1
KNOWLEDGE AND CONTROL OF HYPERTENSION IN THE
YOUNG ADULT POPULATION
by
Marycar Baniaga
A project
submitted in partial
fulfillment of the requirements for the degree of
Masters of Science in Nursing
May 2021
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TABLE OF CONTENTS
Page
CHAPTER 1: INTRODUCTION ............................................................................. 3
Background ....................................................................................................... 3
Problem Statement ............................................................................................ 3
Significance of the Study .................................................................................. 4
Definitions ......................................................................................................... 5
Theoretical Framework ..................................................................................... 5
CHAPTER 2: LITERATURE REVIEW.................................................................. 8
Barriers .............................................................................................................. 8
Strategies ......................................................................................................... 11
CHAPTER 3: METHODOLOGY .......................................................................... 15
Study Design, Study Setting ........................................................................... 16
Population, Instrumentation ............................................................................ 16
Data Collection ................................................................................................ 17
Data Analysis .................................................................................................. 18
CHAPTER 4: RESULTS........................................................................................ 18
First-Level Heading.............................................................................................
First-Level Heading.............................................................................................
First-Level Heading.............................................................................................
REFERENCES ....................................................................................................... 19
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CHAPTER 1: INTRODUCTION
Background
High blood pressure is often referred to as a silent killer. Nearly half of American
adults have high blood pressure. Most of the time hypertension (HTN) or high blood
pressure has no obvious symptoms that indicate that something is wrong. Often times the
signs and symptoms are misunderstood and many people with high blood pressure don’t
even know they have it. High blood pressure develops slowly over time and can be
related to many causes. High blood pressure cannot be cured, but it can be managed
effectively through lifestyle changes and when needed, medication. If left untreated, the
damage that high pressure does to the circulatory system is significant and can lead to
heart attack, stroke, and other health threats. It is crucial to be aware of your own risk
factors because certain physical activities and lifestyles can make a person more likely to
develop high blood pressure. Awareness of risks can help identify changes that can be
made.
Problem Statement
Blood pressure control rates among the young adult population in the United
States is disturbing. High blood pressure is interchangeably referred to as hypertension,
which is a common and manageable chronic disease. It is a disease process that can be a
preventable risk to heart disease, chronic kidney disease, and stroke. According the CDC,
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“In 2018, nearly half a million deaths in United States included hypertension as a primary
or contributing cause” (Fryar et al., 2017).
Blood pressure control can reduce morbidity and health care cost in young adults.
Unfortunately, studies point out the key fact that the adult population between ages 18-39
have the poorest hypertension (HTN) controlled rates. Overall research suggests that
hypertension awareness and control remained low in this population group. My research
question is “Why is it that the young adult population between the ages 18-39 have the
poorest controlled hypertension (HTN)?
Significance of the study
Hypertension among young people remains common, affecting 1 in 8 adults aged
20-40 years. While more prevalent in the older population, an increasing amount in the
younger population is being observed. NHANES conducted a study that compared young
adults with middle-age and older adults. The study showed from 2013 to 2014, 7.3 % of
young adults in the U.S had hypertension. And from 1999-2014, young adults
experienced an increase in awareness, treatment and control than older adults. However,
even with the increase in awareness and management, young adults still remained lower
than older adults. The increasing incidence of hypertension in the young adult population
calls for early surveillance and prompt treatment to prevent future heart diseases. This
study will hopefully provide guidance and education for healthcare providers to help
assist patients in this age population who are seeking information on how to control high
blood pressure.
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The purpose of this study is to collect data regarding the awareness/knowledge of
the young adult population and strategies used to control their blood pressure in the
young adult population ages 18-40. Once barriers are identified then we can explore
strategies to improve self-management.
Definitions
HTN- (hypertension) high blood pressure
NHANES- National Health and Nutrition Examination Surveys
CDC- Center for Disease Control
DASH- Dietary approaches to stop hypertension
Theoretical Framework
Nursing theories are essential in providing principles that guide the proper care
for our patients. The benefits of having a well-defined theory in nursing includes better patient
care, enhanced professional status for nurses, improved communication between nurses, and
guidance for research and education (Nolan et al., 1998). High blood pressure at an early age is
associated with an increased risk of cardiovascular disease and mortality later in life. Therefore,
control of hypertension provides a critical chance to effectively prevent the occurrence of
adverse cardiovascular events in later life. When we look at the young adult population, there are
important aspects of their lives that need to be considered such as unique barriers, personal
factors, and environmental aspects. These aspects of a patient’s wellbeing fall into the hands of
nurses and other health care providers to find ways to address these needs. The two theories that
will be discussed in this paper are The Health Promotion Model (HPM) by Nola J. Pender and
the use of Trajectory of Chronic Illness theory by Corbin and Strauss.
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The Health Promotion Model by Nola J. Pender focuses on three categories: “Individual
Characteristics and Experiences”, “Behavior-Specific Cognitions and Affect”, and “Behavioral
Outcome” (Nolan et al., 1998). Health promotion’s primary focus is to increase a patient’s level
of well-being. The health promotion model describes the multidimensional nature of persons as
they interact within their environment to achieve health. ++In this model, a person’s health by
acknowledging the individual characteristics and experiences. Personal factors are defined as
those distinguishing characteristics which might affect behavior. These personal factors include
biological, psychological, and sociocultural+.
Second the model examines how a specific behavior is perceived by the individual,
whether it seems obtainable, and how the behavior affects the person’s relationship with others,
along with other factors. Using this information obtained, a healthcare provider can help develop
a plan of action the person may be able to comply and commit to. In this study (Alefan et al.,
2019) only 23% of the patients were fully adherent to healthy lifestyle behaviors. This low rate
could be due to the poor relationship between the patient and the healthcare provider and/or lack
of support from family and friends. There is a collaborative effort from both the nurse and the
patient in which the nurse can assist the patient in changing behaviors to allow healthier lifestyle.
Building a great rapport with the patient leads to successful outcomes. The purpose of health
promotion is to empower the individual to have more control of their disease and their
lives (Whitehead, 2003). This can be applied to the study of the adherence to health promotion
activities to help control hypertension in the young adult population.
Lastly the model examines behavior outcome. The patient will commit to the plan of
action designed and agreed upon by the nurse and the patient. A health-promoting behavior is
defined as a behavior, which is “ultimately directed toward attaining positive health outcomes for
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the client” (Nolan et al., 1998). Lifestyle counseling by the healthcare provider about diet, weight
loss, physical activity, and smoking can play an important role in promoting a healthy lifestyle.
This last phase takes into consideration numerous aspects when determining the likelihood of an
individual engaging in health promoting or adherence behaviors to help hypertension control.
“Trajectory Theory views the patient as ‘self’ in the context of a chronic illness that has a
course or trajectory that varies and changes over time” (Granger et al., 2006). Major concepts of
the theory include goals for care designed to achieve those goals, implementing the plan of care,
conditions influencing management, and the fluctuations in clinical outcomes. The first step is to
set a goal. The caregivers of the young adult population diagnosed with hypertension should be
aware that the experience of the patient from this illness may change and should focus on signs
and symptoms separate from emotional experiences. Second, we have to plan the care of an
individual diagnosed with hypertension. The regimen can include prescribed medications for
hypertension, and sometimes that requires taking more than one pill, obtaining, recording, and
monitoring blood pressures, and diet restrictions such as limiting salt, and exercise
modifications. Healthcare providers see a relationship between adherence to the regimen and the
decreased frequency or exacerbations of symptoms. Many patients and family members are not
always aware of that. In the literature review some of the young adults stopped taking their
medications because some did not like the way it made them feel, but also because some did not
have symptoms so they do not take it at all. Unfortunately, sometimes they wait until they have
an exacerbation, like chest pain, headaches, and dizziness to realize they have to take their
medication. Third is being able to maintain that goal. Young adults have so many barriers and
factors that affect their ability to manage their illness on any given day. By carefully assessing
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the patient’s view of self, in conjunction with observed signs and reported symptoms, a more
cohesive and collaborative plan can be formulated in order to address these barriers.
In conclusion, hypertension is no longer limited to middle to older age adults. Now more
young adults have been diagnosed with this disease, stressing the importance of hypertension
awareness and lifestyle interventions early in life (Berg, 2019). Through the use of both theories,
healthcare providers can identify barriers and develop an individualized plan--a reasonable plan-that will help control their blood pressure. By doing so the healthcare providers can help the
individual set a goal that both parties can agree on, one that is achievable, and finally one that
directs the individual to a healthier lifestyle.
CHAPTER 2: LITERATURE REVIEW
There are many barriers that can affect the patients’ ability to understand the longterm effects that high blood pressure can cause. The lack of knowledge and lack of
control of hypertension in the young adult population go hand in hand. Hypertension has
become a worldwide health care concern that has contributed to preventable deaths.
Interventions addressing specific barriers of young adult population are needed to
improve hypertension control. Moreover, education needs to be provided to the patient
population regarding hypertension management. The literature review was divided into
two categories, barriers and strategies
Barriers
A study was done to gain a better understanding on barriers to hypertension
diagnosis, treatment (lifestyle and medication), and control in young adults. It was
comprised of primary care providers who were actively managing young adults with
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uncontrolled hypertension. A total of sixteen questions was used to guide them in a semi
formal one on one interview. These questions were to help identify practice barriers and
knowledge gaps on hypertension and control clinical care for young adult population
(Johnson et al., 2017). The results strongly imply visit adherence, sick identity, and
medication initiation. Visit adherence was an important issue not just for diagnosis and
control of hypertension, but also as safety issue when prescribing blood pressure
medication to young adults. Second, a “sick identity” was projected onto young adults
with elevated blood pressures. Third, some providers were surprised that the study
showed medication initiation lead young adults to unhealthy lifestyle behaviors, which
resulted in delays in their care. These factors identified the need for team-based care to
support ongoing lifestyle modification counseling, even between visits, to support a
combined approach to hypertension control. One limitation is that this study only looked
at the young adults who had access to regular primary care. Overall, there is a need find
an approach that addresses these barriers and change how a hypertension diagnosis is
delivered among the young adult. Furthermore, the need for ongoing support for selfmanagement needs to be addressed (Johnson et al., 2017).
The reports in this article used data from the National Health and Nutrition Examination
Survey. They examined the awareness and medication treatment of uncontrolled hypertension
among adults and divided it even further by categories. They focused on three subcategories.
First, those who are unaware of their hypertension, second, those who are aware but not treated
with medication, and third those who are aware and treated with medication but still have
uncontrolled hypertension. Among adults with uncontrolled hypertension, 39.4% were unaware
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of their hypertension, 64.3% of those without a usual source of health care,56.6% in adults aged
18-44 years, and 51.9% of those without health insurance. An estimated 15.8% were aware but
not pharmacologically treated for hypertension; the prevalence of being aware yet untreated for
hypertension was highest among those without a usual source of health care and adults aged 1844 years” (Valderrama et al., 2012).
This article emphasized that “the major patient barrier to hypertension care and control
stems from resistance to treatment recommendations, especially in low-income minority
groups”(Hill & Sutton, 2000). This may be related to the various methods to control
hypertension lack cultural relevance among minority groups. Another major barrier to
hypertension control is physician related. In conclusion they believe that physicians are reluctant
to treat aggressively. And that physicians believe that education is an essential component to
helping patients control their hypertension. However, research shows that education alone is not
enough to address barriers other than lack of knowledge and misunderstanding (Hill & Sutton,
2000).
The purpose of the study was to compare rates and predictors of antihypertensive
medication initiation between young adults and middle-age and older adults with hypertension
with regular primary contact. In addition to young adults having the lowest prevalence on blood
pressure control they also have a slower rate at initiation of medication treatment. The study
suggest that medication treatment is not well understood in young adults. This maybe an
important intervention to increase the control in young adults who require medication treatment.
The majority of young adults with incident hypertension and regular primary care had untreated
and uncontrolled hypertension (Johnson et al., 2014).
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A study was conducted in 3 different family medical clinics in different counties from
Wisconsin. They stressed the importance of identifying barriers to hypertension control specific
to young adults and develop effective interventions. Understanding young adult population
between the ages 18-39 and their unique perceptions about high blood pressure and perceived
barriers to control the disease is critical to help aid in blood pressure control. A common theme
of words such as surprised, scared, and angry were all descriptions of emotions by the patients
when they were diagnosed with high blood pressure. In conclusion all the young adult
participants named at least one complication associated with hypertension but none of them were
able to identify that chronic kidney disease as a complication (Johnson et al., 2016). If patients
are not able to identify the complications that hypertension can potentially cause than they will
more likely not know that controlling their blood pressure is extremely important.
Strategies
The study focused on the association between clinic blood pressure encounter
(average number of provider visits with blood pressures over time) and hypertension
control rates among young adults who have hypertension. The study revealed that when
the patients came back for follow up in less than a month the blood pressure control rate
in this population was higher than those that came back with a longer wait period for their
next follow up. They also suggest that shorter intervals between follow up appointments
could be an effective tool to help increase the rate for hypertension control among the
young adult population (King et al., 2017).
A randomized study was conducted at a university that included 298 students at
risk for hypertension. The study compared stress reduction with the transcendental
meditation (TM) program and its effects on control or change in BP, psychological
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distress, and coping in young adults. The results showed how the transcendental
Meditation (TM) program, a widely used mind body approaches to reduce psychological
distress, significantly reduced blood pressure in participants. A strength in the methods
used in this study was the sizable racially diverse subject sample it tested. In conclusion,
the TM program significantly decreased BP in association with improved psychological
distress and coping ability in young adults at risk for hypertension. In addition, there were
improvements in mental health in the general student sample and trends toward reduction
of BP. Practice of this mind–body intervention may be an effective method to reduce
psychological distress, BP, and the risk for development of hypertension in high-risk
young adults (Nidich et al., 2009).
This article points out that for the past 25 years, there has been significant progress
in detecting, treating, and controlling hypertension. Nevertheless, the management of this
disease remains suboptimal, and control of high blood pressure is inadequate for more
than half of the 60 million Americans who have hypertension. In summary, (Clark &
Afflu, 1995) believes that, compliance may be enhanced by improving physician and
patient communication, encouraging both physician and patient to make a commitment to
long-term blood pressure control, and selecting an affordable, convenient, and effective
treatment plan that has minimal adverse effects on the patient’s quality of life (Clark &
Afflu, 1995).
This study did not cover the young adult population but it did give general
information on the overall benefits to the DASH diet. This study looked at a primary
care setting in Hong Kong. They studied patients ages 40-70. DASH is an acronym for
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Dietary Approaches to Stop Hypertension. It has been shown to lower blood pressure
in the west. The DASH diet encourages high intake of whole grain, vegetables, fruits,
and low fat as well as sodium restrictions. The randomized study wanted to see if
newly diagnosed hypertension should be referred to dietitian care for early DASH
counselling or just be offered brief advice on fundamental dietary facts from primary
care physician. They hypothesize that one dietary counselling by dietitian base on the
DASH recipe could reduce estimated 10-year cardiovascular risk among hypertensive
patients in real clinical setting. The findings of the study may not support automatic
referral to diet counseling. The study was limited because it was only focused on
Chinese ethnicity. They concluded that none of the individual cardiovascular risk
factors was significantly different between the two groups at baseline and 12 months.
No significant between group differences were detected for the blood pressure
reductions. The two groups also did not report any significant differences in the
changes of cardiovascular risk at 6 months and 12 months (Wong et al., 2016).
The article focused on giving informational insight on the benefits for therapeutic
lifestyle changes. This study focused on the African American population. TLC includes
diet modification, physical activity, and weight management. They strongly believe that
TLC should be part of hypertension management. TLC should continue to be
recommended in the prevention of hypertension and as an adjunct to pharmacotherapy in
patients with high blood pressure. “Many types of interventions for TLC have scientific
evidence demonstrating they can improve BP control. However, many factors may
impede or facilitate the adoption or maintenance of TLC, including characteristics of and
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relationships between the patient, provider, recommended therapy, and environment”
(Scisney-Matlock et al., 2009). In conclusion, patient self-management needs to be
supported by providers, family, and community to overcome barriers to patients making
therapeutic lifestyle changes.
According to national data surveys suggest that only 1/3 of patients with
hypertension have their pressure controlled to recommended levels. This study wanted to
focus on “the assessment of the relationship between gender and hypertension control by
age. They compared men and women in three age group populations: 18-49 years
(young), 50-64 years (middle) and greater than 65 years (older).” (Daugherty et al., 2011)
The primary variable for all analysis was patient gender. Other multivariable models
included age, race/ethnicity etc. The study concluded that younger men and older women
have lower rates of hypertension control compared to women and men of similar age
(Daugherty et al., 2011).
This article performed a new systematic review and meta-analysis to evaluate the quality
of the evidence base and effectiveness of exercise intervention to reduce blood pressure in
younger adult populations. The article suggest that young adult population and public groups
highlight that lifestyle interventions remains a favorable approach to controlling blood pressures.
One limitation of this study is that the majority of the studies reported more than 80 %
compliance at the 3 to 6 months but compliance with behavioral targets dropped to about 40%
beyond 12 months. The review raises concerns regarding the assumption that exercise will
improve blood pressure in young adult, however, the available evidence suggest that current
intervention strategies do not maintain long-term benefits (Williamson et al., 2016).
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This article focuses on several non-pharmacological interventions that are effective in
reducing the blood pressure. It emphasizes the effectiveness of interventions that include
physical exercise, reduction in salt intake, and yoga among young adults (Saptharishi et al.,
2009). They checked blood pressure pre intervention and post intervention. In conclusion the
study has highlighted the effectiveness of physical exercise, salt intake reduction and yoga in
prevention and control of hypertension among young adults (Saptharishi et al., 2009).
Knowledge and control of hypertension in young adult population must be improved
through patient education. Going forward there seems to be a need for strategic overhaul of the
approaches implemented in knowledge and self-management of young adult blood pressure. The
initial steps that can be made is assessing each patients’ understanding and providing better
education.
CHAPTER 3: METHODOLOGY
The purpose of this study is to collect data regarding the awareness/knowledge of the
young adult population and strategies used to control their blood pressure. Hypertension is a
major factor for cardiovascular disease. The prevalence of hypertension will likely increase by
by 2025.The study will investigate gender disparities in hypertension among a sample of young
adults and examine gender disparities in hypertension awareness and control.
Study Design
The design of the study is a descriptive, quantitative design. This will assess the rates of
awareness, treatment, and control among hypertension in young adult patients. It will evaluate
the knowledge and strategies that are used to help control their blood pressure but it will compare
gender differences. The study will use a survey for hypertensive patients from the World Health
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Organization website. The survey will be in English and an IRB approval will be obtained from
California State Fresno Health Center prior to starting the study.
Study Setting
The Study setting will be conducted at Fresno State Health Center Clinic in Fresno
California. The researcher will ask for permission to conduct the study prior to commencing the
study. The Fresno Health Center Clinic provides primary care to enrolled college students at
Fresno State. The patients are of all ages and can be seen for acute, chronic, or preventative care.
The reason for the study will be explained to the participants and directions will be given on how
to complete the survey that is provided.
Population
The study sample will consist of a minimum 32 participants that are college students who
are patients at the Fresno State Health Center. The inclusion criteria will include adults ages of
18-40 and have been diagnosed with hypertension. They must provide consent to participate in
the study. They must speak and read English. Exclusion criteria will be those that are not
between the ages of 18-40 and patients without a diagnosis of hypertension.
Instruments
A written informed consent will be provided to each participant with the understanding
that collected data would be confidential and used only for statistical data. Participants will be
given the option to be part of the study. Blood pressure monitor in clinic will be used to take the
patient’s blood pressure. A pen and printed copy of the survey for hypertensive patients from the
World Health Organization will be provided to each participant.
Data Collection
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Participants will be chosen by asking them if they want to participate in a short study to
assess awareness, treatment and control of hypertension among the young adult population. The
participants will remain anonymous, participation is voluntary, and no compensation is offered.
Subjects will be approached at the clinic while waiting for their appointment. Participants will
receive an explanation of the study, who is conducting the research and why the study is being
conducted. Each participant will be provided the paper that consist of 23 questions and pen to
complete the survey.
Directions on how to complete the questionnaire will be reviewed with each participant.
Participants will be asked to answer each question by marking an answer. This questionnaire
should take no more than five minutes to complete.
There are no potential physical, economic or legal risks. We will ask the patient to
identify male or female gender at the time of the survey. No other identifiers will be used by the
researcher to maintain confidentiality. The questionnaire and any associated data will be kept in
a locked file and shredded upon completion of the study. Only the researcher will have access to
the data.
A trained MA from Fresno state health center will take blood pressure at the time of the
visit. Patient will be in a sitting position and an automatic blood pressure monitor along with the
patient’s cuff size will be used to measure patient's blood pressure.
Hypertension awareness will be defined in how they answer to questions 1-4 on
questionnaire. Hypertension control will be defined as current blood pressure reading below
systolic blood pressure of less than 140 mm Hg and diastolic blood pressure of less than 90 mm
Hg.
Data Analysis
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The analysis of the study will be conducted by using the IBM Statistical Package for the
Social Sciences (SPSS) predictive analytics software. The p-value will be obtained to determine
the level of error in the date collected. The data will weigh gender differences of hypertensive
patients and compare the prevalence of awareness, treatment, and control among hypertensive
patients in different categories will be conducted using Chi-square test.
CHAPTER 4: RESULTS
Our results show that the gender disparities in hypertension are evident
among men and women in their twenties. Men are more likely to be hypertensive
compared to women (N% vs N%). The results also reveal that hypertension awareness
among women (N% of were aware of their hypertensive status) and even lower among
men (N%). We found that gender is associated with hypertension awareness and control.
Given the overall results of hypertension awareness among young adults, public
health policymakers should focus on interventions to improve hypertension awareness
among young adults, both men and women.
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