bare, do not apply cuff
over clothing
Return
Demonstration
Demonstrates correct cuff placement
• Apply cuff snugly
• Center of bladder is
directly above brachial
artery
• Bottom edge of cuff is 1” above
elbow
Return
Demonstration
Demonstrates palpatory technique of
estimating BP
• Inflate manometer while
palpating radial pulse
• Note level at which radial pulse
disappears
Return
Demonstration
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 67
• Release air from cuff slowly
Demonstrates correct technique of
measuring BP
• Place stethoscope on brachial
artery
• Inflate cuff 20-30 mm Hg above
the point where radial pulse
disappeared
• Systolic reading – first two
consecutive sounds
• Diastolic reading – at the level
where the sound disappears, 2
mm Hg below the last sound
Return
demonstration or
verification with
instructor using a
teaching
stethoscope
Verbalizes 2 things that may alter BP
readings
• Caffeine • Smoking
• Medications • Pain
• Incorrect Cuff • Anxiety
• Bad Equipment • Talking
• Bad Pt. Positioning • Needing
to Urinate
• Incorrect Technique • Nurse
Bias
• Level of Brachial Artery
Verbal test
Verbalize the national standard for the
normal BP reading for an
adult…systolic <120 diastolic <80
Verbal test
• If performance step unmet, write action plan here:
Evaluator: _______________________________________
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 68
Appendix G - Permission to use HELM Knowledge Scale
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 69
Appendix H - Survey Tools
H1 - Demographic Data
1. What is your age?
a. 40-49
b. 50-59
c. 60-69
d. 70-79
e. 80 and older
2 What is your gender?
Male Female
3. What is your race or origin?
a. American Indian or Alaska Native
b. Asian American
c. Black/African American
d. White/European American
e. Hispanic origin
f. Other (please specify)
4. What is your highest level of education
a. Less than12
th
grade
b. High School or GED
c. College or higher
5. How long have you been told you have hypertension?
- Less than 3 months
- 3-months to 1 year
- 1 – 5 years
- Over 5 years
6. Do you smoke?
Yes No
7. Do you exercise regularly?
Yes No
8. Do you take blood pressure medication?
Yes No
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 70
H2 - Hypertension Evaluation of Lifestyle and Management (HELM) Knowledge Scale
Pre and Post Hypertension Knowledge Survey Questionnaire
The following questions are designed to test your knowledge of high blood pressure. You may
find many of them to be hard. This is OK, just do the best you can. We will give you the answers
to these at a later date.
Please circle the correct answer:
1.
A person is considered to have hypertension if either their SBP is
130 or higher or their diastolic is 80 or higher on two separate
occasions.
True
False
2.
Most people can tell when their blood pressure is high because they
feel bad.
True
False
3.
People with hypertension do not need to take medicine if they
exercise regularly.
True
False
4.
Most people with hypertension need more than one kind of blood
pressure medicine to control their blood pressure.
True
False
5.
Most of the salt Americans eat is added with a salt shaker.
True
False
Please choose only one answer for each of the following questions:
6. A man reports that his blood pressure (BP) is 148/78 when he checks it using the BP
machine in the pharmacy, 144/66 in his family doctor's office, and 132/74 when he checks it
at home. Which of the following statements is TRUE?
A. It is common for blood pressure readings to vary like this.
B. The highest blood pressure reading is the correct one.
C. The lowest blood pressure reading is the correct one.
D. He can be reassured that his blood pressure is normal.
7. Which one of the following increases your risk of having hypertension?
A. Weight lifting.
B. Drinking more than 2 cups of coffee a day.
C. Smoking a pack of cigarettes daily.
D. Gaining 15 pounds.
8. Blood pressure is measured with two numbers, an upper number and a lower
number. It is usually written as upper/lower. If someone is told that their goal blood
pressure is 126/76, when have they reached that goal?
A. When the upper is below 126 and the lower is below 76.
B. When the upper is below 126, even if the lower is over 76.
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 71
C. When the lower is below 76, even if the upper is over 126.
D. When the average of the upper and the lower is less than 100.
9. An overweight 60-year old man has hypertension. He drinks one bottle of beer and 4
cups of regular coffee a day. He adds regular table salt to his food at most meals. Which
one of the following changes is the most likely to lower his blood pressure?
A. Lose 10 pounds.
B. Stop drinking alcohol.
C. Switch to decaffeinated coffee.
D. Switch to sea salt.
10. Uncontrolled hypertension can lead to which of the following:
A. Lung cancer.
B. Kidney failure.
C. High cholesterol.
D. Diabetes.
11. Which of the following statements about taking blood pressure medicine is TRUE?
A. Blood pressure medicine should always be taken with food.
B. More than one type of blood pressure medicine can be taken at the same time.
C. Blood pressure medicine works best if it is taken at bedtime.
D. Blood pressure medicine should not be taken if a person drank alcohol that day.
12. When measuring your blood pressure at home, you should:
A. Always take your reading before you take your blood pressure medicine.
B. Take several readings, a minute or two apart, and record the lowest one.
C. Take your blood pressure right after exercising and at least two hours after a meal.
D. Take two readings, a minute or two apart, and write down the average value.
13. Which one of the following changes to your diet is most likely to lower blood
pressure?
A. Eat more fruits, vegetables, whole grains and low fat dairy products.
B. Eliminate spicy foods.
C. Drink one glass of red wine daily.
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 72
D. Drink herbal tea instead of coffee.
14. Which one of the following statements about exercise and blood pressure is TRUE?
A. People who are on their feet most of the day will not benefit from more exercise.
B. Exercising for 30 minutes every day lowers blood pressure more than exercising for
30 minutes, 3 days a week.
C. Weight lifting should be avoided by people with high blood pressure.
D. When exercising, you must raise your heart rate to at least 100 beats a minute to
improve blood pressure.
Source: Shapira, et al., (2012). The development and validation of the hypertension evaluation of
lifestyle and management knowledge scale. Journal of Clinical Hypertension, 14(7), 461-466.
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 73
H3 - Pre and Post Lifestyle Behaviors – Salt Intake and Exercise
1. During the past month, other than your regular job, did you participate in any physical
activities or exercises such as running, calisthenics, golf, gardening, or walking for
exercise?
___Yes
___ No
___ Don’t know/not sure
___ Refused
2. How many times per week or per month did you take part in this activity during the past
month?
___Times per week
___Times per month
___ Don’t know/not sure
___ Refused
3. And when you took part in this activity, for how many minutes or hours did you usually
keep at it?
___Hours and minutes
___ Don’t know / Not sure
___ Refused
4. Are you currently watching or reducing your sodium or salt intake?
___ Yes
___ No
___ Don’t know/not sure
___ Refused
5. If yes, how many days or weeks in the last month have you been watching or reducing
your sodium or salt intake?
___Day(s)
___Week(s)
___Don’t know/not sure
___Refused
Source: Centers for Disease Control and Prevention (2014) 2015 Behavioral risk factor
surveillance system questionnaire. Retrieved from
https://www.cdc.gov/brfss/questionnaires/pdf-ques/2015-brfss-questionnaire-12-29-14.pdf
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 74
Appendix I – Project Timeline
Project Activity
Project Months
August 2019 – April, 2020
8
9
10
11
12
01
02
03
04
05
Obtain IRB approval
X
Meet with Pastors, Parish Nurse and other
team members to finalize plans for
recruitment and ongoing meetings during
implementation phase
X
X
X
X
Purchase blood pressure devices, and meet
with team members for training, and
explore best data/times for project
implementation with church officials
X
X
Develop modules for intervention.
Duplicate tools, assemble hypertension
materials take home.
X
X
Post/publish recruitment flyers and
conduct screening and enrolment (over 3-4
weeks). Develop program schedule for
project implementation
X
Implement intervention, collect data
X
X
Collaborate with Statistician to organize
and input data
X
X
X
Analyze data
X
X
Evaluation/summary of project
outcomes/findings
X
X
Final written DNP report
X
Preparation and presentation/defense of
project
X
X
Disseminate results of project
X
Conduct debriefing session with the entire
project team and to identify barriers and
facilitators for sustainability
X
Send out thank you letters to project team
and participants.
X
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 75
Appendix J - Evaluation Planning Matrix
Overall Program
Objective
Evaluation plan
Methods
Improve participants’
knowledge about
hypertension
Increase participants
knowledge of
hypertension by
providing education
All participants
increase will have a
significant increase in
their knowledge score
from baseline
Compare pre
and post- test
HELM
knowledge
scores using
paired t-tests
Improve participant’s
lifestyle behaviors
Increase number of
minutes participants
exercise and increase
number of days
participants watch or
reduce their
salt/sodium intake
All participants will
increase the number
of minutes they
exercise per week
and decrease the
number of days the
watch or reduce their
salt intake
Compare pre
and post
intervention
self-reported
lifestyle
behaviors using
paired t-test
Improve participants’
blood pressure
measurements
Decrease in blood
pressure
measurements
All participants
decrease their
immediate and 2
weeks post-
intervention systolic
and DBP from
baseline
Compare pre-
and post-
intervention
measurements
and 2 weeks
post
intervention
follow-up
measurements
using repeated
measure
ANOVA test
Process Measures
Objective
Evaluation plan
Methods
Feasibility of a
hypertension educational
program to improve
knowledge and blood
pressure control
Increase in
participants’
knowledge and
improve blood
pressure control
-Percentage of
participants who
completed the study
intervention
-Percentage of
participants who
dropped out prior to
completing the study
-Percentage of people
who were willing to
participate in the
study
-Percentage of
participants who were
Categorical data
HYPERTENSION EDUCATION IN A FAITH-BASED SETTING 76
satisfied with the
program
Identify barriers
Identify barriers that
may prevent the
successful
implementation of this
program
Components of the
program that were
identified at barriers
to implementation
process
Qualitative
discussions and
observances by
project team
Successfully involve
stakeholders
Include senior pastors
and parish nurse in the
project team to get
buy-in and support
and serve as change
champions
Stakeholders
supported the
program 100%
Categorical
data- level of
support
Structure
Objective
Evaluation plan
Methods
Supportive leadership,
parish nurse, technology
and space to support
health promotion program
Successful
implementation of a
health promotion
program for
management of
hypertension
-100% leadership
support
-100% Parish nurse
support
-Availability of
audiovisual
equipment
-Availability of a
comfortable and
spacious room to
conduct education
sessions
Yes
No
