THESIS HURS 1998 H459k
c.2

Heeter, Lonnie L.

Knowledge of
nonpharmacological
1998.

Knowledge of Nonpharmacological Treatments
for Hypertension and Blood Pressure Control
in Hypertensive Older Adults.

By
Lonnie L. Heeter

Submitted in Partial Fulfillment of the Requirements

for the Masters of Science in Nursing Degree

Approved by:

2/^7///

Ma^LouKeller, CRNP.PhD
Committee Chaiiperson
Edinboro University of Pennsylvania

__ OaAaJ/______
A^J^'et Geisel, PhD, RN
// ^Committee Member
Edinboro University of Pennsylvania

A?A
Date
7

Dati

(J Judith Schilling, CRNP,^hD
Committee Member
Edinboro University of Pennsylvania

Acknowledgments

I would like to thank Dr. Mary Lou Keller for her support, and assistance as
chairperson during this project. I would like to thank Dr. Schilling and Dr. Geisel for

their assistance as members of my committee. A special thanks to my wife for the
daily emotional support that enabled me to complete this project. Additionally, I must

acknowledge my unborn child as perhaps my greatest motivation to complete this

project and my degree as a Family Nurse Practitioner.

iii

Abstract
Knowledge of nonpharmacological treatments for hypertension
and blood pressure control in hypertensive older adults

Approximately 50 million adults in the United States either have elevated
blood pressure or are taking antihypertensive medications. Unfortunately only 21% of

hypertensive patients are being properly treated in the United States. After reviewing
the literature the researcher found no studies that compare knowledge level of

nonpharmacological treatments of hypertension and actual blood pressures in older
adults.
The propose of the research was to assess the relationship between knowledge

level about nonpharmacological treatments for hypertension and blood pressure

control in older hypertensive adults. Knowledge of nonpharmacological treatments of
hypertension was evaluated with the use of a survey. After the subjects completed the

survey the researcher measured their blood pressures with a sphygmomanometer.
Mean blood pressures were calculated for all the various knowledge levels. The

Pearson r test was utilized to test for a correlation between knowledge level of
nonpharmacological treatments of hypertension and blood pressure in the subjects.
The targeted convenience sample was approximately 34 middle aged adults

ages 45 years and older that can read English. The setting was in the lobby of a

northwest Pennsylvania pharmacy. The subjects were responding to a free blood

pressure screening and were asked to participate in the study.
The research hypothesis was that persons with an increased knowledge level

of nonpharmacological treatments of hypertension will have lower blood pressures.
The study found a negative correlation between blood pressure and

nonpharmacological treatments of hypertension, but they were not found to be
statistically significant.

Table of Contents

Content

Page

Acknowledgment..

Abstract.

iii

List of Tables

vii

Chapter I: Introduction.
Background of the Problem.

Statement of the Purpose

Theoretical Framework.

Research Question.

Assumptions.

Definitions of Terms

Limitations.

Summary...

Chapter II: Review of Literature.

Dietary Modifications

Sodium Reduction.
Alcohol Consumption.

High Potassium...
High Magnesium

Calcium Supplementation.

Weight Control

Physical Activity,

17
19

Stress Management.

.21

Summary,

.22

Chapter III: Methodology,

Hypothesis,

.23

Operational Definitions,

.23

Research Design,

.23

Setting and Procedures
Sample

Informed Consent.

Instrumentation.

.25

Pilot Survey,

.25

Data Analysis,

Summary

Chapter IV: Results
Demographics

Blood Pressure Results
Correlations....
Summary

Chapter V: Summary, Conclusions, and Recommendation

vii

Summary of the Research and Discussion.

Conclusions

.35

Recommendations.

Summary.

References

Appendixes

.44

A: Survey Tool

.45

B: Permission for Data Collection.

.47

C: Oral Introduction.

.48

D: Introduction Script.

E: Consent from Internal Review Board.

viii

List of Tables
Tables

Page

Table 1. Demographic Data.

.28

Table 2. Blood Pressure Readings.

.29

Table 3. Average Blood Pressure vs. Survey Score.

.29

Table 4. Percentage of Correct Answers

Table 5. Pearson r Correlation of Knowledge VS Blood Pressure.

Table 6. Blood Pressures.

Chapter I
Introduction

This chapter provides a brief overview of nonpharmacological treatments of
hypertension and how patient education may affect blood pressure control. Benefits of

controlling blood pressure are discussed, including reducing risks of myocardial

infarction, stroke, kidney failure, and blindness. Dorthea Orem’s (1995) self-care
deficit theory of nursing is utilized as a theoretical frame work for this study and is

described. Assumption, definition of terms, and limitations of the study are also
provided.

Background of the problem

Approximately 50 million, or one in every four adults in the United States,
either have elevated blood pressure or are taking antihypertensive medication (Blake,

1994). Approximately 2 million adults in the United States develop hypertension each
year (The Sixth Report of the Joint National Committee on Detection, Evaluation, and

Treatment of High Blood Pressure, ([JNC VI], 1997). Estimates based on the 1988
through 1991 survey by Joint National Committee (1997) found that prevalence of

hypertension increased throughout the life span. Additionally, prevalence was
approximately 4% in the 18 to 29 year old age group and up to 65% m the 80 years

old and above age group. Age-related progressive rise in hypertension is isolated to
economically developed countries. In third world societies, age-related hypertensive

progression is uncommon. Thus age-related increases in blood pressure are not

merely a biological product of aging (JNC VI, 1997). Population based research has

identified the following environmental exposures as being among the most influential
contributors to age-related increases in hypertension and increased incidence in high
blood pressure, a high sodium chloride intake beyond physiological needs, obesity,

physical inactivity, excessive alcohol intake, and decreased potassium intake. All of
the environmental exposures are preventable with knowledge and understanding of

how to avoid them (JNC VI, 1997).
Unfortunately, in the United States, public understanding and effective

treatment of hypertension need improvement. The Joint National Committee (1997)
survey found that the percentage of Americans that were aware they have high blood
pressure had increased from 51% to 73% in the last 15 years. Also increasing from

10% to 21% was the number of patients on antihypertensive medications who had
their blood pressures controlled at less than 140/90 mmHg (Oparil, 1993). A
contributing factor was that just 64% of patients were compliant with treatment

(Dunbar-Jacob, Dwyer, & Dunning, 1991).These figures demonstrated that a minority
of hypertensive patients had effective blood pressure control.

The goal in hypertensive treatment is to reduce blood pressure thereby

minimizing complications and reducing morbidity and mortality (Oparil, 1993).
These goals are accomplished by maintaining systolic blood pressure under 140

mmHg and diastolic blood pressure under 90 mmHg, and controlling or modifying

risk factors (JNC VI, 1997). Hypertension is associated with an increased risk of

developing coronary heart disease, stroke, congestive heart failure, renal

insufficiency, and peripheral vascular disease. This increased risk has been shown in

both sexes throughout the life span. Increases in diastolic blood pressure by 7.5
mmHg are associated with a 46% increase in strokes (Aiderman, 1993). Similarly, an
increase of 5 mmHg in diastolic blood pressure correlates with a 16% increase in

myocardial infarctions. It is important to note that lowering blood pressure does not

confer total protection against cardiovascular events. In fact more than one-half of all
heart attacks (57%) and almost one-half of strokes (46%) occur in the normotensive

population (Aiderman, 1993). Lowering blood pressure limits a cardiovascular risk
factor and will reduce cardiovascular events in a population, but may not in an
individual.

Current therapy for hypertension consists of life style changes and
antihypertensive medications (Lenient, 1996). Life style changes that have shown real
promise in treating hypertension include low sodium chloride intake, alcohol

reduction, exercise, increased potassium intake, and weight loss. The evidence is less
convincing for calcium supplements, magnesium supplements, fish oils, and dietary

fiber (INC VI, 1997). Life style changes alone may not effectively control
hypertension but may reduce the amount of blood pressure medication needed.

Pharmacological therapy to control hypertension has been show in clinical trials to
effectively reduce mortality and morbidity (Goldsmith. 1993). Additionally, anti-

hypertensive medication has been shown t0 reduce stroke, heart disease, and target
organ damage.
Hypertension is clearly a serious risk factor for the development of

cardiovascular diseases, but still only 21% of the known hypertensive patients are
adequately treated (Oparil, 1993). The Knowledge-Assembly theory states that
knowledge representation and processing change are qualitative, as the degree of

learning increases (Hayes-Roth, 1977). Therefore, in order for hypertensive patients
to maintain a multifaceted treatment plan they must be educated about the disease and

its treatment.
Statement of the Purpose

Fifty million American adults have hypertension which can lead to significant

increases in morbidity and mortality (Blake, 1994). There are pharmacological and
nonpharmacological treatments that have been effective in clinical trials for the

treatment of hypertension (JNC VI, 1997). The purpose of this research is to assess

the relationship between knowledge about nonpharmacological treatments for
hypertension and blood pressure in older adults with hypertension.

Theoretical Framework
Dorthea Orem’s theory of self-care began to evolve as early as 1949. Orem

(1995) builds her theory on beliefs that adult individuals have the ability to meet their

own needs (self-care), and <he needs of their dependents (dependent care). Self-care is
the learned ability to regulate factors that affect one’s own development and

functioning in the interest of life, health, or well-being. An individual’s ability to

engage in self-care is termed self-care agency. The total requirement a person has to
regulate factors of development and function is self-care demand. If the individual’s

self-care agency is not equal to their self-care demands then they will be unable to
properly perform self-care without assistance. In other words, the self-care agent, or

the provider of self-care, requires assistance to meet his or her need for normal
functioning, health promotion, and maintenance of normal growth and development.
The self-care provider performs actions that have either internal or external

orientation (Orem, 1995). Four types of external orientation are: knowing and seeking
knowledge, assistance and resource seeking action sequences, expressive
interpersonal actions, and action sequences to control external factors. The two

internal factors are: resource-using action sequences to control internal factors and
action sequences to control oneself. According to Orem, knowledge level in
hypertensive adults will affect their ability to make life style changes, or to take

actions controlling external factors. Knowledge deficit is a self-care demand. If
hypertensive persons do not have adequate knowledge of nonpharmacological

treatments they will be unable to perform self-care. A health care provider would then
be needed in a supportive-educative capacity.
He health care provider assists individuals to meet their self-care demands.

This is accomplished in five ways: (a) acting for or doing for another, (b) guiding, (c)

providing physical or emotional support, (d) providing and maintaining an

enviroment that supports development, and (e) teaching.
For the middle aged hypertensive adult, the health care provider must adapt
the care provided to meet the individual’s self-care demands (Orem, 1995). With
hypertensive adults the provider must formulate a plan that particularizes for the

person by age, gender, developmental stages, pattern of living and environmental
conditions, and other circumstances.
Orem’s self-care systems result from the use of the knowledge and skill, to

treat and control an individual’s own blood pressure (Hartweg, 1991). Knowledge
level of nonpharmacological treatment of hypertension provides a framework for

patients to practice self-care. If the patient’s knowledge level is inadequate (self-care

agency) to meet the patient’s self-care demand, then a health care provider is needed
to meet this deficit and educate the patient, thus providing them with the tools to

practice self-care (Orem, 1995).

Nurse practitioners are in a unique position to evaluate hypertensive patients’
knowledge levels and the effectiveness of treatment. When there is a deficit in a

patients’ self-care agency, nurse practitioners can provide patient teaching. Patients
that are armed with adequate information may be able to practice self-care effectively
and may have better hypertensive control.

Research Question

Does knowledge level of nonpharmacological treatments of hypertension

affect blood pressure in older hypertensive adults?
Assumptions
The assumptions of this study were that:
1. Participants in the survey will answer the questions honestly.

2. Participants in the study can read and understand the survey.
3. Knowledge and skill promotes behavioral change.

Definitions of terms

The terms utilized in this study were defined as follows:

1. Hypertension is any systolic blood pressure greater than 140 mmHg and /or
diastolic blood pressure greater than 90 mmHg (Devine & Reifschneider, 1995).

2. Older adults are 45 years old and older.

3. Nonpharmacological treatments are life style modifications to reduce blood
pressure.

4. The formula for mean blood pressure is l/3(systolic - diastolic) + diastolic
pressure (Halpenny, Sivarajan Froelicher, Underhill & Woods, 1989).

Limitations
The limitations of this study were that:

1. No previous study was found that evaluated the relationship between

patient knowledge level of nonpharmacological treatments of hypertension and blood
pressure.

2. Convenience sampling method is used and may affect the generalizability
of this study.

3. The survey tool used to evaluate knowledge level was researcher-developed
for the purpose of this study.

Summary
Hypertension is endemic in the economically developed world (JNC VI,

1997). Environmental factors that foster the occurrence of hypertension may include a
sodium chloride intake many times higher than physiological needs, obesity,

inactivity, excessive alcohol intake, poor stress management, and inadequate
potassium intake (Lenient, 1995). Additionally, reductions in these factors have been

shown to treat and prevent hypertension.
Joint National Committee survey (1997) found that only 73% of persons with
high blood pressures were aware of the diagnosis of hypertension. This may

contribute to the finding that only 29% of patients taking anti-hypertensive

medications are maintaining their blood pressures at less than 140/90 mmHg
(Dunbar-Jacob, et al., 1991).

Dorthea Orem’s (1995) self care-deficit theory of nursing was used as a
theoretical framework for this study. The framework defines patients’ health care

deficits and defines the need for nursing agency.
The stated purpose of this study was to evaluate the relationship between
knowledge about nonpharmacological treatment of hypertension and blood pressure

control in older hypertensive adults. The assumptions, definitions of terms, and

limitations of this study were also discussed.

Chapter II
Review of Literature

This chapter provides a review of the current literature on nonpharmacological
treatments of hypertension. This review of the literature will cover the most
commonly practiced nonpharmacological treatments that may have an effect on

hypertension. These treatments are categorized into dietary modifications, weight
control, physical activity, and stress management. There are other life style

modifications that have been suggested to be helpful in controlling hypertension,

however, for this study they were not considered.
Dietary modifications

Dietary modifications that will be discussed for the purpose of this research
are sodium reduction, decreased alcohol consumption, high potassium, high

magnesium, and high calcium intake. There are other dietary modifications that have

been suggested to be helpful in treatment and prevention of hypertension, however
they will not be included in the study.
Sodium Reduction. The relationship between sodium chloride intake and

blood pressure is no news to the food industry, nor to expert committees in the United
States and elsewhere (Thelle, 1996). Expert committees have recommended

reductions in daily sodium intake to 100 mmol or less daily (Thelle, 1996). This is the
equivalent of a 2.3 gram sodium diet. However, Thelle (1996) points out that b«ause
75% of the salt we consume is hidden in processed food, it is difficult to limit sodium

intake. Despite the recommendations made by expert panels, the average sodium
consumption by adults in the United States is between 100 and 200 mmol daily (JNC
VI, 1997). The Joint National Committee VI says this is far beyond our physiologic

needs and appears to be substantially more salt than our ancestors consumed.

More than 70 published studies have reported the effect of sodium on blood
pressure (JNC VI, 1997). A recent study by Denton, Mundy, & Weisinger (1995) on

chimpanzees showed that adding 100 mmol of sodium a day to their food increased
their systolic blood pressures by an average 12 mmHg. Blood pressure rose further

when sodium intake was increased and fell when excess sodium intake was
discontinued. A human study of 24 communities, with data from 47,000 individuals,

found that an increase in sodium intake of 100 mmol per day was associated with an
increase in systolic blood pressure that ranged from 5 mmHg at ages 15 to 19 years to
10 mmHg at ages 60 to 69 (Frost, Law, & Wald, 1991). The differences were much

larger for those individuals with baseline systolic blood pressures greater than 140

mmHg.
Another large international study evaluated the relationship between 24-hour
urine sodium excretion in 10,079 (5,045 men, and 5,034 women) subjects and their
blood pressure (Intersalt, 19SS). The subjects ranged from 20 to 59 years of age, and

were from 52 countries around the world. Sodium excretion ranged from 0.2 mmol
per 24 hours (Yanomano Indians, Brazil)to 242 mmol per 24 hours (north China).

There were positive and significant relationships between median sodium excretion

and median systolic blood pressure across the 52 counties in both age and sex
standardized regression analyses. Median systolic blood pressure was found to be 109

mmHg in subjects with 24-hour sodium excretion of 25 mmol/24h. However, the
subjects with 200 mmol of sodium excretion per 24 hours had median systolic blood

pressures of 122 mmHg (Intersalt, 1988).

Medical authorities agree that appropriate sodium intake ranges from 70 to
100 meq per day (Blake, 1994). An 87 meq (2 gram) sodium diet requires the

omission of foods naturally high in sodium, as well as limiting of the amount of salt
used in food preparation. Blake (1994) also noted that patients should be given

examples of low sodium diets that can be palatable.

Alcohol Consumption. From cross sectional studies it has been estimated that

as much as 5% to 7% of the overall prevalence of hypertension can be attributed to an
alcohol intake of three or more drinks per day (Friedman, Klatsky, & Siegelaub,
1982). The estimates for men alone are as high as 11%. Prospective studies have

found consistent evidence of a strong relationship between baseline alcohol intake
and blood pressure (Gordon, & Kannel, 1983).
The Framingham Study evaluated the relationship between alcohol
consumption and the mean blood pressure in 5,209 subjects (Gordon & Kannel,

1983). The study looked at average blood pressures in relationship to the ounces of
alcohol consumed monthly by the subjects. The increase in systolic blood pressure

between a nondrinker and individuals drinking more than 80 os per month was 9

mmHg for men and 16 mmHg for women. Also important K note is lha, male
nondrinkers’ systolic blood pressures were 2 mmHg higher than those who drank 1 to

9 oz of alcohol per month. Female nondrinkers’ blood pressures were found to be 8
mmHg higher than those females that consumed 1 to 9 oz of alcohol per month

(Gordon & Kannel, 1983).

A study of 44 hypertensive men in a randomized, controlled, crossover study

looked at the effects of reducing alcohol consumption by giving participants low

alcohol beer for 6 weeks. (Beilin, Puddley, & Vandongen, 1987). Alcohol

consumption was reduced from an average of 30 oz per week to 8 oz per week per
subject with the reduced alcohol beer. The study found a reduction of systolic and
diastolic blood pressure as early as 2 weeks among the men drinking reduced alcohol

beer. The average adjusted systolic blood pressure dropped 5.0 mmHg supine and 5.9

mmHg standing at 6 weeks. The corresponding adjusted reduction in diastolic blood
pressure was 3.0 mmHg supine and 2.9 mmHg standing in the same time period.

Weight change itself contributed independently to the fall in systolic blood pressure.
The study found falls in 1.8 mmHg and 2.3 mmHg for supine and standing reading,

respectively, for each kilogram reduction in body weight.

Excessive alcohol intake can raise blood pressure and cause resistance to
antihypertensive therapy. Beevers, Davies, Gill, and Maheswaran (1991) found that

significant hypertension may develop during withdrawal from alcohol, but the effect

of alcohol withdrawal is reversed within a few days, sho^ng a net redaction in Hood
pressure.

High Potassium. A high dietary intake of potassium may be protective against
developing hypertension or helpful in treating hypertension (Lianas, 1991). Currently

there are not any recommended daily allowances for potassium, but unofficially
adults should get 3500 milligrams daily (Kasher, 1996). Unfortunately Kasher’s
(1996) survey found the average United States adult only consumes 2,000 milligrams

daily.
A meta-analysis of six randomized controlled studies of potassium

supplementation was conducted in normotensive subjects. In all the trials, potassium
supplementation was achieved by administration of pills rather than dietary changes.

In five of the six trials, the systolic and diastolic blood pressures were reduced, but
the reduction was statistically significant in only three instances (National High Blood
Pressure Education Working Group [NHBPWG], 1993).

The Hypertension Prevention Trial Research Group (1990) studied 195
healthy men and women, aged 25 to 49 years, with diastolic blood pressures of 78 to

89 mmHg. The study goal was to reduce individual sodium excretion to less than 70

mmol per day and increase potassium excretion to greater than 100 mmol per day.
Researchers evaiuated the subjects evcy 6 months for 3 years. The control group had
equal reduction goals for sodium, but not for potassium. The study results revealed no

added effect on blood pressure for increased podium intake over that achieved by

sodium reduction alone.
In a trial of 100 randomized subjects, common sodium salt was replaced with

a low sodium, high potassium, high magnesium mineral salt. Systolic blood pressure
measurements at 8, 16, and 24 weeks fell a combined average of 7.6 mmHg and

diastolic blood pressure fell a total of 3.3 mmHg in the mineral salt group compared
to the control group. Twenty-five weeks after the subjects stopped substituting with
the mineral salts, blood pressure differences between the two groups were no longer

detectable (Bak, Den-Breeijen, Geleijnse, Grobbee, & Witteman, 1994). Decreases in

blood pressure were of the same magnitude in both sexes and were not modified by
age. There were no side effects from the intervention, unlike some pharmacological
treatments. Joint National Committee VI (1997) says that hypokalemia may increase

blood pressure, therefore they recommend approximately 90 mmol per day, from
fresh fruits and vegetables high in potassium, in prevention and treatment of

hypertension.
High Magnesium. A magnesium deficit is thought to occur in 20% to 80% of

the population, and the mineral is especially important therapy for patients with
cardiovascular disease (Brodsky, 1992). Magnesium is believed to work much like a
calcium channel blocker, theoretically reducing blood pressure by limiting the amount
of calcium that the vascular smooth muscle can take up. Limiting intracellular
calcium in the smooth muscle reduces

vasoconstriction (Brodsky, 1992).

Seventy-one subjects with mild essential hypertension were entered into a
double blind random crossover study of 1 month treatment with 15 mmol magnesium
daily. Despite a significant increase in plasma magnesium, there was no decrease in

blood pressures compared to a control group. These results provided evidence that

magnesium plays no role in blood pressure regulation (Beynon, et al., 1985). These
findings are consistent with JNC VI (1997) conclusions, no convincing data currently

justifies recommending the increased magnesium consumption for treatment of

hypertension.
Calcium Supplementation. Intracellular calcium is involved in the regulation

of vascular tone (Hamet, Lambert, & Mongeau, 1991). Calcium deficiency is

associated with an increased prevalence of hypertension, and low calcium intake may
amplify the effects of high sodium intake on blood pressure control (Hamet, et al.,

1991).

A meta-analysis of 25 randomized clinical trials of increased calcium intake
have been reported (NHBPWG, 1993). Six of the twenty-five clinical trials failed to
find a significant effect of calcium supplementation on blood pressure. Only two of

the trials documented a significant reduction in both systolic and diastolic blood
pressures. Also important is that the two trials that had the largest sample size and
longest duration were among the studies that found no relationship between calcium

intake and blood pressure.

A randomized, double-blind, plaeebo-controlled trial was conducted to
examine the effects of calcium supplementation on normotensive adult men

(Edmondson, et al., 1987). The 75 men were randomly assigned to a treatment
(calcium 1500 mg per day) or to a placebo group for 12 weeks. Multiple blood

pressures were taken every 2 weeks seated and supine. At the end of the 12 week trial,
subjects in the treatment group were determined to have modest but significantly
lower diastolic and systolic blood pressures. Systolic and diastolic blood pressure
reductions averaged a 2 to 3 mmHg greater in African-Americans than in European

Americans, which was not statistically significant.

While an increase in dietary calcium intake may have hypotensive effects, the
results of clinical trials with the use of pill supplements have not been persuasive

(NHBPWG, 1993). In the absence of more compelling results, it would not be

prudent to recommend a high of dose calcium for hypertensive control. JNC VI
(1997) agrees that there is no rationale for recommending calcium supplements to
lower blood pressure. However, calcium intake should remam at the recommended

dietary allowance of 800 mg to 1200 mg per day for the general population, and 1500

mg per day for women over age 50 (NHBPWG, 1993).
Weight Control

Cross-sectional and prospective studies identity . stntng relationship between

body weight and blood pressure (Van Itallie, 1935). This relationship has been noted

in both sexes, all age groups, and in a wide variety of ethnic groups. In most of the

studies, being overweight was associated with a tw<
ro-fold to six-old increased risk of
developing hypertension (NHBPWG, 1993).

With the use of the NHANES II criteria (body mass index greater than 27.8 i
m
men and greater than 27.3 in women), the prevalence of the overweight adult

population in the United States varies from less than 20% in younger white men to
more than 60% in older black women (Blacket, Hall, Macdonald, & MacMahon,

1988). In 1994 there were approximately 32 million overweight Americans, an

increase from 28.8 million in 1976 (U. S. Public Health Service Staff, 1994).
Not only does weight correlate with increased blood pressure but deposition of

excess fat in the upper part of the body (truncal or abdominal) has been correlated

with hypertension as well as other cardiovascular diseases (JNC VI, 1997). This can

be assessed by measuring the waist to hip ratio; above 0.85 for women and 0.95 in
men is considered a disproportionately large amount of fat reserve on the trunk or
abdomen.
Schotte and Stunkard (1990) did a study on the effects of weight reduction on

the blood pressure of 301 obese patients. Weight reduction was achieved by behavior

modification, medication (fenfluramine hydrochloride), or a combination of both.
Subjects started the study at least 20% above their ideal body weights. Blood pressure

reduction was noted in many of the participants after a weight loss of only 10 pounds.
After a weight loss of 20 to 22.2 pounds over a 6 month period, subjects experienced
average reductions of blood pressure of 26 mmHg in systolic blood pressure and 20

mmHg in diastolic blood pressure. On average the subjects’ systolic and diastolic
blood pressures dropped 2.3 and 1.8 mmHg, respectively, per kilogram of weight lost.
The blood pressure reductions in this study from weigh, loss compare favorably with

that of pharmacological monotherapy.
Current recommendations by JNC VI (1997) are to attempt to reduce stage I

hypertension with weight loss and other lifestyle modifications for 3 to 6 months. If
pharmacological treatment then is needed, the weight reduction program should

continue to be vigorously pursued.
Physical Activity

Regular physical acitivity to achieve a moderate level of physical fitness may

be helpful in both treatment and prevention of hypertension (JNC VI, 1997). In
addition to exercise reducing hypertension, it is also associated with weight loss,

which will further reduce hypertension. Sedentary persons are found to have a 20% to
50% higher lifetime risk of hypertension (JNC VI, 1997). Additionally NHBPWG

(1993) also reported this association in both sexes, whites and blacks, and for all age

groups. Exercise is also known to reduce the risk of cardiovascular diseases,
osteoporosis, diabetes mellitus, and falls (Blake, 1994).
A 32 - year longitudinal study of exercise tolerance and its effect on blood

pressure found that systolic blood pressure was 10 mmHg lower in individuals
identified as physically fit (Anderson, Blackbum, Gillman, & Taylor, 1981). Physical

fitness was determined in this study by evaluating the subjects' response to tread mill

exercise testing.
A longitudinal 12-year study of 6,039 men and women measured physical

fitness and its relationship to blood pressure (Blair, et al., 1984). Physical fitness was
defined by physical work capacity as measured by the treadmill exercise test. After
adjustments for body mass index, the relative risk of hypertension for the low fitness

group was 1.52. The incidence of hypertension was 18 per 1,000 in the high fitness
group and 32 per 1,000 in the low fitness group.

A special report by NHBPWG (1993) reviewed 30 studies that evaluated the
impact of increased physical activity on blood pressure. They found statistically

significant reductions in blood pressure in subjects that had higher levels of physical
fitness. Overall, the average reduction in blood pressure for the 30 trials was 6 to 7
mmHg in systolic and diastolic blood pressure. Additionally, blood pressure was

reduced in normotensive as well as in hypertensive patients.

JNC VI (1997) recommended that hypertensive patients exercise aerobically
at least three times weekly, for 20 to 45 minutes every session. Overweight patients
may benefit from more frequent low intensity workouts. Also noted by JNC VI

(1997) was that exercise should be proceeded by warm-up sessions and finished with

cool-down sessions.

Stress Management

Stress
011 has been
oeen associated
associated with
wtth the
the ri
rise in circulating levels of catecholamines,
vasopressin, cortisol, and aldosterone and the reduction of urinary sodium secretion
(NHBPWG, 1993). Knowing that all of these changes could play a part in regulating
blood pressure, speculation has been that long-term control of stress would decrease

blood pressure.

A clinical trial of 192 men and women aged 35 to 64 evaluated the
relationship between relaxation and blood pressure (Carruthers, et al., 1985). The
treatment group had group sessions of 1 hour weekly for 8 weeks in which they were

taught breathing exercises, relaxation techniques, meditation, and managing stress.
Blood pressures were measured in the treatment and the control groups at the initial

visit, and at 8 weeks, 8 months, and 4 years. The treatment group was found to have
significantly reduced blood pressures at all measurements 8 weeks and beyond.

Average treatment group’s blood pressure at 8 weeks was 132/80.5 mmHg verses

140.2/86.6 mmHg in the control group. Reductions were maintained in the treatment
group verses the control group after 4 years, 139/85.2 mmHg and 145.7/92.4 mmHg,
respectively.
Cross-sectional, prospective studies in many different populations have found
that there is an association between

increased stress and the development of

hypertension (House, Metzner, Robbins, & Strecher, 1986). Job stress and

social support seemed to play a role in how subjects managed stress, an

their blood pressures were affected. The Joint National Committee

VI (1997) does not

support the use of relaxation therapies for the treatment or prevention of hypertension.
However based on this literature review it is believed that stress does play a role in
treatment and prevention of hypertension.

Summary
This chapter has provided a review of nonpharmacological treatments of

hypertension. There is a multitude of potential nonpharmacological treatments for

control of hypertension and the purpose of this chapter is to review the most
commonly practiced nonpharmacological treatments. Nonpharmacological

modifications that have been shown to be effective in the treatment of hypertension
were reviewed: including decreased sodium and alcohol intake, increased potassium
consumption, weight loss, physical activity, and stress management. High intake of
magnesium, and calcium were also reviewed, however their benefit on blood pressure

could not be demonstrated.
Dietary changes, weight control, physical activity, and stress management
have been shown in clinical trails to effectively treat hypertension. If the

practitioner educates the patient about nonpharmacological treatment of hype

perhaps more

than 21% of known hypertensive patients will have blood pressures

under 140/90 mmHg. Additionally, better blood pressure control may allow
decreased use of medication.

Chapter III

Methodology
This chapter describes the methodology utilized to determine the relationship
between knowledge level of nonpharmacological treatments of hypertension and

blood pressure in older hypertensive adults. Included in this chapter are the research

design, sample and setting, data analysis, and the procedure utilized for this study.
Hypothesis

There is an inverse correlation between knowledge level of

nonpharmacological treatments of hypertension and blood pressure in older adults.

Operational Definitions
Blood pressure measurements were done by a registered nurse and were

measured with a single zero sphygmomanometer. All measurements (first and last

Korotkoff sounds) were the average of two readings. The first measurement was taken
five minutes or longer after the patient was seated. The second measurement
immediately followed the first in the opposite arm, again while the subject was

seated.
Research Design

This study utilized a nonexperimental descriptive research design. Data was
collected by administering a dichotomous survey tool (Appendix A) and measuring
blood pressure. The goal of the study was to evaluate the relationship between

knowledge level of nonpharmacological treatments of hypertension and blood
pressure.

Setting and Procedures

The setting was in the lobby of a pharmacy in northwestern Pennsylvania.
Permission was confirmed by a written and signed agreement between the owner and

operator of the pharmacy and the researcher (Appendix B). The pharmacy offers free
blood pressure screenings to the public one day monthly. Individuals that arrived for

the free blood pressure screening were introduced to the research and its purpose.

Upon answering their questions, the researcher asked them to participate in the study.
Sample

The targeted convenience sample consisted of older adults that had been
diagnosed with hypertension and could read and understand English. The researcherdesigned survey was administered to subjects presenting at a free blood pressure

screening at a northwestern Pennsylvania pharmacy. Those that agreed to participate

in the study were first asked to complete the survey. After completion of the survey
they remained seated and blood pressures were taken as described in the operational
definitions.

Informed consent
An oral (Appendix C) and a written introduction (Appendix D) accompanied

the survey to enhance the subjects understanding of the study. The completion and

return of the survey to the researcher was deemed as informed consent. All the data

collected remained confidential, the surveys were placed in a security box, there were

no names or other identifying information, and only grouped data has been reported.
The study was reviewed by the Edinboro University Internal Review Board (IRB) and

was given an exempt review prior to being instituted (see Appendix E).

Instrumentation

A survey was utilized to evaluate knowledge level of nonpharmacological

treatments for high blood pressure. Due to the lack of a previous research study in this
area, the tool was researcher-designed. The survey consisted of two sections. A cover

page provided subjects with information about the study, its purpose, and directions

for completing the survey. The first section of the survey elicited demographic
information and history of diagnosed hypertension. Demographic information

obtained was age, use of antihypertensive medication and whether they perceived

high blood pressure to be harmful. The second section of the survey included 12
dichotomous true and false questions. The questions elicited knowledge level of

dietary modifications, weight control, physical activity and stress reduction.
Respondents answered the questions as either true or false.
Pilot Survey

The pilot survey was conducted with five subjects that met the inclusion
requirements for the study. There were no questions on the survey that needed
clarification. All the participants in the pilot study completed the survey in less than

three minutes.

Data Analysis

The study included 34 subjects that met all the research criteria. The Pearson r
test was utilized to test for a correlation between knowledge level of
nonpharmacological treatments of hypertension and mean arterial blood pressure in

older hypertensive adults. Additional evaluation of the data analysis included lists of

whole numbers, means and percentages.
Summary

The goal of this study was to determine the relationship between knowledge
of nonpharmacological treatments of hypertension and blood pressure in older
hypertensive adults. The study was a nonexperimental correlational research design.

Analysis of the data compared blood pressure of those subjects that scored high on the
survey with subjects that showed little knowledge of nonpharmacological treatments

of hypertension.

Chapter IV

Results
This chapter provides the results of the study relating to knowledge level of
nonpharmacological treatments of hypertension and blood pressure in older adults.

Data on blood pressure, knowledge level and correlations between the two is included
within the results.

The researcher conducted this study in the lobby of a northwestern
Pennsylvania pharmacy in February 1998. The subjects were responding to a free

blood pressure screening at the pharmacy and were asked to participate in the study.
Forty-seven surveys were completed by the subjects; 34 subjects met all of the
inclusion criteria. After the surveys were completed the subjects’ blood pressures were
measured as described in the operational definitions.

Demographics

There was an equal representation of males and females, with 17 of each
included within the study (Table 1). All of the participants of the study were 45 years

old or older with a history of hypertension. Twenty-one of the 34 participants were on

antihypertensive medications at the time of the study. All but one of the participants
were aware that hypertension is unhealthy.
Blood pressure results

The average mean blood pressure for all the subjects was 101.7 mmHg. The
average systolic and diastolic blood pressures for all the subjects was 139.9 mmHg

and 81.1 mmHg, respectively (Table 2). Table 3 demonstrates the average mean,
systolic and diastolic blood pressures for the subjects in relationship to their survey

scores.

Table 1
Demographic Data
n

Male

50%

Female

50%

Yes

100%

Yes

97%

Yes

62%

38%

Gender

History of hypertension

High blood pressure is unhealthy

Antihypertensive medication

Note, Percentages rounded to the nearest whole number, na means not applicable

Table 2
Blood Pressure Readings

Average mean blood pressure

101.7 mmHg

Average systolic blood pressure

139.9 mmHg

Average diastolic blood pressure

81.1 mmHg

Note. Blood pressures are rounded to the nearest tenth.

Table 3
Survey Score vs. Average Blood Pressure
Survey scores

Average means Average systolic

Average diastolic

107

148

100.8

142.2

79.9

100

139.3

80.3

105

145.5

84.8

100.4

139.6

80.6

114

165

Note, All blood pressures were recorded in mmHg.

On average the respondents were knowledgeable about nonpharmacological

treatments of hypertension, answering 9.9 questions correctly out of twelve (82.4%).
Table 4 contains the percentage of correct answers for each of the

nonpharmacological treatments that were evaluated by the survey.
Table 4
Percentage of Correct Answers
Nonpharmacological treatment

% of correct answers

Sodium reduction

87%

Alcohol reduction

82%

Frequent exercise

89%

Obesity’s effect

93%

Stress reduction

90%

Increased potassium

50%

Note. Percentages rounded to the nearest whole number.
Correlations
The Pearson r test was utilized to test for a correlation between knowledge

level of nonpharmacological treatments of hypertension and blood pressure. The

Pearson i test was run on the mean blood pressures versus total scores on the survey.
The correlational coefficient was -0.115 which fails to demonstrate a significant

correlation (Table 5). Additional correlations were run to evaluate any correlation

between blood pressures and knowledge level for each of the nonpharmacological

treatments for hypertension. None of the correlations were found to be statistically
significant with a 0.05 alpha level. However knowledge level concerning alcohol and
stress demonstrated the highest correlation in predicting blood pressures.

Table 5
Pearson r Correlation of Knowledge Vs Blood Pressure

Nonpharmicological treatment

Correlational coefficient

Total knowledge score

-0.115

Sodium

-0.059

Exercise

0.165

Obesity

0.195

Alcohol

-0.289

Stress

-0.284

Potassium

-0.044

Note. With 34 degrees of freedom and an alpha of 0.05 the correlational coefficient of
+ or - 0.330 is needed to be significant.

Subjects who understood alcohol’s effect on blood pressure had an average

mean blood pressure of 99.5 mmHg verses blood pressures of 107.1 mmHg for those
who did not understand alcohol’s effect on blood pressure (Table 6). Knowledge level

concerning stress also showed a inverse relationship to blood pressure. Subjects
answering the stress questions correctly had average mean blood pressures of 100

mmHg verses 108.1 mmHg for the subjects answering one or both of the stress

questions incorrectly. Despite the rather large variation in the blood pressures for both
the alcohol and the stress groups, they fail to show a statistical difference at a 0.05

alpha level.

Summary
The subjects answered 82.4% of the questions correctly, demonstrating a good

knowledge base about nonpharmacological treatments of hypertension. Despite a

positive trend in the alcohol and the stress groups there were no statistically
significant correlations found between knowledge level of nonpharmacological

treatments of hypertension and blood pressure in older adults.

Table 6

Blood Pressures

Nonpharmacological treatment

Average mean blood pressure

Alcohol
Group answering correctly

99.5 mmHg

Group answering incorrectly

107.1 mmHg

Group answering correctly

100 mmHg

Group answering incorrectly

108.1 mmHg

Group answering correctly

97.6 mmHg

Group answering incorrectly

103.7 mmHg

Group answering correctly

102 mmHg

Group answering incorrectly

99.3 mmHg

Group answering correctly

102.6 mmHg

Group answering incorrectly

106 mmHg

103.2 mmHg

101.4 mmHg

Stress

Sodium

Obesity

Exercise

Potassium
Group answering correctly

Group answering incorrectly

Note, Blood pressures were rounded of to the nearest tenth.

Chapter V

Summary, Conclusions, and Recommendations
This chapter summarizes the results of the correlational study between

knowledge level of nonpharmacological treatments of hypertension and blood
pressure in older adults. Conclusions are discussed and recommendations are made

for future research.
Summary of the Research and Discussion

The purpose of the research was to assess the relationship between knowledge

of nonpharmacological treatments for hypertension and blood pressure control in

older hypertensive adults. The review of literature evaluated the current knowledge of
nonpharmacological treatments of hypertension. The treatments that were found to be

effective in treating hypertension were categorized into dietary modifications, weight
control, physical activity, and stress management. The Joint National Committee VI

(1997) found all of the above nonpharmacological treatments effective in decreasing
blood pressure, except stress reduction. However, based on this literature review

stress reduction was included in the study.

Forty-seven surveys were completed by the subjects and 34 met all of the

inclusion criteria. The survey was designed to assess basic knowledge level of
nonpharmacological treatments for hypertension. After the survey was completed, the
subjects’ blood pressures’ were taken by the researcher. The data did not show any

statistically significant correlation between blood pressures and scores on the survey.

However, the data did demonstrate nonsignificant blood pressure reductions in those
subjects with greater knowledge concerning sodium, alcohol, stress and potassium.
Blood pressure reductions as knowledge scores increase demonstrated an inverse

correlation. Knowledge of alcohol consumption’s and stress reduction’s effect on

blood pressure showed the most promise. Those answering correctly on alcohol’s

effect on blood pressure had an average mean blood pressure of 7.6 mmHg lower than
those that answered incorrectly. The subjects that answered the stress questions

correctly also had average mean blood pressures of 8.1 mmHg lower than those that
answered the stress questions incorrectly.

This study did not substantiate Orem’s self-care theory of nursing. Orem’s

self-care systems theory (1995) suggests that as knowledge of nonpharmacological

treatments of hypertension improves, persons should demonstrate an enhanced ability
to practice self-care. Therefore as knowledge goes up, blood pressure should go
down. Noncompliance with a nonpharmacological treatment regimen could explain

the lack of support for Orem’s theory of self-care.

Conclusions
Results from the study demonstrate that these hypertensive patients had good

understanding of nonpharmacological treatments of hypertension. This is
demonstrated by 82.4 % of the questions being answered correctly on the survey.

When survey scores and blood pressures were evaluated for a correlation with the
Pearson r test, no statistically significant difference was found. There are several

potential explanations for the lack of significant correlation. The survey did not elicit
any information about whether the subjects actually practiced the nonpharmacological
treatments. It was certainly possible that the subjects understood the potential benefits
from nonpharmacological treatments but still choose not to incorporate them into

their lives. Additionally, with 32 of 34 subjects scoring between 8 and 11 on the

survey, there may not have been enough variance in the score to demonstrate any
correlation. Such a narrow range of score limits the ability of correlational tests

(Gallo, Linton, 1975).
Recommendations
There have been numerous studies that evaluated the effectiveness of various
nonpharmacological treatments of hypertension, however, none were found that
assess outcomes based on knowledge level of these treatments. Additional research

needs to focus on actual blood pressure control in relationship to knowledge of

nonpharmacological treatments. It is important to remember, although controlled
trials demonstrate benefits, this may not equate to real life blood pressure control.
Additional research related to knowledge level of nonpharmacological
treatments of hypertension should include a survey that will demonstrate a wider

range of knowledge level scores. Additional questions that elicit more specific

information related to the nonpharmacological treatments of hypertension maybe
helpful. This would enhance the ability of correlational statistics to demonstrate a

statistically significant correlation.

The most promising data from this study was the correlation between
knowledge level of alcohol and stress, and its inverse correlation with blood pressure.

Although this study failed to demonstrate statistically significant correlations with a
0.05 alpha level, the actual blood pressure variance was substantial and further study
would be considered. Additional studies may consider using surveys that focus on the
roles of stress and alcohol in treatment of hypertension.

Additional research needs to be done to evaluate compliance with
nonpharmacological treatments of hypertension. Knowledge level regarding
nonpharmacological treatments of hypertension will have no effect on blood pressure
unless subjects actively incorporate appropriate strategies into their daily routine.

Summary
This chapter has provided a summary of the research project. The data did not
indicate that there is a statistically significant negative correlation between knowledge

level of nonpharmacological treatments of hypertension and blood pressure control in
older hypertensive adults. Discussion and recommendations for future studies were

provided.

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Appendixes

Appendix A

Survey
1. What is your age?

2. Male?

Under 45

45 or over

Female?

3. Have you ever been told you have high blood pressure?

Yes

4. Are you currently taking blood pressure medications?

Yes

5. High blood pressure is bad for you.

True

False

The following questions are true or false. Please circle the correct
response.
6. High blood pressure is not effected by sodium (salt) intake.

True

False

7. Drinking large amounts of alcohol increases your blood pressure.
True

False

8. Being overweight does not effect your blood pressure.

True

False

9. Regular exercise increases your blood pressure.

True

False

10. Reducing your stress level will reduce your blood pressure.

True

False

11. Eating foods high in potassium may decrease your blood pressure.
True

False

True

False

True

False

12. Eating foods containing high sodium (salt) will increase your

blood pressure.
13. Drinking alcohol has no effect on your blood pressure.

14. Being overweight decreases your blood pressure.

True

False

15. Frequent exercise has no effect on your blood pressure.

True

Flase

16. Reducing stress in your life increases your blood pressure.

True

False

True

False

17. Eating foods low in potassium may increase your blood

pressure.

Appendix B
Permission for Data Collection

The setting of the data collection was in the lobby of The Medicine Shoppe, a

pharmacy in northwestern Pennsylvania. The pharmacy offers the public free blood
pressure screening one day monthly. Individuals that arrived for the free blood
pressure screening were introduced to the research and its purpose. Upon answering

any questions, the researcher asked them to participate in the study.

Permission for data collection at this pharmacy was granted by Anthony
Stellato, R.PIL, the owner and operator of the pharmacy. I would like to thank
Anthony Stellato for allowing me to collect the data for my thesis at his pharmacy.

'Z'-'V-v\yVt

Researcher:
Lonnie Fleeter RN, BSN.

Permission GrarffecL^y:
Anthony Stellato, R.PH.

... /

Appendix C
Verbal Introduction

Hello, my name is Lonnie Heeter. I am a student enrolled in the master’s
program for Family Nurse Practitioner at Edinboro University of Pennsylvania. I am

doing research to evaluate the relationship between knowledge level of
nonpharmacological treatments of high blood pressure and actual blood pressures. If
you choose to participate in the study there is a short survey to fill out. The survey is

17 true and false questions that takes about two or three minutes to complete. After
you complete the survey I will check your blood pressure in both arms.

Your participation in the study is completely voluntary. If you decide to

participate please do not put your name on the survey. Your answers on the survey

will remain anonymous and confidential. Completion and return of this survey to the
researcher will be deemed as informed concent.

Appendix D

Introduction Script

The purpose of this study is to find out if there is a relationship between
knowledge about nonpharmacological treatments for high blood pressure, and blood
pressure in adults who are 45 years old and older with a history of high blood

pressure. The survey consists of 17 true and false questions and takes two or three
minutes to complete. I am doing this study as part of my masters degree as a Nurse
Practitioner at Edinboro University of Pennsylvania. It is important that you answer

all the questions and that you do not have assistance in answering the questions. Upon
completing the survey I will take your blood pressure in both arms while you are
sitting.

The completion and the return of this survey to the researcher will be deemed

as informed consent. All the information collected will remain confidential, the
surveys will remain in a security box, and there will be no names or other identifying

information (please do not put your name on the survey). Please complete the survey
by circling the correct answer.

Thank you for your help!
Edinboro University of Pennsylvania

Nurse Practitioner Student
Lonnie Heeter

EDINBORO UNIVERSITY
OF

PENNSYLVANIA
Appendix E

Consent from Internal Review Board

To:

Department of Special Education and
School Psychology

Edinboro, PA 16444
(814) 732-2200

L. iZZlegTzU___

j zxzi// zuLxiJ________ has been
Your research proposal -___
reviewed and has received an “exempt level* rating of a] Iprovai because the research design met
one or more of the following requirements:

research in common educational settings where the students are not identified.
research using educational tests with no identifiers of subjects.
research using surveys or interviews where respondents are not identified.

research involving observations of public behavior.

research involving collection, study, and use of existing data where subjects are not
identified.

Dr. Sondra L. Dastoli, Chairperson
Human Subjects Review Soard

A member of the Slate System of Htfter Education

Date