Digital Repository Doctoral Projects Fall 2022 Reducing Blood Pressure in Hypertensive Patients using the Community-Based Approach in Ogden, Utah Thomas J. Cox Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Cox, T. J. (2022). Reducing Blood Pressure in Hypertensive Patients using the Community-Based Approach in Ogden, Utah Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. December 16, 2022 Reducing Blood Pressure in Hypertensive Patients using the Community-Based Approach in Ogden, Utah by Thomas J. Cox A project submitted in partial fulfillment of the requirements for the degree of DOCTOR OF NURSING PRACTICE Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, Utah December 16, 2022 Project Consultant: Mary Anne Reynolds, PhD. RN _______________________________ ______________________________ Thomas J. Cox, DNP-FNP Student, RN Date _______________________________ _____________________________ Joyce M. Barra PhD. RN Faculty Project Lead Date _______________________________ ______________________________ Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE Date Graduate Programs Director December 16, 2022 Thomas Cox December 16, 2022 REDUCING BLOOD PRESSURE BY COMMUNITY-BASED APPROACH 2 Table of Contents Abstract ........................................................................................................................................... 4 Community-Based Hypertension Management Ogden Clinic ....................................................... 4 Problem Statement ...................................................................................................................... 6 Diversity of Population ............................................................................................................... 6 Significance of Practice Reflective of Role-Specific Leadership ............................................... 7 Literature Review and Framework ................................................................................................. 7 Search Method............................................................................................................................. 8 Framework .................................................................................................................................. 8 Adult Hypertension ..................................................................................................................... 9 Contributing Lifestyle Factors to Hypertension .......................................................................... 9 Modifiable Factors: Diet and Exercise .................................................................................. 10 Behavioral Factors: Cigarettes and Alcohol Usage ............................................................... 11 Lifestyle Modifications as Treatment of HTN .......................................................................... 11 Diet ........................................................................................................................................ 11 Exercise ................................................................................................................................. 11 Smoking and Alcohol ............................................................................................................ 12 Consequences ............................................................................................................................ 12 Solution: Community-Based Care Focusing on Lifestyle Modifications ................................. 13 Project Plan ................................................................................................................................... 13 Project Design ........................................................................................................................... 14 Needs Assessment/Gap Analysis of Project Site and Population ............................................. 15 Cost Analysis and Sustainability of Project .............................................................................. 15 Project Outcomes ...................................................................................................................... 16 Consent Procedures and Ethical Considerations ....................................................................... 17 Instruments to Measure the Effectiveness of Intervention ........................................................ 17 Project Implementation ................................................................................................................. 18 Interventions .............................................................................................................................. 18 Interventions Align with Short-Term and Long-Term Outcomes ............................................ 19 Project Timeline ........................................................................................................................ 20 Evaluation ..................................................................................................................................... 21 Data Maintenance/Security ....................................................................................................... 21 Quantitative Data....................................................................................................................... 21 REDUCING BLOOD PRESSURE BY COMMUNITY-BASED APPROACH 3 Table 1 ....................................................................................................................................... 21 Table 2 ....................................................................................................................................... 22 Table 3 ....................................................................................................................................... 22 Table 4 ....................................................................................................................................... 23 Table 5 ....................................................................................................................................... 23 Table 6 ....................................................................................................................................... 23 Qualitative Data......................................................................................................................... 24 Table 8 ....................................................................................................................................... 24 Quality Improvement Discussion ................................................................................................. 25 Findings ..................................................................................................................................... 25 Strengths ................................................................................................................................ 25 Limitations ............................................................................................................................. 25 Translation of Evidence into Practice ....................................................................................... 26 Implications for Practice and Future Scholarship ..................................................................... 26 Sustainability ......................................................................................................................... 27 Dissemination ........................................................................................................................ 27 Conclusion ................................................................................................................................. 28 References ..................................................................................................................................... 29 Appendix A ................................................................................................................................... 35 Patient Demographics ............................................................................................................... 35 Health History Questions .......................................................................................................... 36 Focused Health History ............................................................................................................. 36 Blood Pressure Questions.......................................................................................................... 37 Appendix B ................................................................................................................................... 38 Readiness Survey ...................................................................................................................... 38 Appendix C ................................................................................................................................... 40 Well-Being ................................................................................................................................ 40 Nutrition .................................................................................................................................... 40 Exercises.................................................................................................................................... 41 Stress ......................................................................................................................................... 42 Appendix D ................................................................................................................................... 43 Tracking Sheet........................................................................................................................... 43 REDUCING BLOOD PRESSURE BY COMMUNITY-BASED APPROACH 4 Abstract Hypertension is a leading cause of heart disease in the United States. Nearly 27% of Ogden City residents have hypertension (Utah Department of Health, 2020). This percentage is expected to rise even higher by 2025. Implementing a community-based approach to managing hypertension has proven effective and low-cost (Jafar et al., 2020). A community-based approach to hypertension involves local providers educating the population on hypertension interventions, including diet, exercise, medications, and self-monitoring. Purpose: The Doctorate of Nursing Practice (DNP) project was designed to educate and empower the Ogden, Utah, residents about lifestyle changes and self-management of their previously undiagnosed hypertension. Methodology: The DNP project offered each participant a blood pressure cuff and fitness tracker and invited participants to attend three educational classes about self-management and lifestyle modifications. Each participant completed a pre- and post-survey to evaluate learning outcomes and participants’ understanding and confidence in self-management of hypertension with lifestyle modifications. Results: After the implementation, the participants showed a 5.778 point reduction in their systolic blood pressure and a 5.148 point reduction in diastolic blood pressure over 12 weeks. Implications for Practice: Patients provided with equipment to monitor blood pressure and fitness show an increased engagement in their health and self-management—education classes allowed for increased knowledge and a sense of community with participants. Community-Based Hypertension Management Ogden Clinic It is estimated that by 2025, 30% of the world population will have hypertension (HTN) (Mittal & Singh, 2010). The hypertension endemic is the leading cause of major cardiovascular REDUCING BLOOD PRESSURE BY COMMUNITY-BASED APPROACH 5 events like strokes and myocardial infarctions (American Heart Association, 2016). Every year, one out of every four deaths in the United States is from cardiovascular disease (Million Hearts, 2021). Heart disease from hypertension costs the United States 316.6 billion dollars each year. That cost is expected to increase to 545 billion dollars by 2030 (Million Hearts, 2021). The cost of hypertension is unsustainable for the economy and for individuals who experience cardiovascular complications. Many aspects contribute to this notable rise in hypertension, including the population’s age, genetic predisposition, stress management, environmental factors, medication adherence, access to a primary care provider (PCP), hypertension education, and lifestyle behaviors (Kim et al., 2015). Lifestyle behaviors include an individual’s diet, exercise, alcohol consumption, smoking habits, and activity levels. Early modifications of lifestyle behaviors that contribute to hypertension are associated with decreased blood pressure (Centers for Disease Control and Prevention [CDC], 2020b). Specifically, dietary approaches designed to address hypertension, such as the DASH Diet, and moderate exercise, such as brisk walking for 30 minutes daily, have been shown to decrease blood pressure (American Heart Association, 2016). Educating the public through a community-based program emphasizing lifestyle modifications has shown a decrease in patient blood pressure. Decreasing blood pressure is the first goal of the surgeon general to improve cardiovascular disease in the United States (CDC, 2020b). Reducing hypertension on a macro-level throughout the United States is a daunting and costly task; however, community-based hypertension interventions have proven to be a low-cost and effective means of addressing the hypertensive endemic (Jafar et al., 2020). REDUCING BLOOD PRESSURE BY COMMUNITY-BASED APPROACH 6 The aim of the study is to pilot a no-fee service clinic in Ogden, Utah, with a community-based approach that focuses on lifestyle modifications. Hypertension has become endemic in Ogden, with 33% of its residents diagnosed with hypertension (Utah Department of Health, 2020). Problem Statement In Ogden, Utah, 27% of the residents responded in the affirmative to a questionnaire asking if they had been diagnosed with hypertension by a healthcare professional (Utah Department of Health, 2020). Several lifestyle behaviors can lead to HTN within a population. Lifestyle behaviors like smoking cigarettes, consuming excessive alcohol (> 2 drinks for men, > 1 drink for women daily), and maintaining a diet high in sodium have a positive correlation with increased blood pressure (Whelton et al., 2018). A lack of exercise, combined with obesity, contributes to HTN development (Rexhaj et al., 2017). More than half of individuals who smoke, drink, and are overweight have hypertension (American Heart Association, 2021). A patient with poorly managed HTN is at risk for developing cardiovascular events such as myocardial infarction (MI) and strokes. For every 10-mm Hg increase in systolic blood pressure, stroke risk increases by 8% for non-Hispanic whites and 24% for non-Hispanic African Americans (CDC, 2020b). Hypertension causes heart structural and functional changes, leading to heart failure (CDC, 2020b). Prevention of hypertension is vital to ensure patients maintain the lowest risk for developing cardiovascular events. It is imperative patients begin lifestyle modifications early that emphasize a heart-healthy diet and exercise to decrease their blood pressure (BP). Reducing alcohol intake and smoking cessation can also help prevent cardiovascular events. Diversity of Population REDUCING BLOOD PRESSURE BY COMMUNITY-BASED APPROACH 7 East central Ogden consists of 50% White, 40% Hispanic, and 10% other ethnicities (United States Census, 2019). An estimated 25% of this population lives below the poverty level. Just over 15% of White residents and almost 30% of Hispanic residents are uninsured. The uninsured represent a large portion of the population that is considered at risk (United States Census, 2019). Uninsured residents often lack the resources to see a PCP for routine physical wellness checks and, therefore, have a greater risk of undiagnosed hypertension or poorly managed hypertension. This project will seek to recruit at-risk participants with undiagnosed or poorly controlled hypertension. Significance of Practice Reflective of Role-Specific Leadership The family nurse practitioner (FNP) will be a primary care provider throughout the study since hypertension is a common disease affecting middle-aged and elderly individuals nationwide. A DNP-FNP will be the primary care provider for many of these individuals. This project will allow the DNP student to learn why individuals may struggle with hypertension management and provide the student with knowledge of bedside treatment for hypertension. The DNP student will also learn team collaboration by working with the Weber-Morgan Health Department and Weber State University members. Finally, the DNP-FNP student will serve the Ogden, Utah, community by assisting in the creation of a no-fee-for-service, HTN clinic. Literature Review and Framework This literature review aims to establish the efficacy and evidence-based practice standards for a community-based approach to hypertension (HTN) management. A community-based approach to HTN includes lifestyle modifications, self-management, medication adherence, and a team approach with the participant becoming self-sufficient with their HTN management. This literature review condenses and focuses on how lifestyle modifications can REDUCING BLOOD PRESSURE BY COMMUNITY-BASED APPROACH 8 improve HTN management. Lifestyle modifications are a broad-spectrum treatment for HTN, with many avenues for possible modifications to lower blood pressure. For this literature review, lifestyle modifications will include diet, exercise, smoking cessation, and alcohol moderation (< 2, twelve ounces of beer or five ounces of wine for men, < 1 for women daily) (Whelton et al., 2018; Rexhaj et al., 2017). Search Method Search terms for this literature review include hypertension, community-based approach, blood pressure, exercises for hypertension, diet for hypertension, high blood pressure, team approach to HTN management, Dietary Approaches to Stop Hypertension (DASH) diet, Mediterranean diet, step counting, smoking cessation on blood pressure, alcohol consumption on blood pressure, HTN guidelines, HTN management, and self-management of blood pressure. Databases used include Google Scholar, One Search, PubMed, Gov Census, NCBI, and CORE. Journals and articles used were within 15 years of the current year. Incomplete or pre-published journals or studies were excluded. Framework Transformational leadership provides a framework for a successful community-based approach to hypertension management. Transformational leadership consists of four areas: idealized influencer, inspirational motivation, intellectual stimulation, and individual consideration (Farnsworth et al., 2021). Idealized influencers use exemplary role model behavior to gain trust and respect. Inspirational motivation focuses on encouraging and building up individuals to succeed. Intellectual stimulation uses education, critical thinking, and understanding to help individuals incorporate new information into their lifestyles. Finally, REDUCING BLOOD PRESSURE BY COMMUNITY-BASED APPROACH 9 individualized consideration for each participant will ensure everyone receives adequate instructions on hypertension at their current learning and knowledge. Inspirational motivation and individualized consideration will be the focus for teaching lifestyle modifications. These two forms of transformational leadership will allow everyone in the program to receive customized teaching and motivation to improve. Understanding the pathology of HTN and receiving constant motivation from a team increase adherence to medications, lifestyle modifications, and self-management of HTN (Million Hearts, 2021). Adult Hypertension HTN is present in over 1.2 billion individuals worldwide, leading to a global pandemic (Rossier et al., 2017). In the United States, HTN has become one of the most expensive public health problems, with 1.5 million heart attacks and strokes occurring every year and 800,000 deaths occurring annually from cardiovascular disease. That means one out of every four deaths is due to cardiovascular disease, with HTN being the major contributing factor (Center of Disease Control, 2021). Adult hypertension has two stages. Stage 1, also known as pre-hypertension, is systolic blood pressure (SBP) of 130–139 mm Hg or diastolic blood pressure (DBP) of 80–89 mm Hg. The definition of Stage 2 hypertension is an SBP of 140 mm Hg or greater or a DBP of 90 mm Hg or greater (American Heart Association, 2016). Adult patients must have two consecutive clinic visits with high BP to receive a HTN diagnosis. It has been recommended that treatment for HTN should begin for all patients with two BP readings of 130/80 or greater (James et al., 2014). Contributing Lifestyle Factors to Hypertension REDUCING BLOOD PRESSURE BY COMMUNITY-BASED APPROACH 10 Many factors contribute to HTN, including genetics, age, sex, race, diet, exercise, smoking, alcohol, medications, and unknown causes (Unger et al., 2020). Patients must adhere to medication regimens and manage their lifestyles to decrease blood pressure. Lifestyles that include a diet with excessive caloric or sodium intake, a lack of exercise, and prolonged sitting positively correlate with elevated blood pressure. Smoking cigarettes and consuming excessive alcohol also produce high blood pressure (Rexhaj et al., 2017; Makoff et al., 2018 Orth, 2004; Nguyen et al., 2012). Modifiable Factors: Diet and Exercise Diet has a significant impact on blood pressure and overall health. A diet with excessive caloric intake, resulting in weight gain, correlates with hypertensive properties more strongly than smoking (Hall et al., 2019). Any form of weight gain adds peripheral vascular resistance forcing the heart to increase its force of contraction, leading to elevated BP (Stampehl et al., 2017). Another major dietary contributor to HTN is excessive amounts of sodium. Those who consume more than seven grams of salt daily can expect an increase in BP by 2 mm Hg per gram of salt (Rexhaj et al., 2017). The dietary combination of excessive weight gain and salt intake are two significant contributors to HTN. Activity, defined as the movement of the body that requires energy expenditure, also significantly impacts blood pressure. Individuals who are physically inactive compared to their physically active counterparts within the same age, sex, and race categories see a BP increase of nearly 7 mm Hg (Twinamasiko et al., 2018). In addition, prolonged sitting over months is associated with a 30–50% increase in developing HTN compared to active peers (Makoff et al., 2018). Individuals at risk for physical inactivity include the elderly, those with a chronic disease, loss of mobility, or occupations that require prolonged sitting (Whelton et al., 2018). REDUCING BLOOD PRESSURE BY COMMUNITY-BASED APPROACH 11 Behavioral Factors: Cigarettes and Alcohol Usage Behavior choices contributing to HTN are smoking cigarettes and drinking alcohol excessively. Smoking has a positive correlation with high BP, and smoking cessation has shown an average drop in BP of 3-7 mm Hg in men in Vietnam (Nguyen et al., 2012). Smoking increases BP through vasoconstriction of the peripheral blood vessels and causes a positive inotropic (force) and chronotropic (speed) effect on the heart (Orth, 2004). The more cigarettes an individual smokes, the greater the impact and prolongation on their BP. Alcohol levels and a rise in BP have a positive linear association with the prevalence of HTN and cardiovascular disease risk (Unger et al., 2020). Excessive alcohol consumption for men is drinking three or more drinks in one sitting, and for women, two or more drinks (CDC, 2020b). Excessive alcohol consumption contributes to high BP directly through the added fluid volume and indirectly through cirrhosis of the liver and weight gain (Jafar et al., 2020; Stampehl et al., 2017). Lifestyle Modifications as Treatment of HTN Diet Two diets that decrease BP are the Mediterranean diet and Dietary Approach to Stop Hypertension (DASH) diet (Tosti et al., 2017). Both diets incorporate more fiber, potassium, and healthy fats (monounsaturated and polyunsaturated) while decreasing the consumption of sodium, sugar, and unhealthy fats (trans and unsaturated). These diets encourage individuals to eat more fruits and vegetables while reducing their consumption of processed foods. Salt substitutes for flavoring are encouraged to decrease the amount of sodium added to food (Dash for Health, 2015). Exercise REDUCING BLOOD PRESSURE BY COMMUNITY-BASED APPROACH 12 Exercise is a proven prevention and treatment option for HTN (Unger et al., 2020). Moderately intense aerobic exercise such as brisk walking, jogging, swimming, or cycling for 30 minutes three times a week can reduce SBP by 6 mm Hg within six weeks (Sharman et al., 2019). Brisk walking that increases an individual’s heart rate every day for at least 10 minutes shows a moderate decrease in resting heart rate and BP (Unger et al., 2020). Exercise and caloric insufficiency decreases excessive weight, lowering peripheral vascular resistance and BP (CDC, 2020b). Smoking and Alcohol Smoking and excessive alcohol correlate with HTN (Unger et al., 2020). Many individuals wish they could stop their smoking or drinking addiction. The willpower to overcome these addictions is usually not enough, and a program designed to help quit will be necessary for many (Gallup, Inc., 2021). Education on how much each alcoholic beverage contains and the standard alcohol amount limit is also helpful in avoiding excessive drinking. Lifestyle modification for alcohol consumption is moderate consumption. There is no positive correlation between moderate alcohol intake and HTN (CDC, 2020a). Consequences Hypertension has become the most critical and expensive public health problem affecting over 1.2 billion individuals worldwide and 1.5 million Americans (Rossier et al., 2017). Patients with undiagnosed or poorly managed HTN are 54% more likely to have a stroke and 47% more likely to have a myocardial infarction (MI) (Wu et al., 2015). HTN can also lead to vision loss, tinnitus, kidney failure, and sexual dysfunction (American Heart Association, 2016). These complications negatively impact a patient’s quality of life by limiting their independence and adding a financial burden. REDUCING BLOOD PRESSURE BY COMMUNITY-BASED APPROACH 13 HTN costs the United States, on average, 315 billion dollars a year with cardiovascular disease, stroke, and MI (Wang et al., 2017). Individuals with HTN can expect to pay, on average, two thousand dollars more each year on healthcare than their peers without hypertension. Hypertensive individuals have 2.5 times higher inpatient costs, double the outpatient cost, and triple the prescription medication expenditures (Kirkland et al., 2018). Proactive treatment of HTN can prevent these extra financial costs associated with untreated HTN (Fukushima et al., 2018). Solution: Community-Based Care Focusing on Lifestyle Modifications Treatment of HTN through a community-based approach has shown effective HTN management at a low cost (Carey et al., 2018; James et al., 2014; Schwalm et al., 2019). The community-based approach to HTN addresses both significant consequences of undiagnosed and poorly managed HTN by relieving financial burdens and preventing major cardiovascular events. A community-based approach consists of a team of healthcare professionals dedicated to training patients to self-manage their HTN (Dixon et al., 2018). Self-management consists of medication adherence, BP monitoring, lifestyle modifications, and understanding when to seek a provider (Kim et al., 2015). Lifestyle modifications are the first-line treatment for HTN. Implementing lifestyle modifications such as diet changes, exercise, smoking cessation, and moderation in alcohol have proven to decrease HTN (CDC, 2020b). However, lack of access to providers allows HTN to go often undiagnosed or poorly managed (Kirkland et al., 2018). A community-based approach provides this at-risk population with providers, clinics, and medications, and a team-based approach to diagnose, educate, and manage their HTN through lifestyle modifications. Project Plan REDUCING BLOOD PRESSURE BY COMMUNITY-BASED APPROACH 14 This project includes a study of 25–30 participants in the Ogden area. The participants who meet inclusion criteria will be subject to a physical exam, blood tests, educational material on lifestyle modifications for hypertension, and personalized teaching regarding nutrition and exercise. Each participant will learn how to self-manage their BP by tracking their blood pressure, nutritional intake, physical exercise, and medication adherence. The plan includes using the Weber State University community center, two doctorates of nursing practice students, and federal funding of $40,000. Assistance by Weber State University faculty and Weber-Morgan Public Health Department staff is also provided in this community-based approach to hypertension. Project Design This quality improvement project aims to provide a community-based approach to hypertension management. This community-based approach involves Weber State University, the Weber-Morgan Public Health Department, and the residents of Ogden, Utah. This project consists of a 12-week program to lower blood pressure through nutrition and exercise. Each participant will receive education on heart-healthy eating, which emphasizes eating more fruits and vegetables and less red meats, fatty foods, salt, and sweets. Participants will also be encouraged to either take 8,000 steps daily or participate in moderate exercise for 15 minutes each day. Participants will receive a fit band or pedometer and tracking sheet to assist them in monitoring their daily physical activity. The tracking sheet also allows participants to document their nutritional intake of fruits and vegetables, salt, and heart-healthy meals. Every four weeks, there will be an education class to provide further education on nutrition and exercise. The DNP students will provide instruction during these educational classes using the transformational REDUCING BLOOD PRESSURE BY COMMUNITY-BASED APPROACH 15 leadership methodology. Materials will include reading nutrition labels, decreasing sodium intake, making heart-healthy meals, and progressively increasing physical activity and intensity. Needs Assessment/Gap Analysis of Project Site and Population At-risk residents of Ogden experience the following social determinants of health: lack of insurance, absence of a primary care provider (PCP), limited transportation, limited access to prescription medications, insufficient finances for healthcare, and a lack of HTN education (Mysidewalk, 2019). In addition, the Hispanic/Latinx residents, which number 15–20% of the population in the Ogden area, may have a language barrier to overcome (Census Reporter, 2019). This project aims to overcome these social determinants of health by providing no-cost medical care for adults with HTN who reside in Ogden, Utah. Furthermore, the participants in this project will not be required to have insurance, will be provided with educational materials written in English and Spanish, and will receive ongoing in-person classes every four weeks. Cost Analysis and Sustainability of Project The HTN clinic team comprises a clinical lab, doctorate of nursing practice (DNP) students from Weber State University, the Weber-Morgan Public Health Department staff, and a DNP family nurse practitioner (FNP). Funding has come from a federal grant to cover the start-up costs and maintenance of the 12-week program. To maintain this HTN clinic, the Weber-Morgan Public Health Department will evaluate the completed results of this study. Based on the success of this study, the public health department can allocate funds to continue the HTN clinic. Another means of funding would consist of extending the federal grant. A general estimate breakdown will be provided here: $5,000 for equipment, including BP monitors, fit-bands, pedometers, office supplies, and a tent; $9,000 for medical care, such as providers, medications, lab tests, and medical supplies; $7,000 for an annual subscription of the REDUCING BLOOD PRESSURE BY COMMUNITY-BASED APPROACH 16 electronic health record (EHR); and $7,000 for miscellaneous items, including paper, ink, food vouchers, and rent. The total estimate was about $30,000, allowing for this project’s $10,000 safety net. In addition to the cost of the study, it is essential to note the required expenses of the HTN clinic. The cost of the HTN clinic consists of the building, maintenance costs, necessary office equipment, furniture, and medical supplies (e.g., stethoscopes for physical examinations and safety). Personnel and their associated costs will also need to be considered. The HTC clinic will require at least two care providers, several medical assistants, office staff, maintenance personnel, public health officials, and volunteers. Finally, medical malpractice insurance, licenses, fees, and miscellaneous costs contribute to the sustainability costs of the HTN clinic. Sustainability funding strategies include the provider(s) credentialing with insurance companies for reimbursement. Future Weber State University student volunteers in the School of Nursing or the College of Health Professions could provide affordable services for the Ogden, Utah, HTN clinic. Finally, community fundraiser events and community-member donations could increase funding for the HTN clinic and help with overhead costs. Project Outcomes This project has several short-term and long-term outcomes. The short-term goals of the project include recruiting 30 Ogden residents and educating them on HTN, lifestyle modification, self-management, and medication adherence to lower the BP of all participants within 12 weeks. The project’s long-term objective is to file for a grant extension and establish a permanent HTN clinic in Ogden, Utah, by December 22, 2022. To assess the project’s success with these outcomes, the HTN clinic team will evaluate this study to determine if interventions successfully lowered BP. REDUCING BLOOD PRESSURE BY COMMUNITY-BASED APPROACH 17 Consent Procedures and Ethical Considerations This project will have an Institutional Review Boards (IRB) evaluation at Weber State University to ensure ethical standards are met with human participants. This project will strictly follow the four codes of the IRB: respect for persons, beneficence, justice, and informed consent (Kim, 2012). Informed consent will be in English and Spanish. In addition to following the IRB guidelines, the project will follow Healthy People 2020, as cited in Curley, 2019, which includes social equality for all individuals to improve the health of all groups of people. Medical information of the participants, including readiness surveys, will be stored in a cloud-based, password-protected electronic health record system (EHR). This EHR was developed by a company called RXNT, which ensures patient health information is protected. All paper documents will be uploaded into RXNT and then shredded. Data will be entered by Weber-Morgan Public Health employees, Cathy Harmston D.N.P., the two NP students, and Weber-State University faculty. All Weber State University personnel, Weber-Morgan Public Health personnel, and volunteers involved with this project will complete CITI training before starting the study. Instruments to Measure the Effectiveness of Intervention Three instruments will measure the effectiveness of the HTN clinic intervention. At the time of intake, each participant will be given two surveys designed for this project: a pre-readiness survey and a pre-health assessment survey, see appendix A. These instruments identify how the participants feel regarding their readiness to manage HTN and overall health. At the end of the 12-week program, each participant will be given the same readiness and health assessment surveys to establish patients’ new understanding of their overall health and feelings of readiness to manage their HTN after the intervention. The final evaluation will be the BP trend of each REDUCING BLOOD PRESSURE BY COMMUNITY-BASED APPROACH 18 participant. A downward trend of BP over the 12-week program can indicate improved management of BP. Project Implementation This project was implemented at the Weber-Morgan community health center in Ogden, Utah, from January to March 2022. Recruitment of Ogden residents to participate in the interventions took place from October to November 2021, and 30 participants who met the recruitment requirement of having two different blood pressures of 130/80 or higher initially joined the study. The initial intake of participants took place at the Weber State community center in December 2021. Intake consisted of lab work, a class on eating a diet rich in fruits and vegetables, and health evaluations by a nurse practitioner. This project offered three one-hour education classes over the 12-week program, including the class offered on intake. Each course was taught four weeks apart and delivered via in-person and Zoom. The lessons focused on eating more fruits and vegetables, decreasing sodium intake, increasing exercise, reading nutrition labels, preparing heart-healthy meals, and tracking progress. Education courses incorporated English and Spanish 5th-grade reading-level materials. Interventions This project used a multidisciplinary approach with Weber State University and the Weber-Morgan Public Health Department to establish a 12-week program to lower blood pressure through lifestyle modifications. A doctor of nurse practitioner (DNP), Dr. Cathy Harmston, was hired to evaluate and physically assess each participant and prescribe medications. Two DNP students led the education classes on lifestyle modifications, medication REDUCING BLOOD PRESSURE BY COMMUNITY-BASED APPROACH 19 adherence, and blood pressure monitoring. Auxiliary groups consisted of Weber State University laboratories, WSU faculty, and Weber-Morgan Public Health Department staff. This study implemented lessons on lifestyle modifications designed to improve participants’ BP. This first encounter occurred at the Weber State community center with 15 participants in person and four via Zoom. During the first encounter, each participant was encouraged to either reach 8,000 steps each day or exercise for 15 minutes daily with moderate intensity. Lifestyle modifications also consisted of nutritional interventions that emphasized eating 4–5 servings of fruits and vegetables daily while limiting whole milk, fatty foods, processed foods, and red meats to 1–2 servings daily. During the second encounter, a PowerPoint presentation on reading nutritional labels and reducing sodium intake, with a daily goal of 2300mg of sodium or less, was taught at the Weber-Morgan Public Health Department, with 23 in person and four via Zoom. The last encounter at the Weber-Morgan Public Health Department, with twenty in person and six via Zoom, included a PowerPoint presentation on making healthier meal choices and preparing healthy foods. All encounters utilized transformational leadership to motivate and inspire participants to internalize HTN management. After completing the program, each participant was provided the same readiness survey to gather data on their readiness to manage HTN, see appendix B. Post-program labs were drawn, and each participant received a gift for participation. Permanent healthcare providers were established for each participant to maintain HTN management. Interventions Align with Short-Term and Long-Term Outcomes The overarching short-term goal of this study is to teach participants how to manage and lower their blood pressure to near-normal levels through sustainable and affordable lifestyle modifications. The overarching long-term goals of the project are two-fold: first, the participants REDUCING BLOOD PRESSURE BY COMMUNITY-BASED APPROACH 20 will continue to monitor their blood pressure and establish a consistent healthcare provider, and second, the Weber-Morgan Public Health Department will establish a low-cost, long-term hypertension clinic. Lifestyle modifications align with the short-term goal of lowering the participant’s blood pressure by providing evidence-based practice. Multidisciplinary teams with federal funding ensure that each participant receives the same evidence-based teaching and tailored education with motivation for overcoming individual barriers to lowering blood pressure. Individuals adhering to their blood pressure medication regimen experience better hypertension control in shorter timeframes than non-compliant patients (Jachimovicz et al., 2019). Lifestyle modifications and establishing a permanent primary care provider for each patient fulfilled one of the long-term outcomes. Participants can manage their own choices and lifestyle that lowers their blood pressure. These individuals can follow up with their primary care provider when their blood pressure readings are too high or more medications are needed. The long-term outcome of providing a permanent low-cost hypertension clinic in Ogden, Utah, can be resolved by determining this study’s success. Project Timeline This project was a 12-week program emphasizing heart-healthy foods and physical exercise. Each participant tracked the number of fruits and vegetables, sodium intake, and heart-healthy meals they ate on our tracking sheet, see appendix D. Participants also recorded the number of steps taken or minutes exercised every day for the 12-weeks with the goal of increasing physical activity in intensity or duration every four weeks. During the 12-week program, the DNP students called the participants twice, at weeks six and nine, to gather data REDUCING BLOOD PRESSURE BY COMMUNITY-BASED APPROACH 21 from their tracking sheets and enter it into the RXNT electronic health record. This call also served as a reminder of the upcoming HTN meeting. Evaluation The evaluation process for this project involved gathering and analyzing qualitative and quantitative data from the surveys, tracking sheets, and health evaluations to determine the benefits, outcomes, and process of the 12-week HTN program. Data Maintenance/Security All data involving participants’ health, labs, responses, and tracking are stored in a password-protected, cloud-based E.H.R. Only HTN team members could access and use this data. Any paper documents were uploaded into the EHR and then shredded. Data maintenance and security for this project followed all IRB and health insurance portability and accountability act (HIPAA). Quantitative Data Participant demographics can be seen in Table 1, which shows that participants were predominantly Hispanic individuals at 64%, followed by White at 36%. Table 1 Participant Demographics Demographic Description n % Gender Male 11 40.74% Female 16 59.26% Ethnicity White 10 35.71% Hispanic 18 64.29% African American 1 3.51% Education level Some high school 6 22.22% Less than high school 3 11.11% Completed high school 9 33.33% REDUCING BLOOD PRESSURE BY COMMUNITY-BASED APPROACH 22 Some college or technical school 5 18.52% Completed technical school/associate degree 2 7.41% Completed BA or BS. degree 2 7.41% Note. N=27 Participants. Participants’ median age was 55 years. Blood pressure was measured every day for the first two weeks to establish a routine for checking blood pressure. During weeks three through twelve, each participant took their blood pressure weekly. Table 2 depicts the average decrease in blood pressure across all participants. Table 2 Blood Pressure Readings Post Hypertension Clinic Values Point reduction 95% CI p Systolic blood Pressure 5.778 -10.402 – -1.154 0.016 Diastolic blood Pressure 5.148 -7.857 – -2.498 0.001 Table 3 and Table 4 illustrate the participant’s pre-study and post-study fruit intake and vegetable intake, respectively. Both tables indicate that many participants increased eating fruits and vegetables from 1-2 servings to 3–4 servings during the program. Table 3 Fruit Intake Fruit Servings Pre n=27 Post n=27 Pre % Post % None 2 0 7% 0% 1–2 23 17 85% 63% 3–4 2 8 7% 30% 5–6 0 1 0% 4% More 0 0 0% 0% Blank 0 1 0% 4% REDUCING BLOOD PRESSURE BY COMMUNITY-BASED APPROACH 23 Table 4 Vegetable Intake Vegetable Serving Pre n=27 Post n=27 Pre % Post % None 1 0 4% 0% 1–2 19 17 70% 63% 3–4 6 7 22% 26% 5–6 0 2 0% 7% More 1 0 4% 0% Blank 0 1 0% 4% Table 5 illustrates the number of days per week each participant exercised. There was a significant increase from 0–2 days of exercise to 3–4 times per week. Table 6 presents the length of time during each exercise session and shows significant increases in the categories of 20–29 minutes and 30–60 minutes. Table 5 Days per Week of Exercise Days of Exercise Pre n=27 Post n=27 Pre % Post % None 7 1 26% 4% 1–2 7 7 26% 26% 3–4 5 11 19% 41% 5–6 3 7 11% 26% Inconsistently 1 1 4% 4% Blank 4 0 15% 0% Table 6 Length of Exercise Minutes of Exercise Pre n=27 Post n=27 Pre % Post % None 7 1 26% 4% Less than 20 5 5 19% 19% 20–29 2 7 7% 26% 30–60 6 12 22% 44% More 3 2 11% 7% Blank 4 0 15% 0% REDUCING BLOOD PRESSURE BY COMMUNITY-BASED APPROACH 24 Readiness surveys were a quantitative measurement to establish participants’ concerns regarding their hypertension. Table 7 is in response to the last question on the survey. Table 7 Concern for HTN Concern Pre-survey Post-survey Strongly Agree 12 11 Agree 11 8 Unsure 1 1 Disagree 0 7 Strongly Disagree 2 0 Blank 1 0 Qualitative Data For qualitative data, the participants answered two free-text responses: “What did you like most about the program?” and “Any other comments?” Various responses were provided, which were then evaluated by the two DNP students and their respective faculty members. Themes from these responses were established and refined using abbreviated content analysis. These themes are reflected in Table 8. Note some participants’ answers contained multiple themes. Table 8 Participant Feedback Themes Number of themes Caring 19 Community 8 Empowerment 3 Equipment 6 Engaged 10 Knowledge 15 Themes such as caring, engaged, and community are umbrella terms established by the HTN team for responses dealing with how participants felt they were treated. Themes of empowerment and knowledge reflect participant responses that conveyed an increased 85% 4% 7% 70% 4% 26% Agree or strongly agree Unsure Disagree or strongly disagree I am concerned with my blood pressure Pre % Post % REDUCING BLOOD PRESSURE BY COMMUNITY-BASED APPROACH 25 understanding of HTN or overall health. The equipment theme was established for answers dealing with praise or gratitude towards the blood pressure cuffs and fitness trackers. Quality Improvement Discussion The community-based approach to HTN is an ongoing and evolving form of blood pressure management. With a small sample size and a short-term period, this study reveals the potential for a community-based approach in a HTN clinic in Ogden, Utah but does not confirm a longitudinal success. Could the Weber-Morgan Health department continue this project and establish a HTN clinic? Findings The findings of this project are consistent with the outcome of other community-based approach studies to lower blood pressure. The average decrease in systolic blood pressure was 5.8 mm Hg and diastolic 5.2 mm Hg. The use of blood pressure medications, increasing exercise, and improving fruit and vegetable intake lowered blood pressure. This study also indicates that participants value caring, community, empowerment, and equipment in their treatment. Strengths This study had a high completion rate for the 12-week program. Of the 30 recruited patients, 27 completed the 12-week program, the readiness survey, and the pre- and post-survey. Participants were compliant with tracking their blood pressure, taking their medications, increasing exercise, and increasing fruit and vegetable intake. This study also had adequate funding via a grant covering all expenses and a sufficient and highly trained staff for the implementation and evaluation of this project. Limitations REDUCING BLOOD PRESSURE BY COMMUNITY-BASED APPROACH 26 This study has several limitations, including small sample size and a short timeframe for the project. The small study only involved 30 participants, with 27 participants completing the study. Due to the small sample size, this study does not accurately reflect the general population. The racial and ethnic background of the participants was predominately Hispanic and White. This study was a short 12-week program with no longitudinal data on the long-term benefits of a community-based approach to blood pressure. Translation of Evidence into Practice On average, the reduction in systolic blood pressure was 5.8 mm Hg and diastolic of 5.2 mm Hg over 12 weeks. The decrease in blood pressure indicates the ability of a HTN clinic, using the community-based approach, to assist individuals in lowering their blood pressure. The community-based system, which utilizes a primary care provider (PCP), blood pressure medications, diet, exercise, and education, can impact blood pressure. All equipment and educational materials can be reused or expanded for future participants in the HTN clinic. This study also indicates the participants’ acceptance of the community-based approach to HTN. These findings suggest the need for, and potential sustainability of, a HTN clinic in Ogden, Utah. Implications for Practice and Future Scholarship The secondary goal of this study was to create a sustainable HTN clinic. This study indicates that a sustainable HTN clinic is feasible with proper funding and personnel in Ogden, Utah. This HTN clinic would allow many Ogden residents to receive no-cost or low-cost services to help manage their HTN. The HTN clinic would also allow for more community involvement from residents in the area. For example, Weber State University students seeking community-based involvement may benefit from opportunities for scholarship, education, or REDUCING BLOOD PRESSURE BY COMMUNITY-BASED APPROACH 27 volunteer experiences with the HTN clinic. There may be opportunities for further studies on HTN, community health, preventive medicine, or ethnic group health disparities. Students seeking a doctoral-level quality improvement project could improve the recruitment or retention of Ogden residents. Future students may also consider analyzing this study regarding why the 27 participants were able to complete the program. Another practice consideration is bringing awareness of the HTN clinic to the attention of providers and nurse leadership in the Ogden area. This study’s publications and broader publications from the Weber-Morgan Health Department may help facilitate more participants through a referral-based system. Expanding awareness may also help facilitate early HTN interventions allowing for improved BP control in Ogden, Utah, and the surrounding area. Sustainability This project lays the foundations of the HTN clinic by establishing the community-based approach, creating all educational materials, completing a 12-week program with participants, and leading the HTN team. To sustain the efforts of this project, the involvement of key stakeholders, present and future, is vital. Currently, the Weber-Morgan Health Department will continue using all educational materials, equipment, and location of the HTN clinic. Future stakeholders may include local exercise facilities and insurance companies. Further funding for the HTN clinic is yet to be determined. Personnel involved with the Weber-Morgan Health Department can continue working with the HTN clinic. Weber State University students and faculty are recommended to continue volunteering at the HTN clinic to maintain strong community involvement. Dissemination REDUCING BLOOD PRESSURE BY COMMUNITY-BASED APPROACH 28 Dissemination of this project may include publications and oral presentations at local or national health conferences. The findings of this study agree with other studies on the use of the community-based approach to help manage blood pressure. The community-based approach lowers blood pressure and is a low-cost, sustainable method for HTN management. Weber State University plans to publish a newsletter article about this project and the two DNP students’ efforts and participation in this doctoral-level project. Conclusion This study aimed to find 30 at-risk participants affected by HTN and lower their blood pressure through a low-cost community-based approach. The community-based approach includes blood pressure medications, diet, exercise, blood pressure cuff, fitness tracker, and educational meetings. 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C., Spencer, C. C., Stafford, R. S., Taler, S. J., Thomas, R. J., Williams, K. A., . . . Wright, J. T. (2018). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults. Journal of the American College of Cardiology, 71(19), e127–e248. https://doi.org/10.1016/j.jacc.2017.11.006 Wu, C. Y., Hu, H. Y., Chou, Y. J., Huang, N., Chou, Y. C., & Li, C. P. (2015). High blood pressure and all-cause and cardiovascular disease mortalities in community-dwelling older adults. Medicine, 94(47), e2160. https://doi.org/10.1097/md.0000000000002160 REDUCING BLOOD PRESSURE BY COMMUNITY-BASED APPROACH 35 Appendix A Patient Demographics Are you?  Male  Female  _______________ What is your birthdate? Month: __________ Day: __________ Year: __________ What is your race/ethnicity? (Check all that apply)  African American or Black  American Indian or Alaskan Native  Asian  Hispanic or Latino/Latina  Native Hawaiian/Other Pacific Islander  White  ______________________________ What is the highest level of education you have completed?  Less than high school  Some high school  Completed high school or GED.  Some college or technical school  Completed technical school/associate’s degree  Completed BA or BS/ degree  Graduate study/advanced degree(s) What is your current employment status?  Employed full-time (35 hours a week or more)  Employed part-time (less than 35 hours a week)  Not currently employed  _____________________ What is your current marital status?  Single, never married  Married, committed relationship  Separated  Divorced  Widowed How many adults and children live in your household, including yourself? REDUCING BLOOD PRESSURE BY COMMUNITY-BASED APPROACH 36 _____ adults (>18 years old) live in my household _____ children (<18 years old) live in my household What is your total household income in the past 12 months from all sources? Please include income earned by you and other members of your household.  Less than $10,000  $10,000-$19,999  $20,000-$29,999  $30,000-$39,999  $40,000-$49,999  $50,000-$59,999  $60,000-$69,999  $70,000 or more Health History Questions Do you currently carry health insurance?  No  Yes: Who are you insured by or what is the name of your insurance? _________ Who do you usually see for your health needs (Primary care provider)? __________ When was the last time you were seen by a medical person? _________ What clinic or office do you usually go to? ________ What pharmacy that you usually go to? _______ Where do you usually shop for food? ________ Focused Health History How often do you smoke tobacco? How often do you chew tobacco? When did the tobacco use start? How many cigarettes do you have per day? Does anyone in your home smoke? REDUCING BLOOD PRESSURE BY COMMUNITY-BASED APPROACH 37 □ Yes □ No Do you drink alcohol? □ Yes □ No If yes, how often do you drink alcohol? □ Less than once a month □ Less than once a week □ 1-3 times per week □ 3-7 times per week Have you ever used recreational drugs? □ Yes □ No Have you ever abused prescription drugs? □ Yes □ No Do you or a family member have a history of: Cancer:  Me  My family member: _________ Diabetes:  Me  My family member: _________ Heart Disease:  Me  My family member: _________ Stroke:  Me  My family member: _________ Kidney Disease:  Me  My family member: _________ Blood Pressure Questions REDUCING BLOOD PRESSURE BY COMMUNITY-BASED APPROACH 38 Have you ever been told that your blood pressure was high? □ No □ Yes If yes: When were you told (how long ago)? __________________________________________ Who or where were you told that your blood pressure was high? _____________________ What was done about your blood pressure (check all that apply)?  Nothing more was said  I was told to watch it and see if it got better  I was told to exercise more  I was told to change my diet  I was started on medication  I have been working with my doctor to treat my blood pressure Appendix B Readiness Survey POST-R 1.I am concerned with my blood pressure □ Strongly Agree □ Agree □ Unsure □ Disagree □ Strongly disagree POST-R 2. My blood pressure is improving □ Strongly Agree □ Agree □ Unsure □ Disagree □ Strongly disagree POST-R 3. My life is the same, even as I improve my blood pressure □ Strongly Agree □ Agree □ Unsure □ Disagree □ Strongly disagree POST-R 4. I am taking medicine to improve my blood pressure REDUCING BLOOD PRESSURE BY COMMUNITY-BASED APPROACH 39 □ Strongly Agree □ Agree □ Unsure □ Disagree □ Strongly disagree POST-R 5. I am changing my eating habits to improve my blood pressure □ Strongly Agree □ Agree □ Unsure □ Disagree □ Strongly disagree POST-R 6. I am exercising more to improve my blood pressure □ Strongly Agree □ Agree □ Unsure □ Disagree □ Strongly disagree POST-R 7. I understand the impact that high blood pressure can have on my health. □ Strongly Agree □ Agree □ Unsure □ Disagree □ Strongly disagree POST-R 8. How confident are you in your overall understanding of hypertension? □ Very confident □ Confident □ A little confident □ Not at all POST-R 9. How confident are you in taking your blood pressure and recording it? □ Very confident □ Confident □ A little confident □ Not at all POST-R 10. How confident are you in planning a heart-healthy meal? □ Very confident □ Confident □ A little confident □ Not at all POST-R 11. How confident are you that you can exercise regularly? □ Very confident REDUCING BLOOD PRESSURE BY COMMUNITY-BASED APPROACH 40 □ Confident □ A little confident □ Not at all Appendix C Well-Being HPOST 1. Rate your overall well-being □ Great □ Good □ Fair □ Poor □ Bad HPOST 2. Rate your overall health: □ Great □ Good □ Fair □ Poor □ Bad HPOST 3. How safe do you feel? □ Very □ Not Very □ Not at all HPOST 4. How satisfied are you with your life? □ Very □ Not Very □ Not at all HPOST 5. How often do you feel depressed? □ Always □ Often □ Occasionally □ Never Nutrition HPOST 6. How many daily servings of vegetables do you eat? □ None □ 1-2 □ 3-4 □ 5-6 □ more REDUCING BLOOD PRESSURE BY COMMUNITY-BASED APPROACH 41 HPOST 7. How many daily servings of fruit do you eat? □ None □ 1-2 □ 3-4 □ 5-6 □ more HPOST 8. How many daily servings of grains do you eat? □ None □ 1-2 □ 3-4 □ 5-6 □ more HPOST 9. How many daily servings of meat/protein do you eat? □ None □ 1-2 □ 3-4 □ 5-6 □ more HPOST 10. How many daily servings of sugar/carbohydrates do you eat? □ None □ 1-2 □ 3-4 □ 5-6 □ more Exercises HPOST 11. What type of physical activity do you like to do? □ Walking □ Aerobic workout □ Running/jogging □ Bicycling □ Swimming □ None □ Other HPOST 12. How many days per week do you do physical activity/exercise? □ None □ 1-2 □ 3-4 □ 5-6 □ More REDUCING BLOOD PRESSURE BY COMMUNITY-BASED APPROACH 42 □ inconsistently HPOST 13. Length of time spent on physical activity/exercising each day? □ None □ Less than 20 minutes □ 20-29 minutes □ 30-60 minutes □ More than 60 minutes POST 14. Do you have any injuries or conditions that interfere with your exercising? □ Yes; please list the injury/condition/s:_____________________ □ No HPOST 15. How many hours of sleep do you get per night?: _____ HPOST 16. How restful is your sleep? □ Very □ Somewhat □ Not Very Stress HPOST 17. On average, how stressed do you feel in everyday life? □ Super stressed □ Moderately stressed □ Slightly stressed □ Stressed □ Not stressed HPOST 18. Do you believe that your stress level can be improved? □ Yes □ No □ Unsure HPOST 19. How do you cope with everyday stress? □ I don’t □ Exercise □ Spend time outdoors □ Video games or social media □ Sleeping □ Other: ____________________ HPOST 20. What would you say causes the most stress in your everyday life? □ Family □ Financials REDUCING BLOOD PRESSURE BY COMMUNITY-BASED APPROACH 43 □ The news □ Job □ Other: ___________ Appendix D Tracking Sheet Daily Hypertension Tracker: Weeks 1 & 2 Check and Record at the same time every day for two weeks your: BLOOD PRESSURE, HEART RATE, WEIGHT, ACTIVITY, & DIET After 2 weeks you may start recording your blood pressure, heart rate, and weight only once a week. Week & Day Date and time Blood Pressure Heart Rate Weight Type of Activity # of Minutes or # steps Dietary Are you taking your medications WEEK 1 day 1 / __ # of steps __ # of min # Fruits: ___ # Veggi: ___ __yes __ no __ no meds day 2 / __ # of steps __ # of min # Fruits: ___ # Veggi: ___ __yes __ no __ no meds day 3 / __ # of steps __ # of min # Fruits: ___ # Veggi: ___ __yes __ no __ no meds day 4 / __ # of steps __ # of min # Fruits: ___ # Veggi: ___ __yes __ no __ no meds day 5 / __ # of steps __ # of min # Fruits: ___ # Veggi: ___ __yes __ no __ no meds day 6 / __ # of steps __ # of min # Fruits: ___ # Veggi: ___ __yes __ no __ no meds day 7 / __ # of steps __ # of min # Fruits: ___ # Veggi: ___ __yes __ no __ no meds WEEK 2 day 8 / __ # of steps __ # of min # Fruits: ___ # Veggi: ___ __yes __ no __ no meds day 9 / __ # of steps __ # of min # Fruits: ___ # Veggi: ___ __yes __ no __ no meds day 10 / __ # of steps __ # of min # Fruits: ___ # Veggi: ___ __yes __ no __ no meds day 11 / __ # of steps __ # of min # Fruits: ___ # Veggi: ___ __yes __ no __ no meds day 12 / __ # of steps __ # of min # Fruits: ___ # Veggi: ___ __yes __ no __ no meds day 13 / __ # of steps __ # of min # Fruits: ___ # Veggi: ___ __yes __ no __ no meds day 14 / __ # of steps __ # of min # Fruits: ___ # Veggi: ___ __yes __ no __ no meds REDUCING BLOOD PRESSURE BY COMMUNITY-BASED APPROACH 44 Weekly Hypertension Tracker: Weeks 3-12 Check and Record weekly (for the week) Record your BLOOD PRESSURE, HEART RATE, WEIGHT, ACTIVITY, & DIET once a week Week Date & time Blood Pressure Heart Rate Weight Type of Activity # of Minutes or # Steps For the week Dietary For the Week Are you taking your medications WEEK 3 / __ # of steps __ # of min # Fruits: ___ # Veggi: ___ __yes__ no __ no meds WEEK 4 / __ # of steps __ # of min # Fruits: ___ # Veggi: ___ __yes__ no __ no meds WEEK 5 / __ # of steps __ # of min Sodium: ____ __yes__ no __ no meds WEEK 6 / __ # of steps __ # of min Sodium: ____ __yes__ no __ no meds WEEK 7 / __ # of steps __ # of min Sodium: ____ __yes__ no __ no meds WEEK 8 / __ # of steps __ # of min Sodium: ____ __yes__ no __ no meds WEEK 9 / __ # of steps __ # of min ___# Heart Healthy Meals __yes__ no __ no meds WEEK 10 / __ # of steps __ # of min ___# Heart Healthy Meals __yes__ no __ no meds WEEK 11 / __ # of steps __ # of min ___# Heart Healthy Meals __yes__ no __ no meds WEEK 12 / __ # of steps __ # of min ___# Heart Healthy Meals __yes__ no __ no meds