1

15

“Prospectus”

Medication Adherence among Adult African Americans with hypertension in South Central US

Beatrice Ekechukwu

Nursing – DNP General

A00464476:

Medication adherence among Adult African Americans with hypertension in South Central US

Problem Statement

In the United States, it has been recognized that one of every four medical visits results from patients not following the advice they were given, and non-adherence constitutes 33% – 69% of medication-related hospital admissions each year (Scott & McClure, 2010). Similarly, annual deaths due to non-adherence to medication in the United States are estimated at 125,000, and non-adherence to medication also costs an estimated $100 billion annually in both direct and indirect healthcare costs (Scott, & McClure, 2010). These facts are substantiated by Elliot (2003) who identified that non-adherence to prescribed medication and insufficiently intensive treatment as the two challenging obstacles to control high blood pressure.

Existing literature cites non-adherence to prescribed medication and insufficiently intensive treatment (treatment that is not enough to remediate or control a condition) as the two challenging obstacles to controlling high blood pressure (Solomon et al. 2015). Even though African Americans (AAs) constitute about 12.8% of the entire United States population, AAs have the highest rate of hypertension (over 38%) compared to other ethnic groups (Ferdinand & Saunders, 2006; Flávio, 2011). According to Rigsby (2011), African Americans have an earlier age of onset of hypertension increased incidence and prevalence of hypertension; and high hypertension-related morbidity, including mortality rates. Based on the existing facts that AAs are susceptible to high incidences of hypertension due to their genetic heritage, low literacy, and socioeconomic status which are associated to medication adherence, it becomes imperative to develop a staff education manual. The staff education training module guided by the Walden University staff education manual will thus assist the facility to provide quality health education programs to help improve hypertension medication adherence among AAs. The DNP student will adopt the Walden staff education manual in developing training that includes medication adherence evidence-based materials. This approach will in turn expected to reduce the incidence of hypertension within the AA population. Staff education manuals which emphasize behavioral interventions and increased adherence to recommended pharmacological treatments and lifestyle changes have been proposed as intervention strategies (Gross, Anderson, Busby, Erith, & Panco 2013).

According to Healthy Paso Del Notre (2017), the percentage of Medicare beneficiaries who were treated for hypertension in 2015 for El Paso County, Texas was 53.7%. African Americans constitute 3.97% of the entire El Paso County (Healthy Paso Del Notre, 2017). El Paso County has the highest percentage (24%) of adults not taking hypertension medication as prescribed compared to Texas (22%) and the US (21%) respectively (City of El Paso Department of Public Health, 2013). The purpose of this capstone project is to utilize evidence-based clinical practice to develop a staff education manual which can properly guide staff of the facility to educate AA patients with hypertension. The objective is to cultivate the culture of adhering to their medications among the AAs and thereby increasing the goal of achieving improved hypertension medication adherence (HMA) among AA population.

Practice-Focused Question(s)

“Does the literature support the use of a staff education manual in developing education module that can improve medication adherence in AAs patients 21 to 85 years of age with uncontrolled hypertension (HTN, BP > 140/90)?”

“Is literacy a hindrance and associated to medication adherence among AA patients with hypertension”?

“Will patient hypertension medication adherence education provided through staff education training module and guided by Walden’s staff education manual be more effective in achieving intervention outcomes”?

“Does socioeconomic status affect hypertension medication adherence”?

Social Change

AAs are known to suffer a disproportionately large burden of cardiovascular morbidity and mortality in the United States compared to other ethnic groups (Bosworth et al. 2008). Based on this, it is indicated that half of the cardiovascular mortality disparity between AAs and other ethnic groups is directly attributable to hypertension (Bosworth et al. 2008). In this regard, medication nonadherence is of particular interest because it is recognized as a potentially modifiable factor that might be used to reduce this unusual disparity in hypertension control among AAs. Most evidence-based research literature of hypertension treatment cite nonadherence to prescribed medication and insufficiently intensive treatment as the two challenging obstacles to controlling high blood pressure (Elliott, 2003). According to Gross et al. (2013), evidence-based research literature emphasized that educational program that focused on behavioral interventions increased adherence to recommended pharmacological treatments and lifestyle changes.

The United States population has become cosmopolitan and diversified to the extent that any intervention to address a chronic medical issue, such as hypertension medication adherence, requires an individualized, culturally sensitive approach that aligns with the assessment of patients’ beliefs, knowledge, and health habits (Lakshman et al. 2014). The MAAAA project is designed to promote patients’ awareness of their adherence patterns, which can change their behavior and remain the key elements to changing patients’ behavior such as education, motivation, and measurement (Vrijens et al. 2017)

In the South Central United States, it has been recognized that one of every four medical visits results in patients not following the advice they were given, and nonadherence contributes between 33% and 69% of medication-related hospital admissions each year (Scott, & McClure, 2010). Similarly, annual deaths due to nonadherence to medication in the United States are estimated at 125,000 deaths, and nonadherence to medication also costs an estimated $100 billion annually in both direct and indirect healthcare costs (Scott, & McClure, 2010) and AAs particularly those in South Central United States bear huge chunk of these adverse impacts. The implication is that these factors impose a substantial burden on the healthcare system and, therefore, call for the identification of viable alternatives to our society’s heavy reliance on medications (Lauzière et al. 2013). Previous studies on the use of education programs for hypertension medication suggested that the implementation of educational programs included benefits due to the reduction of costs related to treatments . Also, Lauzière et al. (2013) reported the effects of educational programs on HTN that demonstrated the reduction in BP among participants from previous studies. The beauty of the staff education manual is that the facility will use a structured educational program that will be more efficient to increase patients’ knowledge on HTN medication adherence compared to the usual approaches of counseling at the bedside or in the office

Diligent implementation of patient-centered education proposed by the staff education manual for this project should enhance medication adherence to hypertension disease prevention and management programs in low-income populations such as the AAs and may be replicated to other vulnerable ethnic populations.

Context for the Doctoral Project

The MAAAs project will take place at a middle-sized, privately owned medical facility in the South-Central US, which has documented high incidences of hypertension especially among AAs and primarily attributed to medication non-adherence. The management of the facility sees the DNP project’s staff education manual as a window of opportunity in finding a long-term solution to hypertension medication adherence. Also, the facility sees increasing medication adherence across a population is vital to improving its potentials for achieving CMS Five-Star ratings,  and to the success of chronic care management programs. It recognizes that medication non-adherence, particularly among AA patients, causes poor clinical outcomes, which then increases the use of expensive and potentially avoidable healthcare services

The DNP student develops a staff education training module, which is guided by Walden University staff education manual that the facility can use in providing quality evidence-based hypertension medication adherence education to AA patients. The DNP student will train staffs of the facility to provide medication adherence patient education based on the Walden University staff education manual and encourages t he facility to use it as the platform for the patient education. The facility has the entire set of infrastructure and the required resources to implement the project but, its organizational structure and human resources wills are lacking. The beauty of staff education training module that is guided by the Walden staff education manual is that it will provide the facility the opportunity potentially evaluate implementation successes or failures of medication adherence. According to Brown et al. (2017), this approach is essential in examining changes that occur inside the facility, the target population, community, or system.

It is pertinent to note that the facility does not offer staff training on how to access and provide quality patient medication adherence education services to AA patients. Most importantly, the facility does have an incoheren t patient education platform, especially one sufficient enough to provide effective patient education services to AA patients . Furthermore, the staff is not trained in how to utilize evidence-based written documents, such as education handouts in providing programs to improve hypertension medication adherence.

Possible Sources of Evidence

Apart from the US territories with higher Medicare medication non-adherence, the greatest hypertension medication non-adherence in the US mainland occurs in the South Central United States (Ritchey et al. 2016). Higher prevalence of hypertension medication nonadherence in the South Central United States is substantiated with data provided by the US Census Bureau which stated n ational medication nonadherence rate in the United States as follows;, 28.9% for the South, 26.7% for the West, 24.1% for the Northeast, and 22.8% for the Midwest (Ritchey et al. 2016). Also, the same data stated that the South Central United States has a hypertension non-adherence rate of 30.8%, and is second to the highest in the south compared to the south-east and south-wes t (Ritchey et al. 2016). Also, evidence to date indicates that patient education is one of the most successful interventions to improve adherence and patient self-management of chronic diseases such as hypertension (Odusola et al. 2011). Medication adherence is a complex healthcare problem and described as the process by which patients take their medication as agreed upon with their prescriber (van der Laan et al. 2017). Social/economic, condition-, treatment- or health care system-related norms have been identified as causes of non-adherence by patients (van der Laan et al. 2017). Non-adherence to medication has become an alarming problem in the United States healthcare system causing an excess cost of over $170 billion annually (Bazargan et al. 2017). Despite medication nonadherence being a major cause of morbidity and mortality among the AA population, medication non-adherence among underserved minority populations receives inadequate attention (Bazargan et al. 2017).

It is equally important to note that all available evidence-based research literature points in the same direction are showing that nationally and statewide, the incidence of hypertension is higher in the AA patients compared to other ethnic groups (Ferdinand & Saunders, 2006; Flávio, 2011). According to Gross et al. (2013), evidence-based research literature emphasized that educational program that focused on behavioral interventions increase adherence to recommended pharmacological treatments and lifestyle changes. Also, empowering hypertensive patients using a health education strategy with the necessary information and skills required to maintain and improve their health has been attributed to yielding positive outcomes (Leung, Ho, Ho, Lee, & Mark, 2005). Evidence-based research also points out that provider-patient interaction using educational pamphlets will benefit patients with hypertension by enabling them to actively participate in their recovery and learn self-management skills they can use to improve their overall health. In this regard, evidence-based literature also postulates that patients who feel in control of their health are more compliant in making healthy lifestyle changes (Cleary et al. 2011).

On the other hand, Elliott (2003) identified other factors such as lack of a consistent health care provider, inadequate knowledge, or incorrect perceptions to be prevalent in cases of non-adherence. Moreover, beliefs about hypertension; lack of social support, transportation; or control over dietary choices and complexity of the treatment regimen such as inconvenient dosing, undesirable drug-related effects, and difficulty integrating therapeutic lifestyle changes as significant barriers to blood pressure control that many patients face (Elliott 2003). Based on the need to promote medication adherence, national organizations, such as the National Committee for Quality Assurance (NCQA), emphasize the importance of medication adherence as a measure of the quality of health care system performance. Maclean et al. (2012), and Khanam et al. (2014) identified poor adherence as the main cause of failure to control hypertension, including poor adherence to antihypertensive treatment as a significant cardiovascular risk factor. This MAAAA project will, therefore, synthesize the information provided by evidence-based literature including Miller (2016 ) to provide evidence -based staff education training module that can help address the prevalence of hypertension medication adherence.

Approach or Procedural Steps

The MAAAA project is a staff education training module guided by Walden University staff education manual with an end product of brochure and intended to provide medication adherence patient education at an internal medicine facility in South Central United States . The staff education training module will contain a series of steps and approaches the facility can use in providing effective evidence-based patient education on hypertension medication adherence. The staff of the facility after being trained by the DNP student will use be able to apply the staff education training module provide p atient education programs to AAs to improve hypertension adherence. In this regard, the DNP student will plan and implement a six-week teaching session consisting of one-hour weekly power point presentations on how to use this app roach to provide evidence-based information to AA hypertension patients. This is very important especially as the staff education manual will address patients’ beliefs and concerns about the condition and treatment, identifies social cultural and individual barriers to adherence as well as enhances patients’ confidence in their ability to overcome those barriers (Odusola et al. 2011).

During the 14-minutes patient wait-time of the outpatient primary care visits, the staff of the facility can utilize and constitute these moments as teaching sessions. The step-by-step staff education training module will if properly used become a resource with improved confidence and ability in providing effective patient medication adherence education. Also, the staff education training teaching module will be characterized by concentrated, yet integrated, basic evidence-based medication adherence approach designed to integrate all stakeholders in collaborative efforts to achieve reasonable, measured outcomes.

Ethical

The DNP Student will obtain Walden University IRB approval and the facility’s institutional ethical approval as well as maintain the confidentiality of the project process. In this regard, the DNP student will seek IRB approval after the prospectus has been approved. As with any scholarly project in the healthcare arena, the MAAAA project will address ethics and human subjects’ protection appropriately and per IRB approval. If there is the need for the use of protected health information (PHI), the health insurance and accountability act (HIPPA) policy , as well as the facility’s policy, will be adhered to address the issue.

Alignment

It has been recognized that taking specific medications in treating a chronic issue such as hypertension requires motivating individuals/population to change their behavior such that their inner urge is activated to move or prompt them to action. This strategy influences medication behaviors as well as to overcome barriers to adhere to planned prescriptions (Resnick, Wehren, & Orwig, 2003). Factors identified to be influential in promoting individuals’ willingness to adhere to medications include; lack of knowledge about the benefits of the treatment, drugs side effects or unpleasant sensations, economic and social considerations, complexity of the regimen, poor patient-provider communications as well as providers’ beliefs in treatment effectiveness and motivation (Resnick, Wehren, & Orwig, 2003).

Implications of the proposed MAAAA outcomes are that the target population will be better informed and educated to be comply with the prescribed medication regimen. The accompanying change of attitudes and behaviors may then be influenced by perceived efficacy expectations including self-efficacy and the outcome expectations related to taking medications as well as outcome of such behaviors. In this regard, there will be individuals with strong self-efficacy and outcome expectations about medication adherence. Based on these, the effectiveness of the medications will be more motivated and will persist longer in correctly following the recommended medication treatment program. The hypertension medication adherence project will promote enhanced personal attributes such as emotions, perceived health status as well as confidence in the physicians. Also, the project will promote and enhance environmental factors such as routine, distractions, costs and social support, including task-related and behavioral factors such as medication aids, schedules, as well as knowledge about medications, medication delivery system and side effects.

References

Ajzen, I., & Daigle, J. (2001 ) Predicting hunting intentions and behavior: an application of the theory of planned behavior. Leisure Science, 23, 165-178.

Bazargan, M., Smith, J., Yazdanshenas, H., Movassaghi, M, Martins, D. & Orum, G. (2017) Non-adherence to medication regimens among older African-American adults. BMC Geriatrics, 17(163), 1-12

Branscum, P., Sharma, M., Wang, L. L., Wilson, B. & Rojas-Guyler, L. (2013). A process evaluation of a social cognitive theory–based childhood obesity prevention intervention: The comics for the health program. Health Promotion Practice, 14(2), 189-198

Brown, C. H., Curran, G., Palinkas, L. A., Aarons, G. A., Wells, K. B ., ………… Cruden, G. (2017) An overview of research and evaluation designs for dissemination and implementation. The Annual Review of Public Health, 38, 1-22

City of El Paso Department of Public Health (2013) Retrieved from https://www.elpasotexas.gov/~/media/files/coep/public%20health/community%20health%20assessment%20final%20report.ashx?la=en

Cleary, K. K., LaPjer, T. K. & Beadle, C. (2011) Exercise adherence issues, behavior change readiness, and self-motivation in hospitalized patients with coronary heart disease. Journal of Acute Care Physical Therapy, 2(2), 55-62

Elliot, W. J. (2003) The economic impact of hypertension. The Journal of Clinical Hypertension, 2(III), 3-12

Ferdinand, K. C., & Saunders, E. (2006). Hypertension-related morbidity and mortality in African Americans–why we need to do better. Journal of Clinical Hypertension, 21-30.

Girija, M. & Kokilavani, N. (2014) Effectiveness of structured teaching program on knowledge, attitude and practice among patients with hypertension. Asian Journal of Nursing Education & Research, 4(1), 136-139

Gross, B., Anderson, E. F., Busby, S., Erith, K. H. & Panco, C. E. (2013) Using culturally sensitive education to improve adherence with the anti-hypertension regimen. Journal of Cultural Diversity, 20 (2), 75-79

Healthy Paso Del Notre, (2017) Hypertension: Medicare P opulation, El Paso County. Retrieved from http://www.healthypasodelnorte.org/index.php?module=indicators&controller=index&action=view&indicatorId=2063&localeId=2645

Khanam, M. A., Lindeboom, W., Koehlmoos, T. L. P., Alam, D. S., Niessen, L. & Melton, A. H. (2014) Hypertension: a dherence to treatment in rural Bangladesh _ findings from a population-based study. Global Health Action, 7(25028), 1-8

Lakshman, R., Griffin, S., Hardeman, W., Schiff, A., Kinmonth, A. L. & Ong, K. K. (2014) Using the medical research council framework for the development and evaluation of complex interventions in a theory-based infant feeding intervention to prevent childhood obesity: The Baby Milk Intervention and Trial . Journal of Obesity, 1-10

Lawrence, D. B., Allison, W., Chen, J. C. & Demand, M. (2008) Improving medication adherence with a targeted, technology-driven disease management intervention. Disease Management, 11(3), 141-144

Leung, C. M., Ho, G. K., Ho, C. F., Lee, P. K., & Mark, L. S. (2005). Small-group hypertension health education programme: A process and outcome evaluation. Journal of Advanced Nursing, 631-639.

Lin, C., Neafsey, P. J. & Anderson, E. (2010) Advanced practice registered nurse usability testing of a tailored computer-mediated health communication program. Computers, Informatics, Nursing, 28(1), 32-41

Maclean, S., Berends, L., Hunter, B., Roberts, B. & Mugavin, J. (2012) Factors that enable and hinder the implementation of projects in the alcohol and other drug field. Australian and New Zealand Journal of Public Health, 36(1), 1-5

McGinnis, B., Kauffman, Y., Olson, K. L., Witt, D. M. & Raebel, M. A. (2014) Interventions aimed at improving performance on medication adherence metrics. International Journal of Clinical Pharmacy, 36, 20-25, DOI 10.1007/s11096-013-9872-y

Miller, T. A. (2016) Health literacy and adherence to medical treatment in chronic and acute illness: A meta-analysis. Patient Education and Counselling, 99, 1079-1086

NYU Libraries. (2017, October 9). Health (Nursing, Medicine, Allied Health): Search Strategies: Framing the question (PICO). Retrieved from NYU: http://guides.nyu.edu/c.php?g=276561&p=1847897

Odusola, A. O., Hendriks, M., Schultz, C., Stronks, K., Lange, J ., ….. Haafkens, J. (2011) Development and evaluation of a patient centered cardiovascular health education program for insured patients in rural Nigeria (QUICK-II). BMC Public Health, 11(171), 1-8

Pedwell, C. (2017) Habit and the politics of social change: A comparison of nudge theory and pragmatist philosophy. Body & Society, 23(4), 59-94. DOI: 10.1177/1357034X17734619

Peters, R. M., Aroian, K. J., & Flack, J. M. (2006). African American culture and hypertension prevention. Western Journal of Nursing Research, 831-854.

Rigsby, B. D. (2011) Hypertension improvement through healthy lifestyle modifications. Association of Black Nursing Faculty Journal, 41-43

Scott, A. B. & McClure, J. E. (2010) Engaging providers in medication adherence: A health plan case study. American Health Drug Benefits, 3(6), 372-380

Smedegaard, S., Christiansen, L. B., Lund-Cramer, P., Bredah, T. & Skovgaard, T. (2016) Improving the well-being of children and youths: A randomized multicomponent, school-based, physical activity intervention. BMC Public Health, 16(1127), 1-11

Solomon, A., Schoenthaler, A., Seixas, A., Ogedegbe, G., Jean-Lous, G., & Lai, D. (2015). Medication routines and adherence among hypertensive african americans. Journal of Clinical Hypertension, 668-672.

The American Heart Association (2014) Hispanics cut medication adherence gap after Medicare Part D launch. Retrieved from https://news.heart.org/hispanics-cut-medication-adherence-gap-after-medicare-part-d-launch/

Van Der Laan, D. M., Elder, P. J. M., Boons, C. C. L. M., Bosmans, J. E., Nijpels, G. & Hugtenburg, J. G. (2017). The (cost-)effectiveness of a patient-tailored intervention programme to enhance adherence to antihypertensive medication in community pharmacies: Study protocol of a randomised controlled trial. Trials, 18(29), 1-5

Williams, A. B., Burgess, J. D., Danvers, K., Malone, J., Winfield, S. D. & Saunders, L. (2005) Kitchen table wisdom: A Freirian approach to medication adherence. Journal of the Association of Nurses in AIDS Care, 16 (1), 3-12

�Remove quotation marks

�Name your project here and show the abbreviation you will use for it in parentheses

�Omit and – how do you intend to show this? It reads like a research question.

�These all read like research questions, you cannot do research – and if you are doing staff education, none of these will be answered; your first question is adequate – but you don’t need quotation marks; and semi colon after HTN

�An educational

�You cannot use an abbreviation until you have defined it

�Commas to offset nonessential clause

�A huge chunk – but this isn’t a real scholarly term

�Medication or medication adherence?

�Need a citation for these studies

�Is this your social change statement? Need a stronger section to support social change

�Your abbreviation must be the same each time you use it, and relate to the project title

�No comma

�Have you defined CMS? If not, it must be defined before using an abbreviation

�No comma

�What is “it”?

�Which DNP student

�Future tense

�Will be – past tense as this is before the project

�Comma to finish offsetting the nonessential clause

�The staff – no s

�Won’t it be based on the module you developed? It is the module that is based on the manual, isn’t it?

�Check verb tense throughout this section

�Synthesis and clarity

�What entire set?

�what

�a staff education

�to potentially evaluate

�what approach?

�Incoherent?

�What is this section saying? Need clarification

�Comma to finish offsetting nonessential clause

�Reported would be a better verb here

�demonstrated – data doesn’t state

�clarity

�comma

�this doesn’t flow

�is underserved minority and AA population the same group?

�Sentence structure

�Plural

�Plural

�And not comma with only two elements

�No comma with two

�This has no purpose here

�An evidence based

�Isn’t your approach to develop a staff education module?

�Isn’t the project to develop the module?

�A brochure – your staff manual will have an end product of a brochure? What does this mean?

�Need clarity here

�Steps and approached? What do you mean

�Comma around nonessential clause

�Able to apply… provide – look at your sentence structure

�Only to AAs?

�Hypertension adherence or medication adherence?

�Which approach ?

�comma

�keep verbs in agreement

�comma

�how can a staff education manual enhance patient confidence?

�No s

�Constitute these moments?

�What moments?

�Comma around nonessential clause

�A resource doesn’t have confidence, so can’t have improved confidence or ability

�Need clarity here, I don’t know what you are saying

�APA and Walden say to use first person

�Need to define all abbreviations before using

�Reference needed

�No comma

�Look at your guideline and see what should be addressed in this section.

�Period after date throughout

�List first six then THREE dots … and final author

�Italics for ALL volume numbers

�No capital for population

�Capital after colon – I told you that the last time

�Only capitalize first word, proper nouns, and words following a colon in article titles. I told you that the last time

�List the first six authors and only use three dots (elipses)

�Italics