University of Massachusetts Amherst

ScholarWorks@UMass Amherst
Doctor of Nursing Practice (DNP) Projects College of Nursing

2016

Improving Adherence to Antihypertensive

Medications Among Somali Patients in a Primary
Care Clinic
Nimo S. Abdi
University of Massachusetts Amherst

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Abdi, Nimo S., "Improving Adherence to Antihypertensive Medications Among Somali Patients in a Primary Care Clinic" (2016).
Doctor of Nursing Practice (DNP) Projects. 84.
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Running head: IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 1

Improving Adherence to Antihypertensive Medications Among Somali Patients in a Primary Care Clinic

Nimo Abdi

UMass College of Nursing

Running head: IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 2

Capstone Chair: Dr. Pamela Aselton

Capstone Committee Member: Dr. Raeann LeBlanc

Capstone Mentor: Vasumathi Nallusamy

Date of Submission: April, 30th, 2015

IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 3

Acknowledgements

By the grace of God, I have made it this far and I cannot thank you enough. I would like to acknowledge and thank Dr. Pamela

Aselton, Dr. Raeann LeBlanc, Dr. Jean DeMartinis and my capstone mentor Vasumathi Nallusamy for their support and guidance

throughout this project and journey. I would love to thank all my family and friends for their unwavering love and support. Thank you

all for assisting me to reach this milestone in my academic career.

IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 4

Table of Contents

Abstract ................................................................................................................................6

Introduction and Background ..............................................................................................7

Problem Statement ...............................................................................................................9

Review of the Literature ......................................................................................................9

Theoretical Framework ......................................................................................................13

Setting and Resources……………………………………………………………….........16

Sample................................................................................................................................17

Project Design and Methods ..............................................................................................18

Data Collection……………………………………………………………………….19

Organizational Analysis of project site………………………………………………19

Goals, Objectives and Expected Outcomes .......................................................................20

Ethics and Human Subjects Protection .............................................................................21

Materials ............................................................................................................................22

Educational Intervention ..............................................................................................22

Results, Data Analysis and Interpretation ..........................................................................24

IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 5

Demographic Characteristics .......................................................................................24

Data Analysis ...............................................................................................................25

Statistical Analysis .................................................................................................26

Qualitative Data ...........................................................................................................33

Discussion ..........................................................................................................................35

Limitations ...................................................................................................................38

Implications for Practice ..............................................................................................38

Conclusion .........................................................................................................................39

References ..........................................................................................................................41

Appendix ............................................................................................................................48
IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 6

Abstract

Purpose: To evaluate if the use of an evidenced-based educational program delivered to adult Somali hypertensive participants at a

community-based clinic in Minneapolis can improve their adherence to antihypertensive medications and blood pressure control.

Methods: A convenient sample of 10 participants who met the inclusion criterion consented to take part of the educational program.

The Hill-Bone Compliance to High Blood Pressure Therapy Scale was utilized to measure outcomes of the program. In addition to

that, each participant’s blood pressure was checked at pre and post intervention. Results: The statistical test of paired t-test was used to

analyze data. The pre intervention scores had a mean of 21. 80 (SD= 1.55) and the post intervention scores had a mean of 18.30

(SD=1.32). The correlation between pre and post scores was 0.44 (P= 0.21). The mean differences between pre and posttest scores

were 3.50 (SD= 4.86). The resulting t-value with 9 degrees of freedom is 2.28, p= 0.05. There was no statistical difference found

between pre and post intervention scores and BP measurements. Conclusion: Hypertension is known to be a silent killer and poor

adherence to blood pressure medications and treatment therapy is a major risk for cardiovascular diseases and stroke. Even though the

outcome of the educational program did not seen a significant change in such a short time, there is a possible lasting effect of the

education in the long run. A culturally appropriate educational program that is employed using oral communication, storing telling or

visual images has the potential to make a profound change both in the individual and within the community.

Keywords: Hypertension, non-adherence, medication, antihypertensive

IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 7

Introduction and Background

Approximately 68 million American adults aged 18 years or older have hypertension (HTN), which corresponds with 31 % of

the total population (Yoon, Gillespie, George, & Wall, 2012). Hypertension is the most common risk factor for cardiovascular disease

(CVD), surpassing diabetes mellitus, obesity, dyslipidemia, and smoking, and accounts for 49% of the risk of coronary heart disease,

and 62% of stroke risk (American Heart Association, 2013 & Mackay, Mansah, Mendis, & Greenlund, 2004). Additionally, the risk

for CVD doubles for every 10mmHg increase in diastolic blood pressure or for every 20mmHg increase in systolic blood pressure

(Mackay et al., 2004). Despite the clinical efficacy of antihypertensive medications to control blood pressure (BP), adherence to

medication treatment is poor and remains complex in the primary care settings.

Approximately half of all hypertensive patients in the nation are non-adherent to their treatment regimen (Rash, Lavoie,

Feldman, & Campbell, 2014). Recognizing barriers to medication adherence is a critical factor and remains a key challenge for

clinicians everywhere. According to Rash et al., (2014), barriers to antihypertensive medication adherence consists of many factors

that are related to patients, providers, therapy and the health care system. Examples of patient related factors include beliefs about

medication, motivation and mental health. Lack of patient-provider communication and failure to appropriately escalate treatment are

examples of provider related factors. Hypertension as being an asymptomatic disease, side effects and the complexity of regimens are

examples of therapy related factors. Medication cost, health literacy and uncoordinated delivery of services are all examples of system

related barriers to antihypertensive medication.

IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 8

Minnesota is home to the largest population of Somali immigrants in North America (MN Measurement, 2014). A community-

based clinic in Minnesota is challenged with improving adherence to antihypertensive medications to a majority of the patients they

manage. Most of the patients who seek primary care services at the clinic are Somali immigrants. A small study of Somali psychiatric

patients in the United States found a high prevalence of diabetes and hypertension compared with non-Somali patients (Kinzie et al.,

2008). Somalis, like most immigrants face many barriers utilizing the health care system. These barriers include language and

communication, cultural beliefs and access to health care. In addition to barriers, this population is most likely to experience poor

health literacy. Baur & the U.S. Department of Health and Human Services (2010) identified populations that are most likely to

experience limited health literacy as the following: adults over the age of 65 years; racial and ethnic groups other than White; recent

refugees and immigrants; people with less than a high school degree or GED; people with incomes at or below the poverty level; and

non-native speakers of English.

Health literacy is known to play an important role in determining the health outcomes of individuals. Healthy People 2010

defined health literacy as “the degree to which individuals have the capacity to obtain, process and understand basic health

information and services needed to make appropriate health decisions.” They have difficulty obtaining, understanding and

implementing health information; therefore they have a higher risk of poorer health outcomes. Wångdahl, Lytsy, Mårtensson, &

Westerling (2014) investigated health literacy among refugees in different subgroups in Sweden. Among the refugees were Somalis,

who were found to have inadequate or limited functional health literacy and comprehensive health literacy. The researchers found that

low education and/or being born in Somalia was one of the key factors associated with their increased risk of having inadequate health
IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 9

literacy. According to a 2014 MN Community Measurement report, Somalis have the poorest health-care outcomes rates among all

Minnesota minorities. For example, in vascular care, patients who indicated Somali as their preferred language had the lowest optimal

care rate at 37 percent. This rate was significantly below the statewide average. Most data specific to the Somali population is difficult

to elucidate because their biographic information is usually collected under ethnic minority, non-Hispanic Black or African

American/Black.

Problem Statement

The risk of HTN related complications such as stroke, heart failure, and renal failure among hypertensive adult Somali patients

is associated with the high rate of uncontrolled BP readings at a local primary care clinic in Minneapolis resulting from poor

adherence to BP medications and lifestyle modifications. Personal health behaviors, cultural ramifications, beliefs and educational

levels can be varied and thus can have an effect in adherence to antihypertensive medications and treatment. Nevertheless, improving

adherence to BP medications is an important aspect of successful HTN self-management and prevention from complications.

Implementation of evidenced-based practice that support educational interventions and self-monitoring of BP is intended to improve

medication adherence.

Review of the Literature

A comprehensive search of the literature for interventions that improve adherence to BP control include the following

databases: Cochrane and PubMed of the National Library of Medicine. The following Medical Subject Headings (MeSH) terms were

used for both Cochrane and PubMed search: adherence to antihypertensive medications and interventions to improve adherence and
IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 10

antihypertensive medications. Inclusion criteria included English-language peer-reviewed publications, randomized controlled trials

(RCTs) of interventions to improve adherence to antihypertensive medications, and articles that were published from 2007 to 2014. A

total of 30 articles were found from Cochrane database, and total of 13 articles from PubMed. After a detail review of the articles, a

total of seven articles were chosen for review based on their fit with the project and quality of the review.

In the seven articles chosen for review, six are randomized controlled trials and one is a meta-analysis review. Of the six

RCTs, two evaluated use of tailored behavioral/educational interventions targeting patient related factors and four evaluated uses of

electronic systems to improve adherence and BP control, and one meta-analysis review evaluated the cost effectiveness of

interventions.

Tailored Behavioral/Educational Interventions model

Bosworth et al. (2008) confirmed that nurse-administered interventions that are tailored to target HTN related

behaviors/education improve adherence to medications and BP control. Using a randomized controlled trial involving 636

hypertensive patients from two outpatient primary clinics, the nurse-administered behavioral intervention group received a tailored

behavioral intervention bi-monthly for two years via telephone and patient factors were targeted. The results showed that from

baseline to six months, self-reported medication adherence increased by 9% in the behavioral group versus only 1% in the non-

behavioral.

In another study, Bosworth and colleagues (2009) conducted a similar randomized trial using the same sample size to test

whether patients receiving a combination of interventions that consisted of a tailored behavioral telephone intervention (bimonthly
IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 11

nurse-administered targeting hypertension related behaviors), and home BP monitoring (three times weekly) would adhere and have

better BP control than the patients in the usual care or those receiving only one intervention. Over a 24-month period, the researchers

found that the combined intervention group had the most increase in the proportion of patients with BP control. Both studies signified

consistent findings that the implementations of tailored behavioral interventions are effective in improving adherence and BP control.

Furthermore, these interventions are feasible to implement in the primary care settings.

Using Electronic Systems to Improve Adherence and BP control

The use of electronic systems such as the medication reminder software helps improve medication adherence and BP control

(Patel et al., 2013). By recruiting 50 high-risk urban adults with HTN from the internal medicine, renal/hypertension, and cardiology

clinics of the George Washington University Medical faculties, Patel et al. (2013), evaluated if medication reminder software on a

mobile phone can improve adherence and BP control. By reviewing pharmacy refill rates before, during, and after availability of the

medication reminder software, the researchers found a significant difference between the activation and post-activation phases (p =

.001).

In addition, other studies have shown that the use of other electronic monitoring devices such as the Medication Event

Monitoring System (MEMS) may help improve medication adherence and BP control (Santschi, Rodondi, Bugnon, & Burnier, 2008;

& Wetzels et al., 2007). This monitoring system is a pillbox that is equipped with a microchip in its lid and registers the date and time

whenever the lid is open. In a five-month study period, Wetzels et al. carried out a randomized control study using a sample of 258
IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 12

hypertensive participants. Patients in the intervention group were supplied with MEMS and the investigators found that 50.6% of the

patients in the control group reached adequate BP compared to 53.7% in the intervention group.

Santschi, Rodondi, Bugnon, & Burnier (2008) conducted a study using the MEMS electronic monitoring device in

collaboration with community pharmacists and general practitioners in a 12-month clustered randomized trial. The researchers found

that at four-months, the systolic BP was significantly lower in the electronic monitoring group compared to the usual care group. In a

more recent study, involving 398 participants over a six-month period, Christensen and colleagues (2010) found that patients using the

electronic monitoring reported 91% compliance versus 85% in the control group. However, this difference diminished over time (88%

versus 86%) and BP was not affected. The researchers concluded that this intervention was more suitable in newly diagnosed

hypertensive patients and in those who have a tendency to forget taking their medications.

In a meta-analysis review, Chapman and colleagues (2010) evaluated adherence intervention studies in order to compare the

cost effectiveness of different interventions that have shown to improve adherence with antihypertensive therapy and lipid-lowering

medications. After screening twenty-three adherence-improving studies, the researchers found that self-monitoring, reminder and

educational materials, and a pharmacist/nurse management program were found to be cost-effective and should be considered before

other interventions. The researchers used an analytic framework and they were able to adjust for the different levels of adherence that

are often seen in the real world. The researchers concluded that educating the patient is a key component of cost effective intervention

although adherence tends to decrease over time.

IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 13

As stated by Bosworth et al. (2009), improving adherences to HTN medications requires a holistic approach consisting of

educational interventions, behavioral interventions and self-monitoring of BP. Within this realm, an intervention that has ultimate

capacity for augmenting the adherence to BP medications respective to the Somali patients requires comprehensive and multifaceted

approach. The essences of achieving these fundamental steps can be facilitated by a bilingually skilled person, which the DNP student

possesses. The Somali patients prefer to be advised and supervised by someone whose language and cultural upbringings is quite

similar to their own. Employing educational interventions, and self-management of HTN are effective and inexpensive methods to

implement in the clinical setting (Chapman et al., 2010). An educational program offered in smaller class-bases, self-monitoring

demonstrations in terms of monitoring BP, and teaching about the disease process including cultural foods high in sodium vs. low salt

diet translated into their native language are all conducive for improving adherence of BP medication to Somali hypertensive patients.

Theoretical Framework

Orleans (2008) reports that being non-adherence to prescribed medical screening, prevention and disease management

practices are considered to be the four leading behavioral risks factors. This is often seen in low-income and disadvantaged racial and

ethnic populations, and in low resources communities. Chronic conditions such as HTN require both immediate behavior change and

longer-term behavior maintenance. Therefore, the use of the Health Belief Model (HBM) (Becker, 1974) provided a foundation for

this DNP project to help improve adherence to BP medications and overall self-management of HTN for adult Somali patients. The

HBM was one of the first models that adapted theories from the behavioral sciences to predict health behaviors (McEwen & Will,

2011). The model was first developed in the 1950s by a group of social psychologists working for the U. S. Public Health Service in
IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 14

order to improve the public’s use of preventive services. The concepts from the HBM are perceived susceptibility, perceived

usefulness, perceived benefits, perceived barriers, cues to action, and self-efficacy (Champion & Skinner, 2008).

Perceived susceptibility/seriousness. Perceived susceptibility refers to one’s belief about the chances of experiencing a risk or

getting a condition or disease (Champion & Skinner, 2008), whereas perceived seriousness refers to one’s belief about how serious a

condition and its consequences are (McEwing & Wills, 2011). The success or failure of any intervention geared to address the

importance of adherence to BP medications depends to a great extent on how the adult Somalis perceive the threat of HTN to their

lives and its consequences. The importance of health education on the consequences of poor adherence to BP medications, diet, weight

and exercise cannot be overemphasized. Since collectivism is cherished among the Somalis, the hypertensive patients were educated

on the dangers of HTN in their communities and the probable cause of that predicament in those communities.

Perceived threat and seriousness of HTN can be gauged by determining how hypertensive Somali adults feel about their

disease. To develop an appropriate intervention, it’s important to garner from the patients their cultural perspective on HTN and

beliefs about medications. It is important that patients are educated about the serious health repercussions of poor adherence to BP

medications such as heart attack, stroke, kidney failure and even death. Ethnic minority and African American groups have the highest

risk factors for CVD compared to other races (Wong et al., 2002). Providing education should help raise awareness about the negative

health impact of being non-adherent to antihypertensive medications and overall disease management. This will hopefully increase

their adherence with medication regimens and have the potential of spurring behavioral change in the light of this perceived threat.
IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 15

Perceived barriers. Perceived barriers refer to one’s belief about the tangible and psychological costs of the advised action

(Champion & Skinner, 2008). This means that an individual’s participation in the health-promoting behavior is restricted due to

psychosocial, physical, or financial factors. There are several barriers faced by adult Somalis in their desire to adhere to BP

medication and HTN management. These include social determinants of health such as lack of health insurance, financial difficulties,

lack of transportation, knowledge deficit, language barriers, illiteracy (inability to record BP logs), which all contribute to lack of

managing HTN and adhering to medication regimen. Perceived barriers will hopefully be reduced through education, utilization of

resources, and by providing reassurance. In addition, providing live educational sessions demonstrating how to check BP and how to

record readings in a BP log and interpret results may overcome some of their perceived barriers.

Perceived benefits. Perceived benefits refer to one’s belief in efficacy of the advice action to reduce risk or seriousness of

impact (Champion & Skinner, 2008). This means that an individual’s belief that engaging in health promoting behavior will minimize

the risk of susceptibility and severity. In order to keep HTN under control and prevent complications such as end organ damage,

patients must adhere to lifestyle modifications including a low salt diet, healthy eating habits, weight loss program, increase physical

activity, smoking cessation as well as adhere to medication regimen. It is necessary to explore the mental and physical benefits of

engaging in these lifestyle modifications and educate the Somali adults on these attributes. Improving adherence to antihypertensive

medications, along with increasing physical activity, increasing dietary efforts will help keep BP under control.

Cues to action. Cues to action refer to strategies to activate “readiness” (Champion & Skinner, 2008). Some factors are more

likely to motivate adult Somali patients to embark on improving their adherence to BP medications than others. These factors could
IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 16

come in the form of positive or negative reinforcements in the form of symptoms or health measurements. An example of a negative

reinforcement in this case is a patient experiencing headache and chest pain from severely elevated BP. Positive reinforcements could

include just learning that being adherence to BP medications can significantly prevent adverse cardiovascular events.

Self-efficacy. Self-efficacy refers to confidence in one’s ability to take action (Champion & Skinner, 2008). With an adequate

amount of education coming from primary care providers and health educators, along with positive feedback and consistent follow-

ups, the hypertensive adult Somali patients should be able to develop confidence in their ability to manage their disease and increase

adherence to antihypertensive medications by self-monitoring of BP readings. Taking their prescribed medications daily should

become a routine part of their lives as they learn and internalize the importance of adhering to medication regimen. Somalis, like many

groups, thrive on collectivism to a great extent. The adult Somali patients may share the knowledge they learned with the rest of the

people in the community on BP medications and disease management. A diagram of the HBM is demonstrated under appendix A.

Setting and resources

The setting is a primary community clinic located in urban Minneapolis, which serves the majority of the Somali residents

living in the area. Many patients with chronic health conditions such as diabetes type II, hypertension, obesity, and hyperlipidemia

seek primary care at this clinic. The increasing numbers of patients that are non-adherent to treatment and medications, especially in

the older population often challenges the healthcare providers. Even though providers are well aware of the social factors that can

influence non-adherence to medications, yet, there is this cultural belief that has been observed among the older Somali population

that might influence their decisions on medication use. Some of the older hypertensive patients do not view their disease as a chronic
IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 17

condition that requires chronic use of antihypertensive medications and management plan. For instance, one of the providers at the

clinic site shared an example of a statement that is commonly observed, “I did not take the blood pressure medication for few days

now because I felt ‘fine’ [free from symptoms].” There is this strong interest in taking medication only when feeling “ill or

symptomatic” then to take medication daily to manage a disease. These same statements concerning the providers were also reputable

in a study by Pavlish, Noor & Brandt (2010). The researchers carried out a community-based social action study to explore the health

experiences of Somalia-born women who relocated to Minnesota. The study participants included 57 women that were divided into

six focus groups. One of the findings that the researchers point out was that the Somali women in most of the focus groups expressed

concern for treating symptoms rather than an illness explanation that required daily medication use. Many of the women in the focus

groups believed that when symptoms disperse, then treatment should stop. These researchers as well as the providers at the clinic point

out that screening, health prevention and managing diseases are unfamiliar to some Somali patients, especially the older populations,

who are accustomed to only seeking healthcare when feeling ill or symptomatic. In such cases, providers must first educate patients

about what is means to have chronic illness such as HTN versus symptoms or other acute illnesses.

Sample

Participants were recruited by posting flyers in the lobby and in the exam rooms of the clinic. In addition to the flyers, the

healthcare providers at the site had created a folder that identified potential candidates for the educational program. The interpreters at

the site were also given flyers to distribute to patients in an effort to recruit more participants. Each participant that expressed an

interest to take part in the educational program was identified. There were a total of 21 participants that agreed to take part of the
IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 18

educational program. Out of the 21 participants, only 12 met the inclusion criteria. The goal for the project was to recruit 10 to 20

participants. The inclusion criteria’s included (1) background/ethnicity must be Somali, (2) diagnosis of HTN, (3) must be on at least

one antihypertensive medication, (4) age of 50 and older, and (5) participants must be able to consent. The exclusion criteria included

those under age of 50 and those not taking medications for HTN. Participants who were age 50 and older were chosen for the

educational program because they were considered to have a greater challenge in language, education, and cultural and socials barriers

than the younger adults. In addition, the older immigrant populations are at an increased risk for poorer health. Two qualified

participants were unable to participate in the educational program due to leaving the state.

Project Design and Methods

The project provided three sessions of an educational program to a group of hypertensive patients. Since all the patients spoke

little English but were fluent in their native language, the DNP student provided the educational program speaking Somali. It is well

known that low English proficiency is a barrier to healthcare utilization among immigrants (Ding & Hargraves, 2009). By providing

an educational program in Somali this project strove to enhance understanding and knowledge of the disease within their own cultural

framework, with the goal to improve adherence to BP medications and improve BP control.

The educational program was carried out using a PowerPoint presentation that included visual content and videos in Somali

(Appendix E). Emphasis was placed on teaching patients about the basic knowledge of HTN, its complications, side effects of

medications, and benefits of adhering to BP medications. Patients were educated on the Dietary Approach to Stop Hypertension
IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 19

(DASH) diet, and the importance of adhering to a low salt-diet in order to keep BP under controlled. Following the lecture session, a

hands-on teaching/demonstration on how to self-monitor BP was done in order to promote self-management of the disease.

Data Collection

A total of ten participants agreed to take part of the educational program. A written informed consent was obtained from

participants (Appendix C). The Hill-Bone Compliance to High Blood Pressure Therapy Scale (Kim, Hill, Bone, & Levine, 2000) was

utilized to assess patients behaviors on three important behavioral domains of high blood pressure treatment; (1) reduced sodium

intake; (2) appointment keeping, and (3) medication taking. This scale consists of 14 items in three subscales (Appendix B). Each item

is a four point Likert type scale. The instrument is considered to be an appropriate tool to use compared to other existing tools,

especially in low literacy patients (Kim et al., 2000). The reliability and validity of the scale was tested in two large samples of

African American hypertensive adults in urban settings. The scale was found to be clinically useful for diagnosing problems with non-

adherence and to predict BP control status. The researchers found significant correlation between the scale total score and its subscale

scores to BP control. The tool can be administered by interview in less than 10 minutes. In addition, quantitative measurement was

conducted by measuring each patient’s BP prior to the educational intervention. To determine if there was a change in BP readings as

an outcome of the educational intervention, a posttest was conducted using the same tool and BP was measured post intervention.

Organizational analysis of project site. The clinic has five total providers consisting of one Physician, one Physician

Assistant and three Family Nurse Practitioners. Other staff members include management staff, a total of six medical assistants, and at

least four to five interpreters available at the site during hours of operation. The providers collaborate with a community pharmacy
IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 20

that is adjacent to the clinic. Two of the providers at the clinic speak Somali. All the other providers utilize interpreters to bridge the

communication barrier. Prior to the implementation of the project, all providers and staff members working at the site were informed

and given a brief introduction about the program interventions. One of the family nurse practitioners at the site agreed to identify

potential participants for this educational intervention.

Goals, Objectives, and Expected Outcomes

The goal of the educational program was to increase adherence to antihypertensive medications and reach BP target in adult

Somali hypertensive patients who participated at a community-based clinic. Table 1 below lists all of the objectives and the outcome

measures of the program intervention.

Table 1. Objectives & Expected Outcome Measures of Somali Hypertension Education Project

Objective Expected outcome measure

1. Increase the basic understanding of By the end of the educational session, 60%
HTN, and complications of uncontrolled of patients will identify at least 3 major
BP. complications of uncontrolled BP.
2. Help foster a sense of self-confidence By the end of the
with capacity to self-monitor BP readings. educational/demonstration sessions, 60%
of patients will demonstrate how to
measure BP readings using manual BP
cuff, and patients will demonstrate how to
record BP readings in a BP log sheet
(date/time).

3. Improve adherences to BP medication A minimum of 50% of all patients will

regimen to help keep BP under control report increased adherence to BP
medication using a self-adherence
IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 21

questionnaire that will be conducted post

program intervention.
A minimum of 50% of all patients will
reach target BP control by the end of the
program intervention
4. Improve adherence to low salt diet to A minimum of 50% of all patients will
help keep BP under control report decreased intake of low salt diet
using the Hill Bone Compliance
Questionnaire tool at the end of the
program intervention

Ethics and Human Subjects Protection

This project involved the implementation of a quality improvement project (QIP) that administered programmatic educational

interventions to adult hypertensive patients in an effort to improve their adherence to antihypertensive medications. All interventions

that were implemented consisted of educational in-class sessions, and a hands-on educational/demonstration session. Since the

program involved human subjects, the program underwent a review by the Institutional Review Board (IRB). After submitting the IRB

form to the University of Massachusetts-Amherst, this quality improvement project received IRB waiver (Appendix D).

Patients and clinicians had a right not to participate in the QIP. All patients were kept safe from harm and violations of their

rights. The intervention was designed to pose no risks while maximizing potential benefits. Patients’ privacy and confidentially was

maintained throughout the translation project. No patients were identified using names. Informed consents were obtained prior to the

implementation of the project. Patients were kept informed throughout the process and they were protected under the policies
IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 22

surrounding the Health Insurance Portability and Accountability Act (HIPPA). Along with patients, all health care providers at the

clinical site received basic information about the activities of the project while patients confidentially were protected.

Materials

The materials used for the educational program consisted of a PowerPoint presentation (Appendix E), BP cuffs, and visual

items of common cultural foods. Both visual and actual food items were brought during the educational program to teach patients how

to read food labels and to help them learn how to distinguish foods that were high in sodium vs. foods low in sodium vs. sodium-free

foods. Some of the food items that were brought to the educational program included pastas, two different types of oatmeal (sodium-

free vs. high sodium oatmeal), different kinds of lentils, two different types of tuna packages (one low in sodium and one high in

sodium), chicken cubes, canned beans, and empty boxes of other common food items.

Educational Intervention

The contents that were included in the PowerPoint presentation were a total of 49 slides of information, visual pictures, and

two audio videos in Somali. There were a total of three educational sessions held on three consecutive months. Each educational

session lasted about 60 to 90 minutes long. The information contained in the educational intervention included the following:

1). The definition of HTN

2). A 12-minute video clip that summarizes the pathophysiology, causes, risk factors, treatment, medications and lifestyle

modifications that help control high BP. This video is in Somali and the Somali Health & Social Development created it in 2013.

3). Classification of BP in adults

IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 23

4). Recommended BP Goals from JNC-8

5). Statistics and facts of HTN by the American Heart Association (2013)

6). Modifiable and non-modifiable risk factors of HTN

7). Complications of uncontrolled BP

8). Benefits of BP medications

9). Importance of adhering to prescribed medications

10). A 5-minute Medication Safety Video in Somali created by EthnoMed organization

11). Importance of self monitoring of BP

12). Importance of lifestyle modifications to help keep BP under control

13). DASH diet

14). Importance of following salt/sodium reduction

15). Importance of exercise and weight-loss

16). Pictures containing nutritional facts of commonly cultured foods that are eaten on a day-to-day basis.

17). Pictures and lists of foods high in sodium vs. those low in sodium
IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 24

Results, Data Analysis, and Interpretation

Demographic Characteristics

As illustrated on Table 2 below, there were a total of ten participants. For the age of participants, 10.0 percent (n=1) were aged

50-60 years old, 60.0 percent (n=6) were aged 61-70 years old, 10.0 percent (n=1) were 71-80 years old, and 20.0 percent (n=2) were

age above 81 years old. The youngest participant was 59 years old and the oldest participant was 83 years old. The mean age of the 10

participants was 69.70 years (SD = 7.74). For the gender of participants, 60.0 percent (n=6) were female, and 40.0 percent (n=4) were

male. The majority of the participants (70.0 percent; n=7) attended two educational sessions; two participants (20%, n=2) attended all

three educational sessions, while only one participant (10.0 percent; n=1) attended only one educational session out of the three total

sessions.

Table. 2. Demographics of subject participants

Assigned Age Gender Number Pre- Post

ID # of evaluation Evaluation
classes Total Total
attended Score Score
01 59 M 3 23 11
02 66 F 3 17 17
03 64 M 1 17 15
04 67 M 1 29 18
05 66 F 2 27 27
06 83 F 2 16 18
07 76 F 2 23 18
IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 25

08 69 M 2 18 18
09 81 F 2 20 19
10 66 F 2 28 22

Data Analysis

Data for the outcome variables was gathered through scoring the pre- and post- tests to evaluate participants’ behaviors on

three important behavioral domains of high blood pressure treatment; (1) reduced sodium intake; (2) appointment keeping, and (3)

medication taking. The Hill-Bone Compliance to High Blood Pressure Therapy Scale consists of 14 items with a four-point response

format: (4) all the time, (3) most of the time, (2) some of the time, and (1) never (Appendix B). Items are assumed to be additive, and,

when summed, the total score ranges from 14 (minimum) to 56 (maximum). The higher scores reflect poorer adherence to

antihypertensive drug therapy. The medication taking subscale contains 8 items assessing medication-taking behavior; the sodium

subscale contains 3 items assessing dietary intake of salty foods; and the appointment keeping subscale contains 3 items assessing

appointments for doctor visits and prescription refills. Table 3 below lists the participants’ pre and posttest scores. Analyses were

conducted using IBM SPSS version 23.

Table 3. Participant’s Pre/Posttest Scores of each Subscale

Subjects ID Subscale Pre Score Post Score

1. ID #1 Medication Compliance 11 9
Sodium Use 3 4
Appointment Keeping 9 5
2. ID #2 Medication Compliance 8 8
IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 26

Sodium Use 4 5
Appointment Keeping 5 4
3. ID #3 Medication Compliance 10 8
Sodium Use 3 3
Appointment Keeping 4 4
4. ID #4 Medication Compliance 16 9
Sodium Use 7 4
Appointment Keeping 6 5
5. ID #5 Medication Compliance 14 15
Sodium Use 9 5
Appointment Keeping 4 6
6. ID #6 Medication Compliance 8 9
Sodium Use 4 5
Appointment Keeping 4 5
7. ID #7 Medication Compliance 13 11
Sodium Use 5 3
Appointment Keeping 5 4
8. ID #8 Medication Compliance 9 9
Sodium Use 5 5
Appointment Keeping 4 4
9. ID #9 Medication Compliance 11 10
Sodium Use 4 5
Appointment Keeping 5 4
10. ID #10 Medication Compliance 15 10
Sodium Use 9 7
Appointment Keeping 4 5

Statistical Analysis
IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 27

Table 4 presents the descriptive statistics of the pre-and post-test scores for the three important behavioral domains of high

blood pressure treatment. For the pre-test scores for medication use, the lowest score was 8.00, and the highest was 16.00, with an

average of 11.5 (SD=2.87). For the post-test scores for medication use, the lowest score was 8.00, and the highest score was 15.00,

with an average of 9.80 (SD=2.04). For the pre-test scores for sodium use, the lowest score was 3.00, and the highest score was 9.00,

with an average of 5.30 (SD=2.26). For the post-test scores for sodium use, the lowest score was 3.00, and the highest score was 7.00,

with an average score of 4.60 (SD=1.17). For the pre-test scores for appointment keeping, the lowest score was 4.00, and the highest

score was 9.00, with an average score of 5.00 (SD=1.56). For the post-test scores for appointment keeping, the lowest score was 4.00,

and the highest score was 6.00, with an average score of 4.60 (SD= .69).
IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 28

Table 4.

Descriptive Statistics of Pre-test/Post-test Scores (N=10)

Minimu Std.
N m Maximum Mean Deviation
Pre Medication
10 8.00 16.00 11.5000 2.87711
Compliance

Post Medication 10 8.00 15.00 9.8000 2.04396

Compliance

10 3.00 9.00 5.3000 2.26323

Pre Sodium Use

10 3.00 7.00 4.6000 1.17379

Post Sodium Use

Pre Appointment 10 4.00 9.00 5.0000 1.56347

Keeping

Post
10 4.00 6.00 4.6000 .69921
Appointment
Keeping

Paired Sample T-Test

The statistical test of paired t-test was done to determine whether there was a significant difference between pre intervention
IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 29

scores and post-intervention scores. A level of significant of 0.05 was used in the analysis. Correlations between changes in test scores

were explored. The pre intervention scores had a mean of 21. 80 (SD= 1.55) and the post intervention scores had a mean of 18.30

(SD=1.32). The correlation between pre and post scores was 0.44 (P= 0.21). The mean differences between pre and posttest scores

were 3.50 (SD= 4.86). The resulting t-value with 9 degrees of freedom is 2.28, p= 0.05. The 95% confidence interval is (.0239, 6.976).

It appears plausible to conclude that there is no significant difference in the pretest and posttest scores. See the statistical findings in

table 5 below.

Table 5. Statistical Analysis using Paired sample T-test

Paired Samples Statistics

Std. Std. Error
Mean N Deviation Mean
Pair 1 Pretest 21.8000 10 4.91709 1.55492

18.3000 10 4.16467 1.31698

Posttest

Paired Samples Correlations

N Correlation Sig.
Pair 1 Pretest & Posttest 10 .437 .206
 IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 30

Paired Samples Test

95% Confidence Interval of the

Difference
Std. Error
Mean Std. Deviation Mean Lower Upper t df Sig. (2-tailed)

Pretest/Posttest 3.50000 4.85913 1.53659 .02399 6.97601 2.278 9 .049

The first objective of the educational program was to increase the basic understanding of HTN and its complications among

participants. The outcome of this objective was evaluated by asking all participants to identify at least three major complications of

uncontrolled BP. Post educational intervention; all participants (n=10) were able to identify at least three or more complications of

uncontrolled BP. The top three complications identified by participants were heart attack, stroke and kidney failure. The second

objective of the educational program was to help foster a sense of self-confidence with the ability to self-monitor BP. Increasing one’s

ability and confidence to self-monitor BP is very important in managing HTN. Participants were thought how to appropriately monitor

for their BP at home (timing, position, cuff size). By the end of the educational program, all participants were able to demonstrate how

to measure BP correctly using a manual BP cuff. In addition, all participants were able to record their BP reading in a log

The third objective of this educational program was to reach goal BP target in fifty percent of participants. Even though there

was no statistically significant reduction in BP between pre and post intervention, however, fifty percent of participants (n=5) did have

a reduction in BP in post interventions when it was compared to their pre intervention BP check (See Table 6 below). Following the

JNC-8 recommendations, sixty percent (n=6) of participants were identified to reached their target BP goals. Two participants were
IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 31

identified to have inadequate escalation of medication therapy. Seven of the ten participants had at least one to multiple comorbidities

such as diabetes, hyperlipidemia, obesity, chronic kidney disease, coronary artery disease and arthritis. One participant was pre-

diabetic and overweight. Two out of the ten participants had no comorbidities. During the pre BP checks, one of the participants was

found to have severely elevated BP reading. This particular participant did have multiple comorbidities including diabetes, chronic

kidney disease, obesity and hyperlipidemia. The provider was notified immediately to evaluate the patient’s uncontrolled BP readings

and to assess need for escalation of therapy following recommendations from JNC-8. The participants’ medication(s) lists and their

BP measurements in pre and post intervention are listed in Table 6 below.

IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 32

Table 6. Participant’s Current Medications Lists & Pre/Post BP Measurements

Subject ID Current Medications Pre -class Post Reduction

# BP BP In BP

01 Hydrochloro 131/73 129/72 N

-thiazide 12.5

02 Nifedipine XL
90mg, Doxazosin 157/77 151/84 N
8mg

03 Losartan 166/72 144/69 Y

25mg

04 Losartan/HCTZ
100/25mg, 132/72 122/90 Y
Norvasc 2.5mg

05 Losartan 140/63 153/71 N

100mg

06 Losartan/HCTZ
100/25mg 153/86 158/92 N

Metoprolol 50mg
07 Losartan/HCTZ 180/79 142/80 Y
100/25

08 Losartan/HCTZ 148/72 141/75 Y

50/12.5
09 Lisinopril 174/89 161/79 Y
10mg

10 Amlodipine 128/75 129/75 N

5mg
IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 33

Qualitative Data

Engaged Participation & Dialogue

Participants were very engaged and they were encouraged to ask questions and to ask for more clarifications in areas they did

not understand. Many participants were very vocal and they asked questions and made comments throughout the educational program.

The questions and comments made by the participants were in Somali. The DNP student translated some of the comments and

questions that were asked by the participants back to English. The following questions were asked:

“What should my BP be…for someone like my age...?”

“I have been told to take my pills [BP medications] at night time by people before [individuals in the community], should I not take

my pills [BP medications] at night time?

“I have high BP, diabetes and high cholesterol. I am being told to avoid sugar, avoid salt, avoid meats…don’t eat this or don’t eat

that...then what can I eat then?”

“I have a really bad reflux and most of the fruits that I am being told to eat bothers me…what can I eat instead?
IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 34

“Can you bring actual food items for the next class and show us which ones are not good [culturally high sodium food items vs. low

sodium food items]?

Learning Experience

In addition to asking questions, participants provided positive verbal feedbacks and comments throughout the educational

program. Below are some of the comments and feedbacks made by participants:

“Learning about this disease [hypertension] and learning which foods to avoid are important”

“I used to not take my medications for days at times, now I will try really hard not to do that…”

“It’s nice having a class like this where I can actually ask questions and not feel rushed, so thank you”

“We should have more classes like this in the future”

“It would be helpful to do a class for diabetes too especially for the ones that have both high blood pressure and diabetes”
IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 35

“I never checked labels when I am doing grocery before, but now I make sure I check the labels”

Discussion

Improving adherence to BP medication(s) is an important aspect of successful HTN management. The goal for this research

translation project was to increase participants’ adherence to antihypertensive medications, diet and to reach their BP target by

incrementing their understanding and knowledge of the disease process. Delivering the education in Somali without the utilization of

interprets provided an opportunity for the Somali participants to be actively involved in their learning experience. Using a third person

to interpret can delay communication and can break the bond between the learner and the educator. Providing an educational

intervention in which the participants can understand every word that comes out of the educators’ mouth can have a profound effect

on their learning. The participants in this educational program were very engaged in learning, told stories related to their disease

management, and provided positive verbal feedbacks. As an outcome of the educational intervention, there was no significant change

seen in pre and post intervention scores and BP measurements.

Explanation as to why there were no significant change in both pre and post BP readings are influenced by multiple factors. It

is important to point out that the sample size of the participants was very small, which can make it hard to see a meaningful change in

pre and posttest score statistically. In addition, BP measurements can be variable and can be challenging to see a significant change in

such a short time. To get an actual picture of a patient’s BP control, a one time measurement of BP taken at the doctor’s office is not

ideal as this can vary and can be influenced by factors such as emotions, diet, etc. (American Heart Association, 2014). Some of the
IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 36

participants did see a decrease of points in systolic blood pressure and some saw an increase, while others observed no significant

change in BP.

A myriad of factors for not adhering to medications exist; however, culture, diet and availability as to having an access to

healthier food also play a vital role. Immigrants and refugee populations arrive to this nation with healthier cardiovascular risk profiles

than the general population (Singh & Siahpush, 2001), but as time progresses, this advantage tends to decline. The emergence of

cardiovascular risk after years of being residents dramatically increases, since their diets change and many among these individuals

began to consume fast foods. This is seen by their increasing rates of obesity (Goel, McCarthy, Phillips, & Wee, 2004; Kaplan,

Huguet, Newsom, & Mcfarland, 2004) hypertension (Steffen, Smith, Larson, & Butler, 2006), diabetes (Creatore et al., 2010), and

cardiovascular diseases (Lear, Humphries, HageMoussa, Chockalingam, & Manicini, 2009; Lutsey et al., 2008). Therefore, Somalis in

Minnesota have traveled through the known course, which most immigrants are a destined trajectory, and consequently, many suffer

the plague of overweight and obesity (Dalmar et al., 2006).

One noteworthy factor to point out is the utilization of the Hill Bone Scale in this population. An expected interpretational

glitch is the loss of transliteration of languages and the drawback can affect the participants’ response. The feasibility of the

assessment used does not apply to this population since the format of the way questions being phased were found to be culturally

insensitive. For instance, one of the questionnaires in the reduced-sodium subscale of the Hill-Bone Compliance to High Blood

Pressure Therapy scale asks, “how often do you shake salt, fonder or aromat on for your food before your eat it.” The way this

particular question is worded does not seem to be culturally sensitive, as it would not constitute any appreciable outcome. For
IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 37

Somalis, use of flavors are included in the recipe while the food is in the preparation phase; thus, for members in this community,

applying additives to their food is a seldom seen event, though the younger generations may practice otherwise.

Even though, the tool was relatively easy to use, using subjective measures are prone to recall bias and respondents might

provide answers that confirm to their perceived expectations of their interviewer. An example of another question that has raised many

eyebrows when questioned was, “How often do you take someone else’s HBP pills?” Every participant answered this question with

“never.” The applicability of whether medications might be used interchangeably among the individuals might not hold much water

because it might be quite uncommon for a Somali individual to use a medication prescribed for another person. However, using and

sharing herbs and traditional medicines are very common among this community and it is viewed as normally harmless. It is very

common to use herbs for medicinal purposes for chronic illnesses and this is passed from one person to another. If this question were

adjusted by specifying whether he/she has used someone else’s herbs/traditional medication, then the answer to this question would be

completely different.

Nonetheless, the Hill-Bone Scale is a standout amongst the most comprehensively utilized adherence scales. It has been

validated in various settings and populations. It has been tested among African Americans (Kim, Hill, Bone, & Levine, 2000) and in

the local languages of Turkey and South Africa (Karademir, Koseoglu, Vatansevor, & Van, 2009; & Lambert et al., 2006) and on the

medication adherence subscale in Korean language for Korean Americans (Song et al., 2011). However, the psychometric properties

of this scale have never been tested among Somalis and it was found to be difficult to administer it to this population without a

validated translation, and the only hope foreseeable relies on a single area; translation improvement.
IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 38

Limitations

There are some limitations that apply to this quality improvement project that are worth mentioning. First, the size of

participants in this educational program is very small and inferences cannot be made about casual associations. The timing of the class

and lack of access to transportation were found to be two key factors that contributed to the shortage of participants for this

educational program. Second, adherence to medication and diet were based on self-assessment tool that is not culturally sensitive and

has not been validated for use in this community, which hence, increases the potential for bias. The sample size and the data are only

restricted to a small community size clinic located in the heart of Minneapolis most populated Somalis.

Implications for Practice

It is well known that health literacy is increasingly recognized as an important factor in patient’s compliance, screening

utilization, and chronic disease outcomes (Shaw, Huebner, Armin, Orzech, & Vivian 2009). But unfortunately, low health literacy

rates are common in ethnic minorities, the elderly, individuals with lower educational levels, and in individuals with social barriers

such as language and culture (Mårtensson & Hensing, 2012; Ingram, 2012). A study that evaluated barriers to physical activity among

Somali men in Minnesota identified that men over the age of 45 have an increased risk of difficulty in obtaining, processing, and

understanding basic health information (Mohamed, Hassan, Weis, Sia, & Wieland, 2014). Hence, it is vitally important to educate and

increase patient’s knowledge of HTN in an effort to improve their compliance to medical therapy and improve their outcome.

The oral traditions Somalis have been practicing over many centuries is what needs to be thoroughly appreciated, for there is a

profound interest in oral communication above all other forms of communication (Centers for Disease Control & Prevention, 2008). If
IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 39

intended to acquire much productive results with educational programs, then it would be very useful to implement within their

familiarity such as anecdotes, storytelling, chants and epics. Sufficient proof is that most participants of this research translation

project highly preferred and requested more educational sessions through oral communication, rather than in written because it is

widely practiced and an accepted norm that information travels fast when it is shared or spread orally. Ideally speaking, the

improvements needed for future evaluation of educational programs will be prolific with inclusion of larger participants, and with

longer time between pre and posttest measurements. Equally important, healthcare providers and health agents need to focus on

educating the community at large while concurrently employing oral tradition practices, in lieu of individual selection. In so doing, the

totality of above suggestions with awareness of the disease prevention and management will likely bring into greater results.

Conclusion

Hypertension is known to be a silent killer and poor adherence to BP medication is a major risk factor for stroke and heart

attack. Treatment of HTN with medication can decrease the risk of stroke by 31 to 45 percent, and myocardial infarction by 8 to 23

percent (Neal et al., 2000). Hence, it is important for patients to adhere to antihypertensive medications. HTN requires both immediate

behavioral change and long-term behavior maintenance in an effort to manage the disease and prevent end organ damages. The Health

Belief Model provided a foundation for this educational program because the concepts surrounding this model have the potential to

steer positive behavioral changes in regards to participant’s adherence to medication and BP control. The educational program

emphasized the consequences of poor adherence to BP medications, diet, weight and exercise. Considerations were taken to account
IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 40

for the cultural backgrounds, belief systems, and the traditional diets of the Somali populations as it can have an influence on their

decision-making regarding medications use and disease management.

Nevertheless, even though there was no big change seen in this educational intervention in such a short time, there is a possible

lasting effect of the education in the long run. Recognize that Somalis are storytellers (Bentley & Owens, 20080). They embrace oral

traditions, not written. A culturally appropriate educational program that is employed using oral communication, storing telling or

visual images has the potential to make a profound change both in the individual and within the community.
IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 41

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antihypertensive medications: Current Status and Future Directions. Current

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IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 47

Yoon P. W., Gillespie C. D., George M.G, & Wall H. K. (2012). Control of hypertension among

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IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 48

Appendix A

Sample Diagram of the HBM

IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 49

Appendix B

HILL-BONE COMPLIANCE SCALE HILL-BONE HIGH BLOOD PRESSURE

COMPLIANCE SCALE

(4) All the time (3) Most of the (2) Some of the (1) Never
time time
1. How often
do you forget to
take your HBP
medicine?
2. How often
do you decide
not to take your
HBP medicine?
3. How often
do you eat salty
food?
4. How often
do you shake
salt, fondor, or
aromat on your
food before you
eat it?
5. How often
do you eat fast
food? (KFC,
McDonalds, fat
cook, fish and
chips)
6. How often
do you get the
next
appointment
before you
leave the
clinic?
7. How often
do you miss
scheduled
appointments?
8. How often
do you leave
the dispensary
without
obtaining your
IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 50

prescribed
pills? (due to
long line,
closure of the
clinic, forgot)
9. How often
do you run out
of HBP pills?
10. How often
do you skip
your HBP
medicine 1–3
days before you
go to the clinic?
11. How often
do you miss
taking your
HBP pills when
you feel better?
12. How often
do you miss
taking your
HBP pills when
you feel sick?
13. How often
do you take
someone else’s
HBP pills?
14. How often
do you miss
taking your
HBP pills when
you care less?
IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 51

Appendix C

Consent Form for Participation in Quality Improvement Project/Educational Program

University of Massachusetts Amherst

Educator/Investigator: Nimo Abdi, RN, BSN, FNP (c), DNP (c).

Capstone Project Title: Quality Improvement Project: Improving Adherence to

Antihypertensive Medications Among Somali Patients in a

Primary Care Clinic

1. WHAT IS THIS FORM?

This consent form will give you information you will need to understand why this quality

improvement project/educational program is being done and why you are being invited to

participate. It will describe what you will need to do to participate. I encourage you to take some

time to read this form and ask any questions you may have. If you decide to participate, you will

be asked to sign this form and you will be given a copy for your records.

2. WHO IS ELIGIBLE TO PARTICIPATE?

You are encouraged to participate in this quality improvement project if you meet all of the

following criterion: (1) background/ethnicity must be Somali, (2) subject must be at least at age

50 and older, (3) must have a diagnosis of hypertension and (4) must be on at least one

antihypertensive medication.
IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 52

3. WHAT IS THE PURPOSE OF THIS QUALITY IMPROVEMENT PROJECT?

The purpose of this quality improvement project is to evaluate if the use of evidenced-based

interventions such as offering educational sessions and self-monitoring of BP are effective in

improving adherences to antihypertensive medications.

4. WHERE WILL THE QUALITY IMPROVEMENT PROJECT TAKE PLACE AND

HOW LONG WILL IT LAST?

This quality improvement project/educational program will take place in Gargar Clinic and

Urgent Care in Minneapolis. The educational session will take place once a month for a total of 3

months, starting in December and ending in February. Your participation is required from the

beginning to the end of the session. There are two parts of this educational program. The first

part is lecture and will last one hour long. Following the lecture, there will be a hands-on-

teaching/demonstration session which will demonstrate how to self-monitor BP. The second part

will take 30 minutes long.

5. WHAT WILL I BE ASKED TO DO?

If you agree to take part in this educational program, you will be asked to participate in each

class and you are encouraged to follow-up with appointments with provider/DNP student.

A doctorate of Nursing Practice (DNP) student will carry out this educational program by

administrating in-class sessions to participants. The educational program will include a lecture

on hypertension using a PowerPoint presentation. The focus on the lecture will be about the basic

knowledge of hypertension, its complications, and benefits of adhering to blood pressure

medications and diet. The lecture will be one hour long. Following the lectured session, a hands-
IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 53

on teaching/demonstration will take place, which will demonstrate how to self-monitor blood

pressure in order to promote self-management of the disease. The demonstration part will be 30

minutes long. You will be asked to complete a self-assessment tool using the Hill-Bone

Compliance to High Blood Pressure Therapy Scale in order to assess your adherence to taking

blood pressure medications in both before and after the educational sessions ends.

6. WHAT ARE THE BENEFITS OF BEING IN THIS EDUCATIONAL PROGRAM?

There are many benefits for participating in this educational program. I expect this educational

program will help you increase your knowledge of hypertension, and help you learn more about

the complications of uncontrolled blood pressure and the importance of adhering

antihypertensive medications and diet. I expect this educational program will help nurture a

sense of self-confidence with your capacity to self-monitor blood pressure and disease

management.

7. WHAT ARE my RISKS OF being in THIS QUALITY IMPROVEMENT PROJECT?

The interventions being implemented are designed to pose no risks while maximizing potential

benefits. There are known risks associated with this educational program, however, a possible

inconvenience may be the time it takes to complete the educational program.

8. How WILL MY PERSONAL INFORMATION BE PROTECTED?

Your privacy and confidentially will be maintained throughout this translation project. You will

not be identified using names. You will be kept informed throughout the process and you will be
IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 54

protected under the policies surrounding the Health Insurance Portability and Accountability Act

(HIPPA). All of your health information will be kept confidential and protected.

9. WHAT IF I HAVE QUESTIONS?

Take as long as you like before you make a decision. We will be happy to answer any question you

have about this this educational program. If you have further questions about this project or if you

have a problem related to this educational program, you may contact the educator (Nimo Abdi,

email: nabdi@nursing.umass.edu) or you may contact the clinic or your primary care provider by

this phone number (612- 339-3300). If you have any questions concerning your rights as a

participant, you may contact the clinic and notify your primary care provider and/or DNP

student.

10. CAN I STOP BEING IN THE QUALITY IMPROVEMENT PROJECT?

You do not have to participate in this educational program if you do not want to. If you agree to be

in the program but later change your mind, you may drop out at any time. There are no penalties or

consequences of any kind if you decide that you do not want to participate.

11. SUBJECT STATEMENT OF VOLUNTARY CONSENT

When signing this form I am agreeing to voluntarily participate in this educational program. I

have had a chance to read this consent form, and it was explained and translated to me in a

language, which I use and understand. I have had the opportunity to ask questions and have

received satisfactory answers. I understand that I can withdraw at any time. A copy of this signed

Informed Consent Form has been given to me.

IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 55

________________________ ____________________ __________

Participant Signature: Print Name: Date:

By signing below I indicate that the participant has read and, to the best of my knowledge,

understands the details contained in this document and has been given a copy.

_________________________ ____________________ __________

Signature of Person Print Name: Date:

Obtaining Consent
IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 56

Appendix D

University of Massachusetts Amherst Human Research

Protection Office
108 Research Administration Building Research Affairs
70 Butterfield Terrace
Amherst, MA 01003-9242

Telephone: 545-3428 FAX: 577-1728

Telephone: 545-3428
FAX: 577-1728

MEMORANDUM
To: Nimo Abdi
From: Human Research Protection Office
Date: November 3, 2015

Project Title: Improving Adherence to Antihypertensive Medications among Somali Patients in

Primary Care Clinic

IRB Number: 15-027

The Human Research Protection Office (HRPO) has evaluated the above named project and has
made the following determination:

The activity does not involve research that obtains information about living individuals.

The activity does not involve intervention or interaction with individuals OR does not use
identifiable private information.

The activity is not considered research under the human subject regulations. (Research is
defined as “a systematic investigation designed to develop or contribute to generalizable
knowledge.)

The activity is determined to meet the definition of human subject research under federal
regulations, but may qualify for exemption. If uncertain as to whether the scope of the research
falls within an exempt category, please contact the HRPO for guidance. Exempt determinations
must be made by the IRB.

The activity is determined to meet the definition of human subject research under federal
regulations and is not exempt. The research must be reviewed and approved by the IRB and
requires submission of applicable materials.
IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 57

Information regarding Types of Review for human subject research protocols may be found at
http://www.umass.edu/research/irb-guidelines-levels-review

For additional information, please contact the Human Research Protection Office at 545-3428.

Cc: OGCA
IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 58

Appendix E

Understanding blood pressure

Waa Maxay Cadaadiska Dhiigu?

 “Blood pressure (BP) is a measurement of the force against the walls of your arteries as your heart pumps
blood through your body” (National Institutes of Health [NIH], 2014).

Systolic measures
the pressure in your arteries
while your heart is BEATING →Systolic/Diastolic ← Diastolic measures the pressure in your
arteries when your heart is AT REST.

Waa Maxay Cadaadiska Dhiigu?

 Wadnahaagu marku garaac samaynayo wuxuu dhiiga u diraa jirkaga si uu u siiyo tabar iyo oksajiinta uu u
baahan yahay.
 Qulqulka dhiiga ayaa cadaadis ku sameeya gidaarada xididada dhiiga.
Xooga cadaadiskan ayaa la yirahaa dhiig-kar.

Vidiiyow Ku saabsan Dhiik-Kar

 https://www.youtube.com/watch?v=qSkGJZT0ULU

Classification of Blood Pressure in Adults (Age ≥ 18)

Classification Systolic Blood Diastolic Blood
Pressure Pressure
(mmHg) (mmHg)

Normal <120 AND <80

Prehypertension 120-139 OR 80-89

Stage I HTN 140-159 OR 90-99

Stage 2 HTN ≥160 OR ≥100

Blood Pressure Goals

IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 59

Population Blood Pressure Goal

(Systolic/Diastolic)

< 60 years old <140/90 mmHg

> 60 years old <150/90 mmHg

Chronic Kidney Disease <140/90 mmHg

Diabetes <140/90 mmHg

Maxaa Sababa Dhiig-karka?

Ma jiro sabab kaliya oo keenta dhiigkar.
 Da’da
 Jinsiyadaada
 Dhaxal qoys
 Xaalad caafimaad oo kale sida
 Kalyo xanuun (kidney disease)
 Sonkor (Diabetes)
 Wadna xanuun (Heart attack)
 Subaga dhiiga (High cholesterol)

Halis baad ku jirtaa Haddii

 Aanad cunin khudaar kugu filan
 Aad badsato milix/cusbo
 Aanad firfircoonayn
 Miisaankaagu sareeyo
 Sigaar cabtid
 Istares badan
Halista U Keeno Dhiig-Karka
 Haddii cadaadiska dhiigaagu uu sareeyo, wuxuu culays dheeraad ah saaraa wadnaha iyo xididada dhiiga.
Markaay muddo sidaa ahaato, ayaa culayskani waxyeelo u keenaa wadnahaaga iyo xubnaha jirkaaga taas
oo halis ku noqon karta caafimaadkaaga.
Halista U Keeno Dhiig-Karka
 Wadno xanuun
 Wadno-istaago (Heart attack)
 Istarook (stroke)
 Kilyo xanuun (kidney disease)
 Xasuus la ‘aan
 Camoole (Indho beel)
Waxtarka Dawada
 Dhiigkarka lagama bogsado
 Haddii aad u baahato inaad qaadato dawooyin, waxaa hubaal ah inaad waligaa qaadanayso dawooyinkaa.
 Haddii aad joojiso dawooyinka dhiig karkaagu mar kale ayuu kacayaa.
 Waxaa muhim ah inaad qaadato dawooyinkaaga, xataa haddii aanad ku niyadsamayn.
 Dhiigkarkaaga oo aad hoos u dhigta waxay kaa ilaalinaysaa wadnahaaga iyo xiddidada dhiiga inay
waxyeelo soo gaarto.

Waxtarka Dawada
IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 60

 MEDICATION SAFETY VIDEO

 https://ethnomed.org/patient-education/medication/medication-safety-somali.flv/view
Waxtarka Dawada
 Approximately half of all hypertensive patients in the nation are non-adherent to their treatment regimen
 Treatment of HTN with medication can:
 Decrease the risk of stroke by 31 to 45 percent
 Myocardial infarction by 8 to 23 percent
Ka Faa’iidaysiga Dawada
 Qaado dawadaada subax kasta sidii lagugu talagaley
 Qaado dawadaada isku waqti kasta subaxii
 Qaado dawadaada sida lagu talagaley
 Qaado dawadaada hadi cadaadiskaaga dhiiga xataa u maraayo meeshi logu talagaley
 Ha iska joojin dawadaada ado la’hadlin dhaqtarkaaga
 Take medication exactly as prescribed, even if your BP reading is within the normal range
 Do not stop or self-discontinue a medication on your own without consulting with your doctor first.

Muhiimka La shaqeynta dhaqtarkaaga

 Waxaa muhiim ah in aad dhaqtarkaaga la’kulanto marwalba oo aad bilowdid dawo cusub. Tan macnaheedu
waa in la hubsado in dawadu wax kuu tartey iyo in aad wax dhibaato ah kala kulantey
 Haddii aad dareento isbedel marka aad bilowdid qaadashada daawo cusub, waxaa muhiim ah inaad
dhaqtarkaaga la kulantin sida uga dhaqso badan

Is-Cabirka Dhiigkarka marka aad Guriga Joogto

 Iska cabir dhiiga marki daawo cusub lagu qoro
 Isbadal lagu suubiyo dawadaada
 Iyo markaad joogto guriga inta u dhaxeysa ballamaha aad la leedahay dhaqtarka.
Is-Cabirka Dhiigkarka marka aad Guriga Joogto
 Make sure you take your BP reading at the same time each day
 Don’t smoke, drink caffeinated beverages, or exercise within 30 minutes before measuring your blood
pressure.
 Sit with your back straight and supported on a chair and have your feet flat on the floor.
 Your arm should be supported flat on a table with the arm at heart level
Qaab-Nololeed Caafimaad Qaba oo Hoos u Dhigi kara Dhiigkarkaaga
 Cun khudrad badan
 Milixda oo aad iska yarayso
 Culeeyskaaga ilaali
 Noqo Qof Firfircoon

DASH DIET
IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 61

DIETARY APPROACHES TO STOP HYPERTENSION

 CUNTOOYIN WAXTAR U LEH DHIIG-KARKA
 MAALIN WALBA CUN CUNTADAAN KALA DUWAN:
 KHUDAAR BADAN
 FRUITS/MIRO BADAN
 BADAR, QAMADI AMA SARREEN
 LAWS/DIKIRTA QALA LAN
 CUNTOYINKA CAANAHA LA GA SAMEEYO OO DUFANKU KU YAR YAHAY
 HILIBKA AAN BARUURTA LAHAYN/DIGAAGGA/KALLUNKA
 SALIIDAHA/DUFANKA KU YAR YAHAY
 IYO MACMAAN YAR
FA’IIDADA DASH DIET
 WAXAA LA HUBAA IN EEY CADAADISKA SAREEYO UU HOOS U DHIGAAYO
 WAXEEY KAA CAWINEYSAA:
 WADNO XANUUN
 ISTAROOK
 KILYO XANUUN
 SONGOR/KAADI MACAAN
 KAANKARO

Koox Cunto Size Adeegaya

Badar, qamadi ama sarreen Hal jeex oo rooti
Hal koob oo badar/cereal diyaarsan
Koob barkiisa oo ah baasto/bariis ama cereal karsan

Khudaar Hal koob o ah khudaar cayriin

Koob barkiisa oo ah khudradda la kariyey

Miraha/Fruits Dhoor xabo fruit/miro dhexdhexaad ah

Cuntooyinka caanaha laga sameeyo oo dufanka ku yar Hal koob oo caano ah ama hal yogurt
yahay
Hilibka aan baruurta lahayn/Digaagga/kalluunka 1 ounce oo hilib/digaag/kalluun, ama hal ukun

Lawska/digirta qalalan Labo qaando oo laws ah ama koob barkiisa oo digir karsan

Saliidaha/dufanka Hal qaando saliid ah.

Macmacaanka Macmacaan oo dufanka ku yar yahay.

Sonkor hal qaando kaliya

Milixda oo aad iska yareeysid

 Inta badan milixda aad cunto ma aha tan aad ku darto raashinka aad karsato ee waa ta ku jirta cuntooyinka
diyaarsan sida rootiga, qureecda, iyo cuntooyinka kale ee diyaarsan.
 Markaa aad cunto soo gadanaysid, fiiri waraaqda ku dhegsan oo dooro midda milixdu ku yar tahay.

WAA MA’XAY SOODHIYAM?

 SODIUM
AMA
IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 62

 SOODHIYAM

WAA MA’XAY SOODHIYAM?

 Soodhiyam wuxuu kaalin weyn ka ciyaaraa cusbada iyo dheelitirka biyaha jirkaada.

MILIX/CUSBO AMA SOODHIYAM

 IIBSO CUNTOOYINKA LAGU DHUL QORAY:
 “MA LAHA SOODHIYAM” (SODIUM FREE)
 SOODHIYMA YAR (LOW SODIUM) ama
 SOODHIYAM LA YAREEYAY (REDUCED SODIUM)

SODIUM FREE/MALAHA SODHIIYEM

LOW SODIUM/SOODHIYAM YAR

REDUCED SODIUM/SOODHIYAM LA YAREEYE

QIIYAASTA SODIUM/SOODHIYAM
 Ha cunin in ka badan1,500mg oo soodhiyam maalinti
 BARO MARKASTA INAAD CUNTADA ISKA FIIRISID
 MARKAAD ADEEYGANEYSID
 MARKAAD CUNTADA KARSANEYSID

HAL KII BARADHO?

IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 63

IMISA SODIUM KU JIRTO AFARTII XABO TIMIR?

CULEYS KAAGA ILAALI

 Hadii miisaan kaagu sareeyo,inaad rido culeeyska waxay kaa caawin doontaa ineey hoos u dhigto
dhiigkarkaaga waxeeyna yaraynaysaa mushkiladaha caafimaad
 Habka ugu fiican ee aad iskaga dhimi karto miisaanku waa inaad cunto raashinada ay ku yar yihiin dufanka
iyo kaloorigu isla markaana aad jimicsi samayso. Sidan ayaad miisaanku u ridi kartaa addiga oo aan
‘cuntada iska dayn’

BMI CHART
IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 64

Noqo Qof Firfircoon

 30 daqiiqo oo jimicsi dhexdhexaad ah oo aad samayso shan goor todobaadkii ayaa ka dhigi kara
wadnahaaga mid caafimaad qaba sidoo kalana yarayn kara dhiigkarkaaga.
 Haddii 30 daqiiqo aad waqtigaaga maalintii ka dhex samayn kari waydo, hawlaha gacanta aad ka qabato oo
aad in yar kordhiso laftoodu wax bay kuu tarayaan.

Noqo Qof Firfircoon

 Ka fikir siddii aad u noqon lahayd mid aad u firfircoon maalintii.
 Isbedel kooban ku samee raashinkaaga iyo heerka jimcisigaaga kaas oo aad waddi karto waligaa
IMPROVING ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS 65