Implementation Strategies to Improve Blood Pressure Control in the United States: A Scientific Statement From the American Heart Association and American Medical Association.

Hypertension is one of the most important risk factors that contribute to incident cardiovascular events. A multitude of US and international hypertension guidelines, scientific statements, and policy statements have recommended evidence-based approaches for hypertension management and improved blood pressure (BP) control. These recommendations are based largely on high-quality observational and randomized controlled trial data. However, recent published data demonstrate troubling temporal trends with declining BP control in the United States after decades of steady improvements. Therefore, there is a widening disconnect between what hypertension experts recommend and actual BP control in practice. This scientific statement provides information on the implementation strategies to optimize hypertension management and to improve BP control among adults in the United States. Key approaches include antiracism efforts, accurate BP measurement and increased use of self-measured BP monitoring, team-based care, implementation of policies and programs to facilitate lifestyle change, standardized treatment protocols using team-based care, improvement of medication acceptance and adherence, continuous quality improvement, financial strategies, and large-scale dissemination and implementation. Closing the gap between scientific evidence, expert recommendations, and achieving BP control, particularly among disproportionately affected populations, is urgently needed to improve cardiovascular health.

Promoting physical activity in clinical practice through wearable technology.

ABSTRACT: The negative health consequences of physical inactivity continue to be a global problem that must be addressed from the highest levels of government down to local primary care providers. Physical activity has been identified as a useful patient vital sign in health care. Advanced practice nurses should aggressively prescribe physical activity as an evidence-based intervention to help mitigate the increased mortality and morbidity associated with a sedentary lifestyle. A focused literature review was conducted using PubMed, CINAHL, and the Cochrane online databases. Fitness wearables and mobile health trackers are a catalyst for lifestyle behavior change and cultivate a health care partnership between the patient and their provider. The evolution of fitness wearables into mainstream health care hinges on the ability of devices to integrate into electronic health records, uniformity of manufacturer standards, intuitiveness, and the assurance of user privacy and security. It is incumbent on nurse practitioners to educate themselves about the reliability and practicality of fitness trackers for their patient population. Future research should focus on adopting quality standards for all consumer devices, the seamless integration of device data into electronic health records and ensuring personal privacy and security.

Engagement and Advocacy of Community-Based Organizations Serving Older Adults in Native American, Rural, and Homeless Communities During the COVID-19 Pandemic.

Older adults in Native American, rural, and homeless communities have been disproportionately affected by the Coronavirus Disease 2019 (COVID-19) pandemic due to structural and systemic inequities. However, community-based organizations (CBOs) serving these older adults are well positioned as frontline responders and trusted messengers to support their needs and provide vital services that enable them to stay safe. This commentary argues that CBOs are essential for engaging with and responding to community needs during a pandemic. The work of three CBOs is spotlighted to elucidate the importance of partnerships and trust in disseminating strategies for responding to and mitigating pandemic impacts.

Role of Socioeconomic Factors on Physical and Mental Distress Reported by Alabama Adults with COPD.

OBJECTIVES: Educational attainment, income, and race play significant roles in managing and treating patients with chronic obstructive pulmonary disease (COPD). The purpose of this study was to evaluate the impact of these socioeconomic factors and others on the physical and mental distress reported by patients with COPD living in Alabama. METHODS: A cross-sectional analysis was completed of Alabama Behavioral Risk Factor Surveillance System 2015-2019 data collected from 4123 respondents who reported that a health professional told them they had COPD, chronic bronchitis, or emphysema. Univariate analyses examined descriptive differences in physical and mental distress among racial groups. Multivariable logistic regression models were used to assess physical and mental distress as a function of race and demographic variables (age, sex, employment status, household income, education level), controlling for dichotomous healthcare access variables (enrollment in a health insurance plan, having a usual source of care, routine check-up in the past 2 years). RESULTS: Most Alabama adults with COPD from 2015 to 2019 were female (64%) and older than 45 years (88%). Annual incomes were low, with >40% of respondents (43.84%) earning <$20,000/year; adults making between $35,000 and $49,999 were less likely (odds ratio 0.60, 95% confidence interval 0.38-0.96) to experience mental distress. Younger Alabama adults with COPD (25-64 years) were approximately two times more likely than respondents ages 65 and older to report mental distress. African Americans were less likely to report physical distress as compared with Whites (odds ratio 0.61, 95% confidence interval 0.44-0.83). Alabama adults who could not work were more likely than those with COPD who were employed/self-employed, out of work, retired, or identified as homemakers to report physical distress. CONCLUSIONS: Public health and healthcare practitioners across Alabama should use these analyses to direct more targeted, high-yield interventions that will address existing health disparities among state residents living with COPD.

Depressive Symptoms and Risk of Stroke in a National Cohort of Black and White Participants From REGARDS.

OBJECTIVE: The purpose of this study was to examine depressive symptoms as a risk factor for incident stroke and determine whether depressive symptomatology was differentially predictive of stroke among Black and White participants. METHODS: The study comprised 9,529 Black and 14,516 White stroke-free participants, aged 45 and older, enrolled in the REasons for Geographic and Racial Differences in Stroke (2003-2007). Incident stroke was the first occurrence of stroke. Association between baseline depressive symptoms (assessed via the 4-item Center for Epidemiologic Studies Depression Scale [CES-D-4]: 0, 1-3, or ≥4) and incident stroke was analyzed with Cox proportional hazards models adjusted for demographics, stroke risk factors, and social factors. RESULTS: There were 1,262 strokes over an average follow-up of 9.21 (SD 4.0) years. Compared to participants with no depressive symptoms, after demographic adjustment, participants with CES-D-4 scores of 1-3 had 39% increased stroke risk (hazard ratio [HR] = 1.39, 95% confidence interval [CI] = 1.23-1.57), with slight attenuation after full adjustment (HR = 1.27, 95% CI = 1.11-1.43). Participants with CES-D-4 scores of ≥4 experienced 54% higher risk of stroke after demographic adjustment (HR = 1.54, 95% CI = 1.27-1.85), with risk attenuated in the full model similar to risk with 1-3 symptoms (HR = 1.25, 95% CI = 1.03-1.51). There was no evidence of a differential effect by race (p = 0.53). CONCLUSIONS: The association of depressive symptoms with increased stroke risk was similar among a national sample of Black and White participants. These findings suggest that assessment of depressive symptoms should be considered in primary stroke prevention for both Black and White participants.

Heart Health in Teachers-Do We Need to Know More?

OBJECTIVES: To evaluate the relationship between the prevalence and risk factors for cardiovascular disease and hypertension, physical activity, and mental health in teachers. METHODS: Data were drawn from the 2011-2012 National Health and Nutrition Examination Survey. A series of analyses were conducted utilizing exploratory data analysis, nominal logistic regression, and multivariate regression analysis. RESULTS: The study sample included 148 participants. The results showed that an increase in age and BMI contributed to an increase in high blood pressure. Significance was not seen between physical activity, anxiety, and mental well-being as they related to cardiovascular disease and teaching. CONCLUSIONS: Our results showed that the prevalence of cardiovascular disease and hypertension could be related to the occupation of teaching; however, additional research should be done to assess the relationship between the occupation of teaching and cardiovascular disease.

"I'm scared": Journaling Uncovers Student Perceptions Prior to a Psychiatric Clinical Rotation.

BACKGROUND: The United States is experiencing a shortage of mental health practitioners. A growing body of evidence shows that nursing students state that mental health is among the least desirable specialties, citing anxiety as a prominent factor. This study builds on existing knowledge and seeks to understand undergraduate nursing students' goals and perceptions about mental health prior to a mental health course utilizing a semistructured clinical journal. AIMS: To explore undergraduate nursing students' goals and perceptions in order to develop strategies that may positively influence students' thoughts about mental health nursing. METHOD: Utilizing qualitative methodology, students' journal entries (n = 90) were coded into keywords by frequency, forming the basis of themes in this study. RESULTS: Analysis found that nursing students are primarily concerned with their ability to communicate effectively with mental health patients, leading to fears about the upcoming mental health practicum. Although not prompted, students also discussed various stigmas surrounding mental health patients and disorders. CONCLUSION: Students enter the mental health course and practicum with a variety of preconceptions. Nurse educators play a central role in identifying and developing psychoeducational strategies to address student concerns and increase students' interest in mental health nursing.

An Innovative Academic/Service Partnership to Increase BSN-Prepared RNs in a Rural Hospital.

Developing innovative ways to increase BSN-prepared nurses in hospitals in rural regions is a struggle. A partnership between 1 hospital and a local university to support the associate-degree new graduates to progress toward their BSN is proving to be a success.

Psychosocial Factors and Behaviors in African Americans: The Jackson Heart Study.

INTRODUCTION: There are limited reports on the association of psychosocial factors with unhealthy behaviors, which are key mediators in the psychosocial-cardiovascular disease pathway. The Jackson Heart Study was used to examine the associations of multiple psychosocial factors with behaviors among African Americans. METHODS: The Jackson Heart Study is a prospective, cohort study of cardiovascular disease among African Americans recruited from the Jackson, MS, metropolitan area between 2000 and 2004. Between 2015 and 2016, multivariable regression was used to analyze the cross-sectional associations of baseline negative affect (cynicism, anger-in, anger-out, and depressive symptoms) and stressors (global stress, Weekly Stress Inventory-event, Weekly Stress Inventory-impact, and major life events) with the odds of current smoking and mean differences in dietary fat intake, physical activity, and hours of sleep. RESULTS: Men were more likely to smoke than women (p<0.001) and had higher physical activity scores (p<0.001). Women reported more hours of sleep (p=0.001). In fully adjusted models, each negative affect and stress measure was significantly associated with an increased odds of current smoking. For example, the odds of smoking increased by 14% for each 1-SD increase in cynical distrust score (OR=1.14, 95% CI=1.01, 1.27) in the fully adjusted model. Further, each negative affect and stress measure (except anger-out) was significantly associated with fewer hours of sleep in fully adjusted models. CONCLUSIONS: Using a large sample of African Americans, this study found that multiple psychosocial risk factors were associated with unhealthy behaviors that are prevalent among this population.

Psychosocial Factors Are Associated With Blood Pressure Progression Among African Americans in the Jackson Heart Study.

BACKGROUND: Research that examines the associations of psychosocial factors with incident hypertension among African Americans (AA) is limited. Using Jackson Heart Study (JHS) data, we examined associations of negative affect and stress with incident hypertension and blood pressure (BP) progression among AA. METHODS: Our sample consisted of 1,656 normotensive participants at baseline (2000-2004) (mean age 47±12; 61% women). We investigated associations of negative affect (cynical distrust, anger-in, anger-out, and depressive symptoms) and stress (perceived stress, weekly stress inventory (WSI)-event, WSI-impact, and major life events) with BP progression (an increase by one BP stage as defined by JNC VII) and incident hypertension by examination 2 (2005-2008). Poisson regression analysis was utilized to examine the prevalence ratios (PRs; 95% confidence interval (CI)) of BP tracking and incident hypertension with psychosocial factors, adjusting for baseline age, sex, socioeconomic status (SES), and hypertension risk factors. RESULTS: Fifty-six percentage of the sample (922 cases) had BP progression from 2005 to 2008. After adjustment for age, sex, and SES, a high anger-out score was associated with a 20% increased risk of BP progression compared to a low anger-out score (PR 1.20; 95% CI 1.05-1.36). High depressive symptoms score was associated with BP progression in the age, sex, and SES-adjusted model (PR 1.14; 95% CI 1.00-1.30). High WSI-event scores were associated with BP progression in the fully adjusted model (PR 1.21; 95% CI 1.04-1.40). We did not observe significant associations with any of the psychosocial measures and incident hypertension. CONCLUSIONS: Psychosocial factors were associated with BP progression, with the strongest evidence for number of stressful events that occurred.

Race and Sex Differences in Correlates of Systolic Blood Pressure in Community-Dwelling Older Adults.

OBJECTIVES: To describe correlates of measured systolic blood pressure (SBP) among community-dwelling older African American and White Medicare beneficiaries. METHODS: Participants completed an in-home assessment and factors significantly correlated with SBP were tested using multivariable models. RESULTS: Among the 958 participants (mean age= 75.3 [SD = 6.8]; 49% African American; 49% female; 52% rural) African Americans were more often diagnosed with hypertension, more likely on anti-hypertensives, and on more anti-hypertensive medications. SBP was 2.7 mmHg higher in African Americans than Whites (p=.03). SBP was higher in women than men. Multivariable models revealed differences in the factors associated with SBP by race/sex specific groups. Having a history of smoking and reports of being relaxed and free of tension were associated with higher SBP among African American men. DISCUSSION: Although more likely prescribed anti-hypertensives, mean SBP was higher for older African Americans than Whites. Results support the hypothesis that behavioral and psychosocial factors are more important correlates of SBP levels among older African Americans than among Whites.

A Qualitative Examination of Barriers for Urban and Rural Custodial Grandparents.

Focus groups were conducted with 33 community dwelling, urban and rural, custodial grandparents to explore their willingness to comply with a behavioral intervention targeting improving their well-being and financial management. Most participants were African American (91%), female (79%) and middle-aged. Major themes included: 1) inability to access social services; 2) legal assistance; 3) emotional well-being; 4) problems related to the parents of grandchildren; and 5) identification of structured activities for grandchildren. Findings suggest custodial grandparents underutilize services. Future research should address methods to enhance grandparents' utilization of resources facilitated via a peer navigator system along with policy level changes.

Building from within: pastoral insights into community resources and assets.

OBJECTIVES: To explore perceptions of community pastors regarding the extent of community resources and assets in a rural, Southern, African American community. DESIGN AND SAMPLE: Utilizing a qualitative, descriptive design, interviews were conducted with six African American pastors. MEASURES: Interviews were conducted using a semi-structured interview guide based on an assets-oriented approach. RESULTS: Pastors discussed various resources and assets, probable within the community that may be considered as support for program development. Key themes included: (1) community strengths, (2) community support, and (3) resources for a healthy lifestyle. The church was identified, throughout the interviews, as a primary source of strength and support for community members. CONCLUSIONS: In this study of African American pastors, various perceptions of community resources were identified. Findings indicate that a sample, rural, Southern, African American community has a wealth of resources and assets, but additional resources related to health promotion are still necessary to produce optimal results. Specific programs to prevent chronic conditions such as cardiovascular disease can provide an effective means for addressing related health disparities. Programs implemented through churches can reach large numbers of individuals in the community and provide an important source of sustainable efforts to improve the health of African Americans.

Benefits, barriers, sources of influence, and prostate cancer screening among rural men.

OBJECTIVE: The objective of this study was to explore 3 research questions: (1) What are the perceived benefits of screening for prostate cancer (PC)? (2) What are the perceived barriers to screening for PC? and (3) Is there an association with perceived benefits or perceived barriers and participants' reported source of influence related to prostate cancer screening (PCS) decisions? DESIGN AND SAMPLE: A nonexperimental exploratory design was used for the study. Sample included 94 rural-dwelling male participants aged 40 and older. MEASURES: The instruments used included an adapted version of Champion's (1999) revised Health Belief Model scale and a researcher-developed demographic and PCS patterns form. RESULTS: Both benefits and barriers were significantly associated with PCS and sources of influence. Health care providers and family were highly reported, at 81.8% and 59.5%, respectively, as sources of influence regarding PCS decisions. CONCLUSIONS: In this primarily African American sample, significant barriers to PCS among rural men were indentifed. PC health education may need to include family, whom study participants highly reported as a source of influence regarding their PCS decisions.

The mock trial: a collaborative interdisciplinary approach to understanding legal and ethical issues.

To provide high-quality, safe, patient-centered care, RNs must exhibit a strong understanding of legal and ethical issues. The authors describe an interdisciplinary teaching learning strategy, the premock, actual, and postmock trial, to augment student retention of legal and ethical concepts and enhance the development of their personal accountability.

Perceptions of hypertension and contributing personal and environmental factors among rural Southern African American women.

OBJECTIVE: This study aimed to describe the perceptions of Southern, rural, African American women regarding personal and environmental factors that affect their hypertension. DESIGN: A purposive sample of 25 African American women aged 40-74 years, who lived in rural Alabama, participated in seven Talking Circles for 60 minutes. RESULTS: Most felt that hypertension was a "common occurrence" and that it was "typical in the African American community." They associated hypertension with stroke and heart attacks and referred to hypertension as the "silent killer." Barriers to following the treatment plan were low income, high medical expenses, and lack of insurance. Barriers to medication were cost, dislike for taking medication, running out of medication, side effects, forgetting, and being tired; and barriers to exercise were being tired, busy schedule, and safety. Walking paths, fitness centers, or malls to walk around were not available in all communities, and not all sidewalks were well-lit, limiting their walking exercise opportunities after work hours. Healthcare facilities were accessible, but it was easier to get an appointment and receive respect from healthcare providers if the women had money or insurance. Blood pressure monitors were available in their homes, at grocery stores and at Wal-Mart. No church health programs were available, but some churches had nurses on duty who offered blood pressure and cholesterol screening; however, no medication was provided. Grocery stores were accessible, and they had a flea market with fresh fruits and vegetables. Social environment/support by families and friends for persons with hypertension was not always positive. CONCLUSION: The findings of this study indicate that personal and environmental factors play important roles in hypertensive status. The modified ecological framework used in this study may help us explore perspectives of family members and friends regarding their support for persons with hypertension. More serious efforts and resources need to be made available for preventive measures of hypertension in this population.