Hypertension and Health Advocacy for African Americans

Introduction

Hypertension, as a disease more prevalent in African Americans, presents a serious public issue because current policies do not focus on the population from a culturally appropriate approach. The education of the population is based on accepted approaches that do not consider cultural specifics. The policy proposed in the paper will target African Americans specifically, providing a new, evidence-based, and culturally appropriate policy that will help increase the management of hypertension in the African American population and add a spiritual approach to it. The paper considers numerous aspects of developing campaigns, including previous experience, goal-setting, current legislations, and ethical dilemmas.

Summary

The paper is aimed at developing a health advocacy campaign to reduce the problem of hypertension in African Americans. Using the experience of previous campaign developers, it was decided to choose the following areas of attention: patient education, physician assistance, cross-cultural awareness, spiritual counseling, and media coverage. Hypertension and difficulties with the control of blood pressure are more common in African Americans than in the white population. The premature onset of the condition (elevated blood pressure) complicates the issue as other comorbidities such as diabetes mellitus or chronic kidney disease lead to an elevated risk of mortality among African Americans even with no regard to the blood pressure (Ortega, Sedki, & Nayer, 2015). Other factors that complicate and contribute to the development of hypertension include prevalent obesity among African Americans (one in six African American women are extremely obese) and salt sensitivity that is often present in African Americans with hypertension (Ortega et al., 2015).

Previous Advocacy Campaigns

Equitable Care Health Outcomes (ECHO) was an advocacy campaign that aimed to address the disparities in control of hypertension among African Americans. Specific emphasis was put on the education of participants, culturally appropriate storytelling, behavioral counseling, self-management of blood pressure, and its monitoring (Bartolome, Chen, Handler, Platt, & Gould, 2016). In this campaign, proactive health care teams were engaged to provide African Americans who participated in the study with education and counseling. An important tool, in this case, was culturally appropriate and responsive care that was provided by trained and motivated physicians.

The second campaign was aiming at spreading and supporting disease prevention strategies among African Americans with the help of community-based churches and the clergy who worked there. As communication is believed to be one of the major components of disease prevention, the authors of the study and the campaign decided that the church as one of the most trusted institutions among African Americans could be engaged in the education of disease prevention (Lumpkins, Greiner, Daley, Mabachi, & Neuhaus, 2013). The study demonstrated how pastors in predominantly African American churches advocated for health management. The identified strategies included the way pastors communicated behavior strategies that could help address disease prevention, pastors’ view of health problems in the congregation, the use of authority to promote health strategies, the relation between spirituality, religion, and health, and pastors’ encouragement of health events and advocacy (Lumpkins et al., 2013). An important factor was also the church’s role in health advocacy, where the church acted as an agent for health care equity.

Attributes That Made Campaigns Effective

In the first campaign, the attributes that contributed to the effectiveness of the campaign were the following: educational programs that targeted treatment intensification were led by physicians; care teams consisted of motivated professionals where individual responsibilities were defined and divided accordingly; the use of new care delivery design, which aim was to encourage patients to have and follow their treatment plan; the use of risk stratification of the target population; and included culturally tailored programs (Bartolome et al., 2016).

The effectiveness of the second campaign was in its emphasis on spirituality and the support coming from the clergy. Here, the authors of the campaign considered the authority that the church had and measured the role of pastors in health promotion (Lumpkins et al., 2013). The empowerment of individuals, the encouragement of them becoming proactive, the use of interpersonal and group communication, pastors’ authority, and spirituality resulted in individuals’ increased attention to their own health. The campaign demonstrated how effectively the combination of spirituality, health advocacy, and church authority could be utilized to encourage African Americans to pay more attention to their health, manage chronic illnesses and prevent conditions (including hypertension).

Health Advocacy Campaign Plan

The proposed solution consists of multiple steps:

• Physician-led care teams with clear team roles and responsibilities that will help patients monitor hypertension and manage it
• Cross-cultural awareness workshops to increase the effectiveness of medical personnel in the provision of care appropriate for the chosen population
• Team-building activities to positively influence the engagement of team members (Bartolome et al., 2016)
• Blood-pressure follow-up programs for nursing professionals that stimulates BP to recheck
• Hypertension patient education by RNs or other team members
• Implementation of spiritual practices and patient-centered education
• Assistance from pastors and the clergy in promoting health-related events
• Events dedicated to health practices should be integrated into the life of communities (Lumpkins et al., 2013)
• Possible media coverage to attract supporters (Dorfman & Krasnow, 2014)

Hypertension is a serious issue that can lead to complications and even fatal outcomes in the African American population. Although the healthcare system in the United States has different programs that target vulnerable populations (such as Medicare and Medicaid), prevention techniques and advocacy campaigns that emphasize the importance of disease prevention and management can be highly beneficial for the African American population (Knickman & Kovner, 2015).

The objectives of the policy are the following:

• Increase patient education effectiveness in hospitals and other healthcare facilities with the help of physician-led teams
• Provide care that is based on cross-cultural awareness
• Create workshops dedicated to patients’ healthcare plans and integrate them into healthcare facilities
• Add spiritual counseling as a complementary form of care in healthcare facilities
• Increase the number of patients (throughout the state) who complete BP recheck and visit follow-ups
• Promote dietary and physical activity interventions among African American patients to decrease the risk of hypertension and subsequent complications
• Support evidence-based approaches in teams that provide care to African Americans with hypertension
• Increase the number of events dedicated to hypertension in African American communities (Leyk et al., 2014)
• Engage the church in African American communities as an advocate for correct self-management and screening for cardiovascular risks

New Approach Toward Policymaking

It is proposed to introduce a new regulation because of the differences between old and new paradigms within the context of health care. For example, a new regulation is more likely to implement a team approach, make nurses full members of teams, promote coordinated holistic care, focus on patient-centered home health, involve value-based organizations as well as “relevant professionals” that can help patients make informed decisions about their health (Milstead, 2016, p. 6). Therefore, in order to manage the problem of hypertension in African American population, there should be a firm action to support the integration of new policies and regulations that will follow the latest paradigms of healthcare and take into consideration the specific needs of the population group.

Role of Existing Legislations

The existing regulations on the management of hypertension as a problem are likely to contribute to the proposed campaign through providing a guideline, on top of which new efforts can be built. It is expected that the American College of Cardiology (2017a) guideline for high blood pressure in adults will influence the proposed regulations the most because it includes specific rules on how patients with hypertension should generally be approached, screened, followed-up, what are the most appropriate strategies of drug therapy, as well as how special populations should be treated. Also, it is important to mention that in November 2017, ACC and AHA lowered the definition of hypertension “from 140/90 mm Hg to 130/80 mm Hg […] to account for complications that can occur at lower numbers and to allow for earlier intervention” (American College of Cardiology, 2017b, para. 2). Therefore, when creating a regulation to address the issue of hypertension in African American population, it is important to take into account the recent developments in already existing policies.

Three-Legged Stool: Influencing Policymakers

In order to influence policymakers to support the implementation of the proposed regulation, extra attention should be given to national nurse groups that can play the roles of advocates for the target population. Since the proposed regulation targets the African-American population, the representatives of this ethnic group from the nursing profession are likely to better communicate the problem that the population faces to relevant policymakers. Cultural and ethnic representation of the target population should be the key strategy for influencing relevant policymakers because the issue has initially appeared from the lack of attention to the specific needs of this group.

For analyzing how policymakers will be influenced, it is important to mention Milstead’s (2016) three-legged stool of lobbying model. The first leg implies the act of influencing to make sure against what stakeholders should or should not vote. Influencing in the case of the campaign to manage the problem of hypertension in African American population can be done through getting feedback from real patients on how the condition influences their quality of life as well as what challenges they encounter when seeking care. Learning about the issue from the stories of those who are directly impacted by it will create a better idea of whether the proposed regulation is needed. The second leg is linked to grassroots (indirect) lobbying, which implies the influencing of the public opinion on the legislation and encouraging the general audience to take action. With the availability of such forms of information sharing as social media, the campaign can be lobbied on websites, local forums, Facebook profiles of relevant organizations (e.g., ACC or AHA), and so on (American Heart Association, 2014).

Getting the attention of the public will inevitably increase the awareness of the problem and subsequently lead to discussions about the need for introducing a regulation that will address the issue of adverse effects of hypertension on the African American population. The third leg of the lobbying stool refers to the financial contribution targeted at getting the legislative agenda to move forward. Larger organizations such as the American Heart Association or the American College of Cardiology should be involved in the financial support of the proposed regulation. In addition, public funding through charitable donations will also be encouraged because the more financial support the regulation gets, the easier it will be for the involved parties to facilitate its implementation in real life. In addition, strong financial support is especially high on the agenda for the proposed regulation because African American households have lower median incomes compared to other groups as reported by Long (2017) from the Washington Post. Overall, the three-legged model applied to the proposed regulation will take into consideration the key problems that exist in the context of African American health care because the cultural and ethnic needs of the populations remain unaddressed.

Challenges of the Legislative Process

Within the legislative process, several challenges and obstacles are expected to arise. The first potential obstacle relates to the financial support of the proposed regulation because the distribution of governmental funds is significantly limited to the existing regulations and legislation and there may be not enough financial resources to address the needs of the proposed program. The second possible barrier to the implementation of the proposed program refers to the lack of nurses’ education on cultural and ethnic specifics of the African American population as well as why such patients are more likely to be susceptible to adverse risks of hypertension (Ortega et al., 2015). For addressing the mentioned barriers, the proposed legislation should not only appeal to the public for gaining support but also encourage healthcare facilities to assess their professionals’ expertise in the specifics of care for diverse ethnic and cultural groups. With the appropriate education of nurses, the campaign is expected to gain momentum quickly. When it comes to financial support, state representatives should be contacted and asked to present the problem to the higher-standing legislations. Also, local efforts of different communities should become integral players in the campaign.

Potential Ethical Dilemmas and Resolving Them

The implementation of the planned health advocacy campaign can involve certain ethical dilemmas related to the distribution of roles in a team and secondary goals of healthcare providers related to the campaign. When speaking about them, it is necessary to mention that both of them can pose a significant threat to the success of the planned health advocacy campaign since they involve conflicts of interest.

Inappropriate practices used during the stage of role distribution often act as a source of ethical dilemmas in healthcare and other spheres. One of the key issues that may arise is the presence of an evaluator who fulfills two or more roles simultaneously and is responsible for both implementing a campaign and evaluating it (Milstead, 2016). Knowing that they are held responsible for the outcomes, such evaluators can avoid disclosing facts that speak in favor of their programs’ ineffectiveness. To resolve the dilemma, it is necessary to choose program evaluators who have no personal interests in reference to campaign outcomes. Thus, the principle of transparency in the evaluation should guide the decision-making process in this sphere.

Also, the presence of specialists who are interested in advertising specific medicinal drugs and services should be eliminated. Trying to achieve financial success, some pharmaceutical companies in the United States and abroad collaborate with healthcare specialists using a quid pro quo model. Drugs that need to be advertised can be effective, but there is a range of factors to be taken into account when making such decisions. For instance, the presence of more affordable analogs and patients’ specific health issues should be considered.

Many people from the target group are economically disadvantaged and have relatively low salaries. In this connection, a lack of interest in advertising expensive drugs is crucial. According to the ninth provision of the ethical code, maintaining professional integrity remains one of the key responsibilities of a nurse (Fowler, 2015). Another thing to be emphasized is the responsibility to provide enough care (Craig, 2010). To prevent the negative impact of the dilemma, it is important to conduct preliminary research prior to forming teams to avoid including healthcare specialists whose medication recommendations would not be objective.

Lobbying Laws and Special Ethical Challenges

Trying to influence decision-making at a high level to encourage positive changes, it is pivotal to take into account lobbying laws used in the country. Within the frame of the proposed campaign, it is planned to implement changes in different locations, including New Jersey and other states. In this connection, the actions of specialists involved in the proposed campaign should align with regulations identified in N.J. Stat. Ann. § 52:13C-20 (National Conference of State Legislators, 2017). According to the law, to be qualified as a lobbyist, a natural person or a juridical entity should use any civil services to impact existing legislations. As it is clear from the law, there is a range of actions (exceptions) that are not considered lobbying activities. They include social activity aimed at protecting religious freedom, fulfilling official duties that include legal and political actions, etc. (National Conference of State Legislators, 2017). Importantly, a health advocacy team should be informed about all restrictions related to lobbying such as giving gifts and representing self-contradictory interests.

Ethical challenges that are peculiar to the chosen population are strictly interconnected with racial inequality that still exists in the country. To begin with, African Americans and the members of other ethnic groups widely represented in the United States are not equal in terms of wage level and access to education. It is clear that these unwanted tendencies have a bearing on the paying capacity and financial position of many African Americans. With that in mind, special consideration should be given to the most affordable self-care measures when providing patient education in healthcare facilities.

Another fact that acts as a source of challenges are the prevalence of obesity in African Americans. The weight status of such patients often becomes the cause of prejudiced attitudes, and specialists implementing the proposed campaign are expected to have high communicative competence. When working with patients whose hypertension is obesity-related, they should be able to provide recommendations in a non-judgmental manner to avoid negative reactions. To achieve this objective, it can be necessary to provide additional provider education to eliminate stereotyping that is often detrimental to patient outcomes.

Conclusion

Both structural and transformative changes are required to reduce the negative consequences of hypertension in African Americans. Teams that provide care to African Americans with hypertension need to learn how cultural specifics can assist them in making management and treatment more effective. The church and the clergy can help in promoting healthcare-related events at local communities, as well as provide psychological and spiritual help to those African Americans who have the condition and need spiritual guidance. As it is clear from specific ethical challenges that may be detrimental to patient outcomes, all healthcare providers should implement all ethical standards when working with the target population. In particular, it refers to providing affordable solutions and non-judgmental recommendations.

References

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