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Managing Hypertension in African-Americans

Motivational interviewing promotes health, education and wellness

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Studies show that a diagnosis of hypertension, especially if uncontrolled, increases risk for major disease complications including a stroke (CVA) or congestive heart failure. Motivational interviewing is a style of patient-centered counseling developed to facilitate change in health-related behaviors. Motivational interviewing techniques with educational methods will enhance awareness and motivation towards lifestyle change among African-Americans with hypertension.

When teaching health promotion among African-Americans, it is imperative to consider access to health care, knowledge of the cultures and subcultures and effective communication skills.

Demographic Challenges
The African-American community has been a public health challenge; especially those diagnosed with hypertension. Sometimes these individuals do not fully understand the severity of the diagnosis. The multiple outpatient visits, with subsequent hospital admissions individuals endure, is related to a lack of cognitive awareness required for promoting and maintaining health. 

SEE ALSO: Cultural Implications at the End of Life

Obviously these events do not have to persist. The behaviors can be modified to promote changes in health outcomes, leading to prevention of complications. The Advanced Practice nurse (APN), as a change agent, patient advocate and a clinical leader, will be part of the health care team in the educational support of the African-American population with hypertension (HTN). The APN's goal when using motivational interviewing techniques with teaching methods, is to evoke motivation for lifestyle change. 

Motivational interviewing techniques serve as that first rung on the ladder leading to a therapeutic patient education. Sole use of the standard method of educating is not effective for producing positive behavioral lifestyle changes. The APN should be trained to utilize motivational interviewing techniques when counseling the African American with HTN. The techniques should be incorporated with standard education, for effectively eliciting and promoting positive healthy behavioral outcomes.

One in three American adults in the U.S. have high blood pressure. High blood pressure costs $47.5 billion each year; this includes the cost of health care services, medications to treat high blood pressure, and missed days of work. In 2010, 488,000 people with high blood pressure were discharged from short -stay hospitals. Caucasians had a hospitalization rate of 24 per 100,000 population. Among African-American women aged 18 to 44 yeatrs, it was 128 per 100,000 population from 2007-2010. Hypertension affects a much higher percentage of African-Americans than other ethnic groups.

Factors such as culture, education, socioeconomic status, access to dietary choices, lack of exercise and obesity, could create barriers for reduction of hypertension prevalence among African-Americans.

Importance of Self-Care
According to a CDC report, at least 200,000 deaths could have been prevented through changes in health and lifestyle habits; among other things, it lists habits such as increased physical activity, dietary modifications, and community changes to create a healthier environment.

African-Americans have a low prevalence of engaging in HTN-prevention self-care and healthy lifestyle behaviors proven to decrease the risk of developing hypertension. Interventions at the patient level can combine educational/cognitive (e.g., patient education), behavioral/counseling (e.g., reducing complexity, cueing) and psychological/affective (e.g., social support) approaches. Improving provider competencies (e.g., reducing regimen complexity), implementing new care models inspired by principles of chronic illness management and interventions at the healthcare system level can be combined.  

Motivational interviewing (MI) is a conversational approach designed to help people identify their readiness, willingness, and ability to change and make use of change-talk. It is designed to strengthen their commitment to changing behavior.

This evidence-based technique addresses ambivalence to change. It is a patient -centered counseling style approach based on negotiation instead of conflict. The technique is a gradual process of listening, reflecting, and clarifying; it employs the principle of enhancing motivation to change, as the patient articulates the benefits and costs involved. MI is grounded in client-centered therapy, social learning theory and cognitive behavioral therapy.

Patient-First Approach
MI should integrate culturally sensitive communication skills. Incorporating a change model with motivational interviewing is essential; the outcome relies on a patient's responsiveness to the techniques utilized. Patients with HTN can discover interests and consider and/or make a change in their lives (e.g. managing symptoms of physical or mental illness), express desire for change (i.e. "change -talk), plan for and begin the change, enhance confidence in taking action (aware that small changes are important), and strengthen their commitment to change.

Principles of motivational interviewing involve supporting self-efficacy, side stepping resistance, thus building the patient's confidence that change is possible. Patients can tease out ways current unhealthy behaviors conflict with the wish to be compliant. Because people are at different stages of motivational readiness for engaging in health behaviors, intervention methods are most useful when tailored to a person's stage of change.

Strategies for evoking change include asking evocative open-ended questions: ask about the good and not-so-good things to explore decisional balance. Additionally, ask for and give examples, elaborate on examples and ask if things are better or different.  Ask about a five year time-line; inquire about extremes, ask about the worse things that might happen, ask patients to place examples on a scale from zero to ten. Finally, explore their goals and values in life.

Individuals with hypertension exposed to motivational interviewing, in a culturally sensitive way during their health educational sessions, are likely to experience behavioral change. Motivational interviewing can be an effective strategic support for patients; creating a sense of security about their behaviors and ways to deal with them-- motivating the patient towards change. A health education program, which adapts MI techniques can promote health and wellness and enhance disease prevention in African Americans with hypertension.

Janice A. Simpson works in Ambulatory Medical Oncology at Montefiore Medical Center in New York.

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Articles Archives

Your glaring omission of the effects that living with systemic racism and daily microaggressions have on Africans Americans is startling. Surely you are familiar with the reasearch in this area.

Shelley Hobson,  RN,  Montefiore Medical CenterAugust 12, 2015
Bronx, NY


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