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Hypertension Prevalence in the Ethnic Minorities and Immigrant Populations Living in the Oak Park Village

University

NURS

Professor

April 2nd 2021

Abstract

Hypertension (HTN) continues to be the leading risk factor for cerebrovascular and cardiovascular disease. Multiple studies have investigated the prevalence of HTN in the U.S. and its determining factors. Immigrant populations and ethnic minorities living in the U.S. although comprise a smaller portion of the total U.S. population, are at an increased risk for uncontrolled and undiagnosed HTN. The Oak Park community, although White in its majority, includes a number of ethnic minorities and immigrant groups that can be at an increased risk for uncontrolled HTN and the chronic diseases it can lead up to. The risk factors for HTN (poor nutrition, sedentary life styles, educational and socioeconomic attainment, heredity, access to health care resources) are augmented in the immigrant population and ethnic minorities by certain processes such as acculturation, limited access to health insurance, limited English language proficiency, living in poorer communities (that can also be food deserts), and not lastly, ethnic and racial discrimination.

Because of their historic background and professional training, Advance Practice Nurses (APNs) are in the unique position to advocate and correct the imbalance that exists in preventative and screening services for the immigrant populations and ethnic minorities. Culturally sensitive interventions and ongoing education on life style changes among these population groups, can help correct some of the discrepancies in HTN prevalence. The Transcultural Nursing Theory and the Chronic Care Model can help guide the APNs through the process of working with these underserved and vulnerable populations, while advocating and lobbying health care policy makers can help prevent future imbalances and inequalities in the provision of health care services in the U.S.

Table of contents

1. Introduction………………………………………………………………4

2. PICO statement…………………………………………………………..5

3. Definition, Epidemiology, and Pathology……………………………….5-6

4. Determinants of Health…………………………………………………..6-7

5. Literature Review…………………………………………………………7-8

6. Diagnoses, Plan of Care, and Interventions……………………………...8-11

7. Role of the Family Nurse Practitioner……………………………………11-12

8. Conclusions…………………………………………………………………12-13

9. References…………………………………………………………………..14-17

Hypertension Prevalence in the Ethnic Minorities and the Immigrant Populations

Introduction

Hypertension (HTN) has been named “the silent killer” and rightfully so. HTN affects more than 108 million people living in the U.S., and is one of the leading modifiable risk factors for cardiovascular disease (CVD). HTN continues to be the main contributor to increased morbidity and mortality from cardiovascular conditions for both men and women living in the U.S. (Ali, Commodore-Mensa, & Yi, 2021).

This paper keeps in line with Healthy People 2030 goals and recommendations for improving the overall cardiovascular health of the U.S. population and reducing morbidity and mortality from CVD through addressing the main risk factors of CVD which include HTN, hypercholesterolemia, high blood sugars, and obesity (Office of Disease Prevention and Health Promotion [ODPHD], n.d.). Multiple studies have shown that certain immigrant populations (both documented and undocumented) and other ethnic minorities living in the U.S. are disproportionately affected by HTN (Rodriguez, et. al., 2019; Commodore‐Mensah et. al., 2016; Commodore‐Mensah et. al., 2018; Ali, Commodore-Mensa, & Yi, 2021; American College of Cardiology [ACC], 2020, Guadamuz et. al., 2020). The focus of this paper will revolve around the HTN prevalence, diagnosis and treatment of these populations living in the U.S. This paper will also analyze the conditions that lead to the disproportionate prevalence of HTN among these vulnerable populations and the interventions that can be put in place at the community, state, and federal level to help reduce the said disparities.

PICO statement

In the adult immigrant population living with hypertension (HTN) in the Oak Park community does acculturation and lack of access to health care resources contribute to the development of uncontrolled HTN, compared to US born adults who are fully insured and have access to health care services?

The stakeholders of this project are the immigrant population and ethnic minority groups living in the Oak Park village, however, at a larger scale, the entire immigrant population and ethnic minorities living in the U.S. can benefit from increased research on how HTN affects these vulnerable groups.

Definition, Epidemiology, and Pathology

HTN is defined as the force created by the blood pushing against the walls of our blood vessels that is consistently too high (American Heart Association [AHA], 2016). Most major guidelines define HTN when the SBP is greater than140 mm Hg, and the DBP is greater than 90 mm Hg with two to three consecutive measurements at 1-4 weeks time interval (Unger, et. al., 2020). HTN is usually a combination of genetic, environmental and social factors and is influenced by modifiable and non-modifiable risk factors. The pathology of HTN is not fully understood, however lifestyle choices such as diets high in sodium and fats, processed foods, sedentary life style, high alcohol intake, and smoking have been shown to be major contributors to the development of HTN. Hereditary predisposition is also a major contributor to HTN development. Only a small percentage of individuals (2-5%) suffer from HTN that is caused by underlying pathophysiological disorders such as adrenal gland or renal disease/failure (Ali, et. al., 2018). For the purpose of this paper, mostly factors that influence the HTN prevalence in ethnic minorities and immigrant populations in particular will be considered.

Ethnic minorities and immigrant populations tend to be affected by HTN and CVD more often than the general White U.S. population. Although there has been a steady decline in the past few decades of deaths due to CVD, the rates of morbidity and mortality from CVD for minorities and various ethnic-groups populations have not been as great as for the rest of the population (Balfour, Rodriguez & Ferdinand, 2015). African-Americans in particular have the highest prevalence of HTN in the world and are 30% more likely to die from CVD compared to the White population .The prevalence and morbidity linked to CVD is estimated to increase by 10% by 2030 and the treatment of cardio metabolic risk factors (obesity, HTN, and DM) costs the U.S. economy about 628 billion dollars annually (Commodore‐Mensah, et. al., 2016).

Determinants of Health

In the U.S., certain social determinants of health such as educational status, access to healthcare services, health insurance, and low socioeconomic status, play an important role in in the prevalence of HTN. Acculturation has also been an important determinant of health and HTN prevalence in the immigrant and ethnic minority populations. Acculturation (the process through which an individual is assimilated into a foreign culture) has been shown by multiple studies to increase the risk of developing the cardio metabolic risk factors (HTN, DM, obesity, and hypercholesterolemia) that lead to CVD. These studies have found that the greater the acculturation period (> 10 years) the higher the risk for immigrant populations to suffer from the cardiovascular risk factors mentioned above (Yi, et. al., 2013; Commodore-Mensah, et. al., 2016; Divney, et. al., 2018; Ali, Commodore-Mensa, & Yi, 2021). Newly arrived immigrants (both documented and undocumented) have a hard time accessing health care resources, and have poor insurance coverage (if at all) because of logistical, economic or cultural exclusions, which is a determining factor for their overall health. Screening services that could help identify and correct their modifiable risk factors are not available for these individuals and that increases their risk for HTN and CVD (ACC, 2020; Cole, et. al., 2018). Also, in the general population, it was found that people who carry health insurance are far more likely to know they suffer from HTN, than people who don’t have health insurance (70% vs. 86%)(Carey, et. al., 2018). Access to health care resources remains a major concern for the immigrant communities, due to their ineligibility for certain health care programs, limited in-language health care support, lack of knowledge of how to access health care resources, and distrust in the U.S. health care system and fear of deportation due to policies that link documentation status to use of public services (Ali, Commodore-Mensa, & Yi, 2021). Furthermore, immigrants and ethnic minorities tend to live in underserved communities (that can be food deserts and have limited access to health care facilities), have a lower socioeconomic status and educational attainment, which further increases their risk for HTN (Guadamuz, et. al., 2020; Divney, et. al., 2018).

Literature Review

Multiple studies show that U.S. immigrants tend to have better health than U.S citizens when they arrive from their home countries, however this changes with increased years spent in the U.S. This is known as the “healthy immigrant effect”, and it is mostly due to changes in the socioeconomic, physical, and cultural environments (Commodore-Mensah, et. al., 2018; Cole, et. al., 2018). The process of acculturation tends to have a negative effect on the overall health of immigrant population with studies showing increased risk for HTN and CVD the longer immigrants reside in the U.S (Yi, et. al., 2013; Commodore-Mensah, et. al., 2016; Divney, et. al., 2018; Ali, Commodore-Mensa, & Yi, 2021). Asian Americans and Latino who are two of the largest ethnic minority populations living in the U.S., are also at an increased risk for higher HTN prevalence compared to the White population, while African Americans have the highest HTN prevalence in the world (Divney, et. al., 2018; Commodore-Mensah, et. al., 2018). A study done on Asian American and Latino immigrants showed that those who use their native language as their primary form of communication at home had better BP control than those who used English as their primary form of communication (Rodriguez, et. al., 2019). This study aligns with the rest of the studies that show that the higher the acculturation period (>10 years) the higher the HTN prevalence in the immigrant populations.

Diagnoses, Plan of Care, and Interventions

The problem of uncontrolled HTN is not specific only to immigrants and ethnic minorities living in the U.S. A third of the U.S population has been diagnosed with HTN, however, according to the American Heart Association, about half of the US population suffers from high blood pressure and nearly half of the people afflicted by HTN are not even aware of having this chronic condition (AHA, 2017). The community that I surveyed for the previous 3 Capstone projects was the community of Oak Park village that is located to the West side of the city of Chicago. This community is predominantly White (63.6 %) but it does have a mix of African Americans (18.3%), Latinos (8.8%) and Asians (5.1%), while the rest are a mix of 2 or more races. Oak Park has an immigrant population that accounts for 9.3% of its total population (United States Census Bureau, 2020). One of the reasons why I chose the topic of HTN prevalence in the immigrant populations and ethnic minorities, is because a large percentage of the patients that I have worked with during all of my clinical rotations were ethnic minorities such as Latinos and African Americans, and a large majority of them were affected by the cardio metabolic risk factors discussed above (HTN, DM, obesity and hypercholesterolemia). Also, the family needs assessment project that I worked on last semester was on a family of Eastern European immigrants, and all of the adult family members were suffering from HTN, obesity, and/or hypercholesterolemia. Both the husband and wife had medical insurance although they were reluctant to use it due to its high deductible costs. The grandmother (who was living with them part of the year) did not have medical insurance due to her being in the country on a travel visa and not a legal U.S. resident. For this immigrant family, their cultural practices combined with a poor diet, and sedentary life styles were a large part of the problem. This family had a high degree of acculturation (>10 years living in the U.S.), and this translated into their diet and life style. Commodore-Mensah, et. al., (2016) point out that the negative effect between higher acculturation levels and an increase in the cardio metabolic risk factors is probably due to certain factors such as dietary acculturation (higher consumption of highly processed, high sugar foods that are easily available in the U.S.), limited availability of ethnic foods, decreased physical activity levels/ increase in sedentary activities, and other socioeconomic challenges that immigrants face which limit their leisure-time physical activity.

My working diagnoses for all the family members were in fact the risk factors for CVD discussed in this paper (excepting DM). HTN, obesity and hyperlipidemia I found to be the most common working diagnoses during the clinical rotations, and life style modifications were the starting point for all my plans of care. Continuing education on the risk factors for HTN, and frequent follow-ups to see how well the BP is controlled needs to be an integral part of any plan of care. Prevention and control of HTN can be achieved through targeted interventions at the community, state or federal levels. These interventions should first of all increase the awareness of HTN prevalence in a given community or population group, and secondly provide the at-risk populations with the tools and knowledge needed to help control HTN. Diet modifications should include reduced sodium intake and red meats, increased potassium intake, avoidance of heavily processed foods that contain high levels of sodium and fats, and increased intake of chicken, fish, whole grains, and fresh fruits and vegetables of at least 5 servings per day. The Dietary Approaches to Stop Hypertension or the DASH diet has been proven to help prevent and control HTN (AHA, 2016). Pharmacologic interventions should be initiated only after life style modifications have been attempted.

The theoretical framework that guided this Capstone project was Madeleine Leininger’s Theory of Transcultural Nursing. This theoretical framework encourages nurses and providers to include cultural considerations into the plans of treatment specific to the individual or population being cared for. APNs should perform a culturalogical assessment prior to developing a plan of treatment and include cultural components into the plan of treatment for HTN (i.e. food preferences, activity routines, spiritual or religious considerations, etc.).

The Chronic Care Model (CCM) is a care model that was designed as a framework for dealing with chronic conditions such as HTN. The CCM was developed based on research that places the patients at the center of care and empowers them to take ownership of their high blood pressures management with the support of physicians, the health care system, and their community (Carey, et. al., 2018). This model can be applied to the immigrant community also since it encourages patients with HTN to take control of their own care without relying on extensive outside control. By using this model immigrants with limited access to health care resources should be encouraged to start making the necessary life style changes, become compliant with their medication therapy, perform self BP monitoring at home, return for follow up appointments with their health providers, and access the community resources available to them (i.e. Oak Park programs that offer discounted or free fresh fruits and vegetables, forest preserve routes for biking or walking, free English classes in the community, etc).

Role of the Family Nurse Practitioner

Historically, the role of the Advance Nurse Practitioner (ANP) has been created to help the underserved communities and vulnerable populations that had limited access to health care resources. From this point of view, the ANPs are perfectly positioned to help the immigrant and ethnic minorities in the fight against HTN. Although the Oak Park Village is not necessarily considered an underserved community, some of its minority residents are considered to be part of the vulnerable populations. Family Nurse Practitioners (FNPs) are primarily filling the roles of primary family care providers, which involve working with both children and older adults. FNPs working in the Oak Park village can start screening children and teenagers for risk factor for HTN such as obesity, unhealthy diets, and sedentary life styles. Obese children are five times more likely to develop into obese adults, thus carrying the risk of HTN development from an earlier age (CDC, 2018). FNPs should start developing, and advocate for screening programs that are geared toward the most vulnerable populations. Individualized and population based interventions should include both legal and illegal immigrants, and resources should be allocated towards individuals who don’t qualify for health insurance and/or other health care resources. FNPs should engage with community partners such as religious organizations, community health care workers, and community volunteers, and attempt to create a permanent collaboration with these leaders for future programs and endeavors that can help improve the ethnic minorities and immigrant community’s health.

FNPs should lobby the state and federal policy makers to include these at risk populations in any future health care policies. FNPs can help organize health fairs and community screenings for HTN, and encourage their patients to spread the word around the community about these efforts. Becoming culturally competent and understanding how HTN affects specific races and ethnic populations living in the area, can help FNPs better plan future interventions in the communities they serve.

Conclusions

HTN continues to be the leading risk factor for CVD, and CVD continues to be the number one killer of both men and women in the U.S. Immigrant populations and ethnic minorities are at an increased risk for developing HTN, due to certain socio-economic, political and personal risk factors. Overlooking the immigrant populations’ needs and risk factors for HTN development can be a risky strategy since HTN will lead to the development of multiple chronic diseases that can be a lot more costly to treat than to prevent. This is important to consider from a financial standpoint since although underinsured immigrants don’t consume as many health care dollars as the U.S citizens, the majority of Medicaid emergency expenditures for immigrants is used up for chronic conditions such as renal failure, cerebrovascular and heart disease (Zallman, et. al., 2013). FNPs and nurse practitioners in general, have a moral obligation to help disadvantaged populations be brought up to par with the general U.S. population on routine screenings and basic preventative services for chronic conditions like HTN.

References

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Ali, S. H., Islam, N. S., Commodore-Mensah, Y., & Yi, S. S. (2021). Implementing Hypertension Management Interventions in Immigrant Communities in the U.S.: a Narrative Review of Recent Developments and Suggestions for Programmatic Efforts. Current Hypertension Reports, 23(1). https://doi.org/10.1007/s11906-020-01121-6

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