effective strategies for blood pressure control

Effective strategies for blood pressure controlVerna L. Lamar Welch, PhD, MPHa,b,*,

Martha N. Hill, RN, PhD, FAANc

aFormerly, Division of Applied Public Health Training, Epidemiology Program Office, assigned

to the Cardiovascular Health Branch, Division of Adult and Community Health, National Center

for Chronic Disease Prevention and Health Promotion,

Centers for Disease Control and Prevention, 4770 Buford Highway, Atlanta, GA, USAbCenter on Health Outcomes and Quality, Emory University, School of Public Health, 1518 Clifton Road, NE,

Room 670, Atlanta, GA 30322, USAcCenter for Nursing Research, Johns Hopkins University School of Nursing, 525 N. Wolfe Street,

Baltimore, MD 21205-2110, USA

Hypertension is the leading preventable cause

of premature morbidity and mortality from cor-

onary heart disease, stroke, heart failure, and kid-

ney failure. Although substantial progress has

been made in developing and distributing both

antihypertensive medications and guidelines for

hypertension treatment, rates of blood pressure

control remain dismal. Of the estimated 50 million

Americans with hypertension, less than one fourth

have their blood pressure under control. One-year

costs of failing to control hypertension were

recently estimated at $964 million for the total

US hypertensive population and $467 million for

those being treated [1]. This article describes effec-

tive strategies for blood pressure control at

national, state, and community levels.

Background

One in four US adults, as many as 50 million

Americans, has hypertension [2]. From the second

phase (1991–1994) of the National Health and

Nutrition Examination Survey, researchers esti-

mated that of persons with hypertension, 31.6%

were unaware of their condition, 14.8% were not

on any therapy (including special diet or medica-

tions), 26.2% were on inadequate therapy, and

27.4% were on adequate therapy and had their

blood pressure under control. Hypertension is a

costly disease that is associated with an increased

risk for most forms of cardiovascular disease,

especially in the coronary, cerebrovascular, renal,

and peripheral vascular beds [2–6].

The Healthy People 2010—National Health

Promotion and Disease Prevention Objectives in-

cludes as one objective an increase to 50% by

the year 2010 in the proportion of adults with high

blood pressure who have it under control [7]. This

is a major challenge but one that seems attainable

with community-based and team approaches.

Effective strategies for blood pressure control are

summarized in Table 1.

Public health approaches

in hypertension prevention

Research has shown that reducing sodium con-

sumption, losing weight, engaging in regular physi-

cal activity, and taking medications can lower

elevated blood pressure. To translate research into

practice, in 1972 the National Heart, Lung, and

Blood Institute (NHLBI) undertook amajor initia-

tive, the National High Blood Pressure Education

Program (NHBPEP), which has used mechanisms

ranging from setting guidelines for optimal blood

pressure levels, to national educational campaigns,

to community-based demonstration projects.

Cardiol Clin 20 (2002) 321–333

* Corresponding author. Center on Health Out-

comes and Quality, Emory University, School of Public

Health, 1518 Clifton Road, NE Rm. 670, Atlanta, GA

30322.

E-mail address: [email protected](V.L.L.Welch).

0733-8651/02/$ - see front matter � 2002, Elsevier Science (USA). All rights reserved.

PII: S 0 7 3 3 - 8 6 5 1 ( 0 1 ) 0 0 0 0 7 - 8

NHBPEP

The NHBPEP is a cooperative effort of profes-

sional and volunteer health agencies, the federal

government, state health departments, and com-

munity groups. NHBPEP’s goal is to reduce

death and disability related to uncontrolled

hypertension through programs of professional,

patient, and public education. The program offers

resources in information collection and dissemina-

tion; public, patient and professional education;

community program development, evaluation,

and data analysis; and technology transfer and

electronic distribution [8]. There is no empiric eval-

uation data for the NHBPEP, but the vast inc-

rease in public knowledge signals its effectiveness.

In 1972, less than one fourth of the American

population was aware of the relationships between

hypertension and both stroke and heart disease

and the benefits of treating and controlling hyper-

tension. Today, more than three fourths of Amer-

icansareawareof these relationships.Furthermore,

Americans know the importance of having their

blood pressure measured, and three fourths have

it measured every 6 months [9].

NHLBI community-based demonstration projects

In the 1970s, responding to new evidence on

the effectiveness of hypertension control, the

NHLBI began to sponsor innovative community-

based demonstration projects. The overarching

goal of four NHLBI sponsored projects, begun

in 1972, 1978, and 1980 (two projects), respec-

tively, was to develop and evaluate educational

strategies leading to a decreased population risk

of cardiovascular disease. The studies were carried

out independently but concurrently and in tech-

nical cooperation with each other.

Table 1

Effective strategies for blood pressure control

Level Setting/program Strategy

National National High Blood Pressure

Education Program

Provide resources in information collection and

dissemination; public, patient, and professional

education; community program development;

evaluation and data analysis; and technology

transfers and electronic distribution

Community-based

demonstration projects

See Table 2

State-run programs Preventive Health and Health

Services Block Grant

Provide funds to 61 grantees for preventive health

services to reduce illness and premature death and

improve quality of life

Centers for Disease Control and

Prevention—Cardiovascular

Health Branch

Provide funds, technical support, surveillance data,

epidemiologic analyses, and public health

recommendations to states and territories

Community health

partnerships

Work site Onsite screening, onsite antihypertensive treatment

during work hours, referrals to community

resources, and health education

Faith-based organizations Health education, onsite screening, referrals; use

existing volunteer pool and lay health workers.

Barbershops/beauty

salons/fire stations

Onsite screening, health education, referrals, regular

clientele, and convenient locations

Pharmacies Onsite screening, health education, referrals, follow-up

calls for encouragement and to monitor compliance,

home blood pressure monitoring, and management

of drug reactions

Community outreach Comprehensive approach with social, psychological,

behavioral, economic, and biomedical components

Clinical care Nurse-run clinics Comprehensive approach incorporating information

regarding the patient’s background, social

environment, lifestyle, health history, and other

relevant factors to develop a health plan; referrals,

follow-up, and maintenance therapy

322 V.L.L. Welch, M.N. Hill / Cardiol Clin 20 (2002) 321–333

The Stanford Three-Community Study

(1972–1975)

The Stanford Three-Community Study was a

demonstration project conducted in northern Cali-

fornia in three nonrandomized communities: two

treatment and one control. Designed to develop

and evaluatemethods for achieving positive behav-

ioral change that would be both cost-effective

and applicable to large populations, the study

involved comprehensive media campaigns to edu-

cate community residents about cardiovascular dis-

ease risk factors, including hypertension. Special

programs were developed for Spanish-language

media, and school-based programs were developed

to reach students, parents, teachers, and adminis-

trators. In the two treatment communities, health

promotionmaterialswere disseminated via a 2-year

mass media campaign; in one of these communities

individual counseling was provided to a randomly

selected subset of residents at high risk of develop-

ing coronary heart disease.

Residents of each community were interviewed

and examined before, during, and after the project

to assess their knowledge of and risk factors for

cardiovascular diseases. Results showed a signifi-

cant reduction in overall cardiovascular risk in

both treatment communities, when compared with

the control community. Specifically, changes in sys-

tolic blood pressure were significant for the inter-

vention communities, ranging from 6.6 mm Hg to

8.9 mm Hg. Results for diastolic blood pressure

were mixed: the media-only community expe-

rienced a 2.5 mm Hg increase; in the second treat-

ment community, a 6.2 mm Hg decrease in

diastolic blood pressure was observed among the

high-risk subset and a 3.9 mm Hg decrease among

the remainder of the community. Diastolic blood

pressure decreased by 5.4 mm Hg in the control

community, resulting in no significant difference

between the treatment and control communities

on that measure [10–13].

The Stanford Five-City Project (1978–1998)

The Three-Community Study generated the

Stanford Five-City Project, which involved five

cities: two treatment and three control. A 6-year

educational intervention targeting multiple risk

factors was delivered through television, radio,

newspaper, other print materials, direct educa-

tion, and community events. Community groups

and organizations participated by conducting

activities such as workshops, conferences, and

other community forums. Health professionals

from various intermediary agencies were trained

to provide educational information on risk factors

and behavioral change [14–17].

To evaluate the effect of the intervention on

cardiovascular disease risk factors, four indepen-

dent cross-sectional surveys and four repeated

surveys of a cohort were conducted in the treat-

ment cities and two of the three control cities.

After 5.3 years of intervention, the treatment cities

observed a decline of 7.4 and 5.5 mm Hg for sys-

tolic and 5.0 and 3.7 mm Hg for diastolic blood

pressures, respectively, in the cohort and indepen-

dent surveys. The overall difference in change over

time between the treatment and control cities ran-

ged from )1.1 to )3.8 mm Hg [14].

The Minnesota Heart Health Program

(1980–1993)

The Minnesota Heart Program selected three

pairs of nonrandomized communities, with one of

each pair assigned to educational intervention

and the other to comparison status. The commu-

nities were matched for size, type, and distance

from the Minneapolis–St. Paul metropolitan area.

Means of education interventions consisted of

direct education, mass media campaigns, and com-

munity organization, the last of which was used to

involve community groups and organizations in

promoting the reduction of risk factors for cardio-

vascular disease. Constituents of the community

involved in disseminating information included

health care professionals, schools, work sites,

churches, organizations, city task forces, mass

media, grocery stores, and restaurants [18–21].

Cross-sectional surveys, a longitudinal survey,

and surveillance of morbidity and mortality were

used to evaluate the program. For the comparison

communities, the cross-sectional survey showed a

declining trend in blood pressure (annual change

of )0.4 mm Hg for systolic and )0.2 mm Hg for

diastolic), whereas the longitudinal analysis indi-

cated a flat or slightly rising trend, which is

expected with an aging cohort. In the education

communities, after 3 years the cross-sectional analy-

sis showed that both systolic and diastolic blood

pressure declined modestly (systolic from 121.7 to

118.2 mm Hg, diastolic from 76.2 to 71.6 mm Hg);

the cohort survey found after 4 years that the

systolic declined from 122.3 to 120.4 mm Hg and

the diastolic declined from 76.2 to 75.0 mm Hg.

At 6 years, the cross-sectional analysis showed a

decline in systolic pressure from 121.7 to 118.6

mm Hg and in diastolic pressure from 76.2 to

73.3 mm Hg, but none of these findings on blood

pressure was statistically significant [18].

323V.L.L. Welch, M.N. Hill / Cardiol Clin 20 (2002) 321–333

The Pawtucket Heart Health Program

(1980–1997)

The Pawtucket Heart Health Program used a

longitudinal design to follow a treatment (Paw-

tucket, RI) and a control (New Bedford, MA)

community, which were similar sociodemographi-

cally. Pawtucket received a 7-year intervention

consisting of community-wide educational strat-

egies that emphasized public awareness campaigns,

behavioral change, and community activation to

promote involvement and environmental change.

More than 500 community organizations, includ-

ing schools, faith-based organizations, social orga-

nizations, work sites, and city government, were

involved [22–24].

An evaluation unit conducted random house-

hold surveys, designed and implemented a complex

process evaluation system, and monitored relevant

changes in Pawtucket and New Bedford. The over-

all outcome evaluationwas based on surveys froma

cross-sectional random sample of 1200 persons

aged 18 to 65 years in Pawtucket and an equal num-

ber from New Bedford. The initial survey was con-

ducted in 1981 and repeated every 2 years through

1993. No statistically significant effect on blood

pressure was found for the program.

The community-based intervention projects

highlighted above had several common interven-

tion strategies, including direct education of the

general public and health professionals through

media and personal contact and community

mobilization to foster institutional and environ-

mental support (Table 2). Variations were ob-

served in effectiveness, but each study successfully

developed and implemented its community-based

intervention. Taken together, the estimated net in-

tervention effect for systolic blood pressure was an

annual reduction of approximately 0.6 mm Hg in

the treatment cities. Overall, no significant differ-

ences were observed in diastolic blood pressure

between treatment and control cities [25].

State-run programs in hypetension detection,

treatment, and control

In the early 1980s, broader initiatives emerged

at the national, state, and local levels to address

the burden of cardiovascular disease and the need

for risk factor intervention. Although these initia-

tives had a goal similar to the community inter-

vention trials, a different approach was taken,

not as scientifically rigorous and more focused on

community involvement. Broad coalitions invol-

ving groups such as patients, the medical commu-

nity, family and children services, community

organizations, pharmaceutical companies, and

government adopted initiatives. Programs to iden-

tify persons with hypertension, refer them to care,

and improve blood pressure control rates incorpo-

rated the principles of health promotion as the

first step in disease prevention. Funding came

from federal, state, and local government as well

as private sources. State-run programs in hyper-

tension detection, treatment, and control were

instrumental to the success of these initiatives.

The next section of this article reviews two fund-

ing mechanisms for the state-run programs.

The Preventive Health

and Health Services Block Grant

In the 1970s, earmarked funds were designated

to states for hypertension screening programs. All

the states participated and eventually developed

hypertension detection and control programs. In

1981, Congress combined various areas of health

funding, including the hypertension program, into

the Preventive Health and Health Services Block

Grant. This grant provides funds to 61 grantees to

reduce illness and premature death and improve

the quality of life [26]. Grantees are the 50 states,

the District of Columbia, eight territories, and

two tribes. The goal is to provide states with the

flexibility and autonomy to tailor prevention and

health promotion programs to address their prior-

ity health needs. In 1992, changes were made that

require states to (1) submit a state health plan

that specifies health outcome objectives, describes

health problems, and identifies target populations,

and (2) account for their funding by evaluating and

reporting on program activities and health indica-

tors [26].

Chronic disease prevention and health promo-

tion is one of the seven major program areas

funded; funds secured under this umbrella can

be used for hypertension detection, treatment,

and control. For fiscal year 2000, more than $26

million was given to 47 of the 61 grantees to

address health issues related to coronary heart dis-

ease, and stroke, and end-stage renal disease.

Cardiovascular Health Branch of

the Centers for Disease Control and Prevention

The mission of the Centers for Disease Control

and Prevention’s Cardiovascular Health Branch

(CHB), which is within the agency’s Division

of Adult and Community Health, is to promote

cardiovascular health and prevent disability and


Table

2

Community-baseddem

onstrationprojectsoftheNationalHeart,Lung,andBloodInstitute

Study

Interventionactivities

Setting(treatm

ent:control)

andpopulationsize

Years

ofintervention

Changes

inbloodpressure

(mm

Hg)

Stanford

Three-Community

Study

TV,radio,new

spaper,

printedmaterials,

directeducation

3towns(2:1);n¼45,000

1972–75

SBP:)6.6

to)8.9

DBP(m

edia

only

group):+2.5

Stanford

Five-CityProject

TV,radio,new

spaper,

printedmaterial,

directeducation,community

activities

5cities

(2:3);n¼350,000

1980–86

SBP(city1):)7.4

SBP(city2):)5.5

DBP(city1):)5.0

DBP(city2):)3.7

Minnesota

Heart

Health

Program

Mass

media,community

organization,directeducation

2towns,

2cities,2suburbs(1:1);

n¼412,371

1981–88

SBP:)0.4

DBP:)0.2

Pawtucket

Heart

Health

Program

Communityorganization,printed

materials,environmental

programs,community

volunteers

2cities

(1:1);n¼169,682

1984–91

SBP(treatm

ent):)1.81

SBP(control):)0.42

DBP(treatm

ent):0.28

DBP(control):1.12

Abbreviations:DBP,diastolicbloodpressure;SBP,systolicbloodpressure


premature death. Prevention of hypertension is

a major initiative. To accomplish this goal, the

CHB provides funding, technical support, state-

specific surveillance reports, epidemiologic anal-

yses, and public health recommendations to states

and territories. In fiscal year 2001, 25 states received

more than $15 million from the branch to develop

state cardiovascular health programs. The CHB

also funds two projects designed to reduce the

high prevalence of hypertension in older, African-

American women in two low-income communities:

Project Joy, a church-based project in urban Balti-

more,MD, and TheUniontown Project, a commu-

nity-based project in rural Alabama. Both projects

are evaluating the efficacy of a lay leader model

in delivering a 12-month cardiovascular health

program to the leader’s peers [27].

Community health system partnerships

Community health system partnerships offer

approaches that complement hypertension control

programs in the primary care setting, with a wide

variety of organizations and community members

working collectively to accomplish a common

goal. Such partnerships use diverse strategies,

including health education, community develop-

ment, advocacy for policy and environmental

change, screening and early detection and treat-

ment. These strategies can provide monitoring of

hypertension control and, with appropriate coun-

seling, reinforce the achievement of hypertension

treatment and control goals.

The community-wide approach potentially

involves all persons living or working in the com-

munity, including community leaders, policy-

makers, employers, employees, business owners,

members of volunteer and civic organizations,

faith-based organizations, and families. Box 1

summarizes lessons learned from community

health system partnerships. The following are

examples of community settings in which hyperten-

sion programs have been implemented.

Work sites

Promoting health in the workplace serves as a

vehicle for employees to increase their awareness

of specific health risks, develop more positive

health attitudes, and adopt healthier lifestyles.

Box 1. Community Health System Partnerships: Lessons Learned

Work site hypertension programs are• economically feasible• easy to implement• safe, acceptable, and effective when overseen by nurses

Faith-based organizations are• present in most communities and have a history of volunteering and outreach• ideal settings for hypertension programs• important venues for health promotion and disease prevention programs, not only

among their members but nonmembers as wellBarbershops and beauty salons are

• prevalent in most communities• venues for social, political, and educational activities• ideal for screening because customers visit frequently and are a captive audience while

receiving servicesFire stations are

• attractive settings for screening because they are easily accessible• ideal for screening because they are open 24 hours a day, 7 days per week

Pharmacists are• positive influences on medication compliance when included in the health care delivery

team• valuable resources who can encourage compliance, answer questions, manage mild

drug reactions, monitor blood pressure, and provide referrals when needed


The goal is to increase healthy behaviors among

employees and thereby improve job performance.

Hypertension is a common condition at most

work sites, with prevalence estimates ranging from

15%to25%[28].Manycompanies,whichasagroup

spend billions on health care costs, realized some

time ago the advantages of health promotion pro-

grams. Studies have shown that work site hyperten-

sion programs, which are primarily overseen by

nurses, are safe, acceptable, and effective [29,30].

Their success is due in part to the controlled envir-

onment and because these programs are economic-

ally feasible and easy to implement. Screening can

be done fairly quickly during working hours.

Employees diagnosed with hypertension can be

referred to community resources for treatment or

providedwith antihypertensive therapy at thework

site. Referring to community resources has been

found less effective in maintaining a long-term regi-

men than systematic approaches to care at thework

site [29,31,32]. Alderman [29] reported that less

than 50% of workers referred to community

resources actually visited a physician, and among

those who did, only 50% had achieved and main-

tained control of their blood pressure 2 years later.

In contrast, more than 80% of those managed at

the work site achieved and maintained control.

Similarly, a voluntary onsite screening, referral,

and follow-up hypertension program conducted

by the Massachusetts Mutual Life Insurance

Company resulted in an increase of controlled

hypertension from 36% to 82% after 1 year of

operation [33].

Work site programs that focus on hypertension

have shown potential for success in reducing

blood pressure. The programs are accessible at

little or no cost to the recipient with systematic

monitoring and ongoing patient education pro-

vided. These programs generally rely on multidis-

ciplinary teams working by a well-defined,

stepped-care protocol. Globally instituting such

programs might serve as a mechanism to improve

hypertension control. The cost of work site hyper-

tension programs may vary substantially, how-

ever. When calculating cost, employers must

consider program frequency, level of control

achieved, cost of treatment, impact on disability

costs, effect on absenteeism, cost of heart attacks

and strokes, and so forth [28]. Once established,

work site hypertension programs benefit both

the employees and the employers. For the

employee, they provide a convenient and econom-

ical means for hypertension management. For the

employer, the initial start-up cost is recovered

through a healthier and more productive work-

force [28].

Faith-based organizations

Faith-based organizations can be an ideal set-

ting for detection, treatment, and control pro-

grams. These organizations exist in virtually every

community and may serve not only as places for

worship but also as places for social, political, and

educational activities. Their leaders are often well

known and respected in the community and sought

after for advice. Generally, the organizations have

congregations with a diversity of experience (blue

collar, white collar, government, industry, etc.)

and a history of volunteering and outreach. Mem-

bers may work in a variety of settings and be

involved in other community organizations. The

collaboration between faith-based organizations

and the community further facilitates the dissemi-

nation of health programs. These traits make

faith-based organizations attractive sites for imple-

menting and sustaining health programs [34–38].

Since 1970, Hatch and colleagues have imple-

mented faith-based education programs in rural

black communities in the South, with hyperten-

sion often a major focus. Positive results from

these programs show that it is feasible to conduct

health education programs in faith-based organi-

zations [34–39]. In 1978, a consortium of health-

related organizations requested and received

funding from the NHLBI to organize churches

as hypertension control centers. Three years later,

the National Black Health Providers Task Force

on High Blood Pressure Education and Control

recommended the use of faith-based organizations

for health education [40,41].

In 1994, the American Heart Association laun-

ched a national faith-based campaign, ‘‘Search

Your Heart,’’ to reach persons in church settings

and encourage them to change their lifestyle so

as to make their bodies heart healthy. This cam-

paign, which also focused on high blood pressure

education, was revamped in 1997 to include com-

ponents addressing blood pressure screening, phy-

sical activity, nutrition, and stroke [42].

Although data on the effectiveness of faith-

based hypertension programs is not readily avail-

able, this approach has wide support [34–38], In

addition, a 1994 Gallup survey found that 60% of

Americansbelieved that religionwas important and

that 42% attended church weekly or almost weekly

[43]. Results from the Pawtucket Heart Program

support the use of faith-based organizations


for health promotion; 58% of persons attending

health education events at faith-based organiza-

tions were members of the sponsoring organiza-

tion, 24% were members of another faith-based

organization, and just 18% were not members

of any faith-based organization. These results

suggest that not only members of the sponsoring

organization but also nonmembers attend health

education events sponsored by faith-based organi-

zations [22–24]. Furthermore, although much of

the experience has been in the black community,

faith-based organizations may serve as important

venues for health promotion and disease preven-

tion programs with other minority groups, particu-

larly Hispanics [34,44–46].

Barbershops/beauty salons/fire stations

Barbershops, beauty salons, and fire stations,

as in the case with faith-based organizations, may

serve as places for social, political, and educational

activities. Two published accounts, both by Kong

[47,48], document the use of barbershops and

beauty salons as alternative settings to churches

for health programs. After researchers involved

in faith-based programs realized that men were

not using the services as frequently as were women,

they investigated the barbershops as an alternative

setting for reaching the male population. Many

men visit the barbershop on a monthly basis and,

while seated in the chair, are captive audiences

for 15 minutes of health education and could easily

get their blood pressure checked.

Beauty salons also provide opportunities to

reach unique audiences not present in other set-

tings. ‘‘Healthy Hair Starts with a Healthy Body’’

is a program started by the National Kidney Foun-

dation in Michigan in June 1999 to prevent kidney

disease. Program partners include the Michigan

Department of Community Health, Diabetes Out-

reach Networks, American Heart Association,

local health departments, hospitals and managed

care programs, and 55 stylists from 39 salons. Sty-

lists give their clients a ‘‘health chat,’’ brochures, a

risk survey, blood pressure check, and a canvas bag

of health- and beauty-related incentives [49].

Fire stations are an attractive setting for

screening because they are generally easily accessi-

ble and open 24 hours a day, 7 days per week.

Firefighters trained in measuring blood pressure

can provide free screening and counseling while

they are waiting to fight fires, affording them the

opportunity to provide an additional and needed

service while interacting with the public [47,48].

Pharmacists

With 16% to 50% of hypertensive patients dis-

continuing their medications within the first year

of treatment, compliance is a major issue. Phar-

macists, if included in the health care delivery

team, can positively influence compliance and

help achieve blood pressure control [50–53]. A

simple pairing of a physician and pharmacist

may also be effective, judging from the results of

a study by Bogden and colleagues [54]. They con-

ducted a 6-month trial in a resident teaching

clinic, in which the intervention arm consisted of

a pharmacist interacting with physicians and

patients on each visit to optimize antihypertensive

drug therapy. Patients assigned to the control arm

received the same medical care as those in the

intervention but did not receive input from a

pharmacist. At the end of the trial, almost three

times as many persons in the intervention arm

controlled their hypertension (55% versus 20%,

P\0.001) compared to the control arm. Systolic

blood pressure declined by 23 mm Hg in the inter-

vention arm and 11 mm Hg in the control arm

(P\0.01). Diastolic blood pressure dropped 14

mm Hg in the intervention arm and 3 mm Hg

among controls (P\0.001).

In another study, the intervention group mon-

itored their blood pressure at home using manual

electronic monitors and received monthly tele-

phone calls from their pharmacist to evaluate

their blood pressure response; controls received

neither intervention. After 6 months, 44% of the

intervention arm, but only 22% of controls, had

controlled their hypertension [53].

Incorporating the concept of ‘‘pharmaceutical

care,’’ in which the pharmacist assumes additional

responsibility for the patient by ensuring the

appropriate use of specific drugs to achieve the

desired outcome, is overdue in the arena of hyper-

tension control. The role of the pharmacist can and

should go beyond filling the prescription. The

pharmacist can encourage compliance, answer

questions, manage mild drug reactions, monitor

blood pressure, and provide referrals when needed.

Community outreach

Effective hypertension control programs require

a comprehensive approach that incorporates

social, psychologic, behavioral, economic, and bio-

medical components. Community outreach, which

is a proven strategy, encompasses many of these

approaches and has gone far beyond its traditional


role of helping tomeet the needs of the underserved.

It provides the link between health professionals

and health care organizations with current or

potential patients and connects to resources in the

patients’ communities. Indeed, today community

outreach is an extension of medical and nursing

care that is used to meet marketing, public rela-

tions, and population needs as well as health pro-

motion and disease prevention objectives. Hill

and colleagues [55] cite, from the clinical perspec-

tive, three important lessons learned from including

community outreach in hypertension care and con-

trol programs:

1. Clinicians can use resources in the community

to directly enhance their care of patients, thus

improving long-term control of hypertension

and reducing associated target organ damage.

2. Community programs can provide reinforce-

ment of the clinician’s recommendations and

teaching efforts.

3. Physicians, nurse practitioners, and other

clinicians can provide community service

and leadership by accepting referrals, pro-

moting outreach programs, and acting as

consultants.

Results from clinical trials unequivocally

demonstrate that lifestyle changes combined with,

if necessary, pharmacologic intervention contri-

bute to hypertension control and reduce asso-

ciated morbidity and mortality. The challenge,

however, is translating research into practice,

which is where community outreach can play a

major role. Involving community leaders in the

design, implementation, and evaluation of out-

reach programs so that they are acceptable and

responsive to the community can be critical.

Incorporating the priorities and strategies of both

the community and health professionals reflects a

broader definition of health by recognizing its

social, cultural, and economic context [56]. To

accomplish long-term blood pressure control,

health care providers need to know and be sup-

portive of the social context of their patients’ lives.

Community outreach offers new opportunities to

explore the most cost-effective and efficient strate-

gies for hypertension control among diverse popu-

lations and those bearing a disproportionate

burden of hypertension and its sequelae [55].

Clinical care

There is no doubt that the effective control of

high blood pressure saves lives, but reaching

higher rates of control can be a daunting task.

Multidisciplinary teams involving professional

associations, government agencies, volunteer

health agencies, health care facilities, consumer

groups, community groups, community health

workers, social workers, nurses, and pharmacists

have been very successful in raising rates of high

blood pressure detection and treatment. Specia-

lized clinics with designated, well-trained staff

have achieved impressive control rates. Descri-

bed next are programs involving nurses and

pharmacists.

Nurse-managed clinics

Management of hypertensive patients, as out-

lined in many published national and interna-

tional guidelines, is complex and time consuming,

and increasing demands on physicians make them

less able to deliver such care. Since the 1950s,

however, nurses have been involved in screening

for hypertension and caring for hypertensive per-

sons and thus are ideal for delivering such care

[55,57]. Numerous studies, including national

multisite clinical trials such as the Hypertension

Detection and Follow-up Program (HDFP) and

Systolic Hypertension in the Elderly Program

(SHEP), have demonstrated the effectiveness of

nurses and nurse-managed clinics in hypertension

detection, treatment, and control [58,59].

Both the HDFP and SHEP showed that blood

pressure could be reduced effectively and that

rates of cardiovascular disease events could

be lowered by controlling hypertension [58,59].

The HDFP observed an average reduction of

5 mm Hg in diastolic blood pressure; the SHEP

showed a reduction of 4 mm Hg in diastolic blood

pressure. Less often noted is that the care in both

trials was delivered primarily by nurses, who were

responsible for screening, counseling, and medica-

tion management.

The Division of Hypertension at the Mayo

Clinic, in Rochester, MN, established a hyperten-

sion clinic that relied on a multidisciplinary team

of physicians specializing in hypertension, nurses,

dietitians, and nurse educators to achieve optimal

control of hypertension in their outpatients. A

horizontal rather than hierarchical approach was

used to manage the clinic. Nurses were responsible

for maintaining blood pressure equipment,

teaching patients, addressing compliance issues,

managing medications, reinforcing therapeutic

goals, and ensuring follow-up visits. The patients

benefited by their interaction with health care


providers in setting goals, having easy access to

medical care with no treatment delays, and

having access to home monitoring [60].

Because the nurse is often the first professional

the patient encounters within the health care

delivery system, his or her interaction with the

patient and the family influences the patient’s

behavior and attitude toward the health care sys-

tem significantly. Often the nurse incorporates

information regarding the patient’s background,

lifestyle, health history, and other relevant factors

into determining the patient’s health status and

health care plan. By understanding the social

environment, the nurse can assist the patient in

attaining and maintaining a healthy lifestyle.

Nurses can facilitate and support high blood pres-

sure control by developing a health care plan and

providing referrals, follow-up, and maintenance

of therapy after the original diagnosis of hyperten-

sion. Ultimately, having a nurse manage the

hypertensive patient instead of making a referral

to specialty care keeps patients in the primary care

setting with their provider, which can result in

more comprehensive care and an increase in com-

pliance [55,61].

Rates of control of hypertension in nurse-run

clinics are comparable to those achieved by physi-

cians [57]. Still, although the success is documented,

financial reimbursement for patient education and

counseling is usually unavailable, and in some set-

tings medical opposition to nurse practitioners

has impeded the development of nurse-managed

clinics for hypertension control. Additionally,

many people prefer to have a physician be their pri-

mary care provider and manage their health care.

Still, nurses play a critical role in the health care

delivery system and have proved beneficial in the

detection and control of high blood pressure.

Conclusion

Since the initiation of the NHBPEP, we have

seen remarkable increases in awareness, treatment,

and control of hypertension. During the past dec-

ade, however, rates of awareness and treatment

have leveled off and rates of control have declined.

Thus, health care providers and patients must not

become complacent. Providers need to give their

attention both to those with moderate hyperten-

sion and those with uncontrolled hypertension.

Hypertension that is uncontrolled usually reflects

nonadherence, undermedication, or both. Nonad-

herence to hypertension therapy is a major public

health problem, suggesting the need for innovative

intervention that takes advantage of underutilized

venues already existing in the community. Regard-

ing undermedication, additional research is needed

to explore the extent to which health care providers

are adopting the current guidelines for detecting,

treating, and managing of hypertension in daily

practice. Also warranted is an exploration of the

decision-making process used by health care provi-

ders to determine when to start drug therapy and

when to adjust the regimen to achieve optimal

blood pressure.

Technologic advances have made it possible

for patients to take a more active role at home

in their care. Telephone, fax, fax modems, electro-

nic mail, handheld and personal computers, vir-

tual physician’s offices, and the Internet are

examples of advanced technology being used suc-

cessfully to transmit data between the home and

health care settings. These technologies provide

opportunities for patient self-monitoring and

communication of information between patients

and laboratories, nurse case managers, primary

care physicians, and specialist physicians. Extend-

ing patient care into the home via these mechan-

isms has been shown to improve adherence by

allowing quick tailoring of therapy and has earned

high levels of patient and provider satisfaction

and improved outcomes [62,63].

In summary, effective strategies for blood pres-

sure control at the national, state, and community

levels are presented here. It is the intent of the

authors to provide an impetus for discussing

why the rates of hypertension awareness, treat-

ment, and control are stable in spite of the afore-

mentioned successes. Is there a need to redefine

our strategies? Clearly, increasing our prevention

efforts, improving entry into care, and promoting

adherence to treatment recommendations are

areas that demand our commitment.

References

[1] Flack JM, Doyle J, Casciano R, Arocho R,

Casciano J, Gonzales MA. The health economic

impact of failure to reach blood pressure goals. Am

J Hypertens 2000;13:17A–8A.

[2] Burt VL, Whelton P, Roccella EJ, Brown C,

Cutler JA, Higgins M, et al. Prevalence of hyperten-

sion in theUS adult population: results from the Third

National Health and Nutrition Examination Survey,

1988–1991. Hypertension 1995;25:305–13.

[3] National Institutes of Health. National Conference

on High Blood Pressure Education: report on


proceedings. 1973. Bethesda, MD: Public Health

Services, Department of Health Education and

Welfare Publication (NIH) 73–486.

[4] The Pooling Project Research Group. Relation-

ship of blood pressure, serum cholesterol, smoking

habit, relative weight and ECG abnormalities to

incidence of major coronary events: final report of

the Pooling Project. J Chronic Dis 1978;31:201–306.

[5] JointNational Committee on Prevention.Detection,

Evaluation, and Treatment of High Blood Pres-

sure. The sixth report. Arch Intern Med 1997;157:

2413–46.

[6] American Heart Association. High blood pressure

statistics. http://www.americanheart.org/Heart_and_

Stroke_A-Z_Guide/hbp.html. Accessed April 11,

2001.

[7] U.S. Department of Health and Human Services.

Healthy people 2010: national health promotion

and disease prevention objectives. Washington, DC:

Government Printing Office; 2000.

[8] Roccella EJ, Burt V, Horan MJ, Cutler J. Changes

in hypertension awareness, treatment, and control

rates: 20-year trend data. Ann Epidemiol 1993;3:

547–9.

[9] National High Blood Pressure Education Program.

The National Heart, Lung, and Blood Institute

page. Available at: http://www.nhlbi.nih.gov/about/

nhbpep/index.htm. Accessed April 11, 2001.

[10] Williams PT, Fortmann SP, Farquhar JW, Varady

A, Mellen S. A comparison of statistical methods

for evaluating risk factor change in community-

based studies: an example from the Stanford Three-

Community Study. J Chronic Dis 1981;34:565–71.

[11] Farquhar JW. The community-based model of life

style intervention trials. Am J Epidemiol 1978;108:

103–11.

[12] Meyer AJ, Nash JD, McAlister AL, Maccoby N,

Farquhar JW. Skills training in a cardiovascular

health education campaign. J Consult Clin Psychol

1980;48:129–42.

[13] Maccoby N, Farquhar JW, Wood PD, Alexander J.

Reducing the risk of cardiovascular disease: effects

of a community-based campaign on knowledge and

behavior. J Community Health 1977;3:100–14.

[14] Fortmann SP, Winkleby MA, Flora JA, Haskell

WL, Taylor CB. Effect of long-term community

health education on blood pressure and hyperten-

sion control. The Stanford Five-City Project. Am J

Epidemiol 1990;132:629–46.

[15] Farquhar JW, Fortmann SP, Maccoby N, Haskell

WL, Williams PT, Flora JA, et al. The Stanford

Five-City Project: design and methods. Am J

Epidemiol 1985;122:323–34.

[16] Flora JA, Maccoby N, Farquhar JW. Commu-

nication campaigns to prevent cardiovascular

disease: the Stanford Community Studies. In:

Rice RE, Atkin CK, editors. Public communication

campaigns. Newbury Park, CA: Sage Publications,

1989. p. 233–52.

[17] Farquhar JW, Fortmann SP, Flora JA, Taylor CB,

Haskell WL, Williams PT, et al. Effects of commu-

nitywide education on cardiovascular disease risk

factors. The Stanford Five-City Project. JAMA

1990;264:359–65.

[18] Luepker RV, Murray DM, Jacobs Jr. DR, Mittel-

mark MB, Bracht N, Carlaw R, et al. Community

education for cardiovascular disease prevention:

risk factor changes in the Minnesota Heart

Health Program. Am J Public Health 1994; 84:

1383–93.

[19] Mittlemark MB, Luepker RV, Jacobs DR, Bracht

NF, Carlaw RW, Crow RS, et al. Community-wide

prevention of cardiovascular disease: education

strategies of the Minnesota Heart Health Program.

Prev Med 1986;15:1–17.

[20] Blackburn H, Luepker RV, Kline FG, Bracht N,

Carlaw R, Jacobs D, et al. The Minnesota Heart

Health Program: a research and demonstration

project in cardiovascular disease prevention. In:

Matarazzo JD, Weiss SM, Herd JA, Miller NE,

Weiss SM, editors. Behavioral health: a handbook

of health enhancement and disease prevention. New

York: Wiley and Sons: 1984. p. 1171–8.

[21] Jacobs Jr. DR, Luepker RV, Mittelmark MB,

Folsom AR, Pirie PL, Mascioli SR, et al. Commu-

nity-wide prevention strategies: evaluation design of

the Minnesota Heart Health Program. J Chronic

Dis 1986;39:775–88.

[22] Carleton RA, Lasater TM, Assaf A, Lefebvre RC,

McKinlay SM. The Pawtucket Heart Health Pro-

gram: I. an experiment in population-based disease

prevention. Rhode Island Medical Journal 1987;70:

533–8.

[23] Carleton RA, Lasater TM, Assaf AR, Feldman

HA, McKinlay S. The Pawtucket Heart Health

Program: community changes in cardiovascular

risk factors and projected disease risk. Am J Public

Health 1995;85:777–85.

[24] LefebvreRC,LasaterTM,CarletonRA,PetersonG.

Theory and delivery of health programming in

the community. The Pawtucket Heart Health

Program. Prev Med 1987;16:80–95.

[25] Winkleby MA, Feldman HA, Murray DM. Joint

analysis of three U.S. community intervention trials

for reduction of cardiovascular disease risk. J Clin

Epidemiol 1997;50:645–58.

[26] U.S. Department of Health and Human Services.

Fulfilling state priorities for prevention: The

Preventive Health and Health Services Block

Grant. Washington, DC: Government Printing

Office; 1998.

[27] National Center for Chronic Disease Prevention

and Health Promotion. Cardiovascular Health.

Available at: http//www.cdc.gov/nccdphp/cvd.

Accessed April 10, 2001.

[28] Fielding JE. Health promotion and disease preven-

tion at the worksite. Annu Rev Public Health

1984;5:237–65.


[29] Alderman MH. Hypertension control programs in

occupational settings. Public Health Rep 1980;95:

158–63.

[30] Alderman MH, Madhavan S, Davis T. Reduction

in cardiovascular disease events by worksite hyper-

tension treatment. Hypertension 1983;5(6 Pt 3):

V138–43.

[31] Foote A, Erfurt JC. Hypertension control at the

work site: comparison of screening and referral

alone, referral and follow-up, and on-site treatment.

N Engl J Med 1983;308:809–13.

[32] Logan AG, Milne BJ, Achber C. Work-site treat-

ment of hypertension by specially trained nurses.

A controlled trial. Lancet 1979;2(8153):1175–8.

[33] National High Blood Pressure Education Program.

At Massachusetts Mutual off-site care and good

monitoring reduce medical costs. RE: High Blood

Pressure Control in the Work Setting [Newsletter].

1980. Washington, DC: National Heart, Lung, and

Blood Institute.

[34] Lasater TM, Becker DM, Hill MN, Gans KM.

Synthesis of findings and issues from religious-

based cardiovascular disease prevention trials. Ann

Epidemiol 1997;7(S7):S46–S53.

[35] Hatch JW, Lovelace KA. Involving the south-

ern rural church and students of the health profes-

sions in health education. Public Health Rep 1980;

95:23–8.

[36] Hatch JW, Jackson C. North Carolina Baptist

church program. Urban Health 1981;10:710–71.

[37] Hatch JW, Voorhorst S. The church as a resource

for health promotion activities in the black com-

munity. Health Behavior Research in Minority

Populations: Access, Design, and Implementation.

Bethesda, MD: US Department of Health and

Human Services; 1992. NIH-NHLBI Publication

92–2965:30–33.

[38] Hatch JW, CallanA, Eng E, JacksonC. TheGeneral

Baptist State Convention Health and Human

Services Project. Contact, 77 1984; February.

[39] Eng E, Hatch J, Callan A. Institutionalizing social

support through the church and into the commu-

nity. Health Educ Q 1985;121:81–92.

[40] Bronner YL. Session II wrap-up: community-based

approaches and channels for controlling hyperten-

sion in blacks: barriers and opportunities. J Nat

Med Assoc 1995;87(Suppl 8):652–5.

[41] National Institutes of Health. Churches as an

avenue to high blood pressure control. Bethesda,

MD: National Heart, Lung and Blood; 1987. NIH

Publication 87–2725.

[42] American Heart Association. Search your heart, a

church-based heart health and stroke program [kit].

Dallas, TX: American Heart Association; 1997.

[43] EdmondsonB.UnclaimedbyGod.AmericanDemo-

graphics 1995;17:60.

[44] Castro FG, Elder J, Coe K, Tafoya-Barraza HM,

Moratto S, Campbell N, et al. Mobilizing churches

for health promotion in Latino communities:

Companeros en la Salud. J Nat Cancer Inst

Monogr 1995;18:127–35.

[45] Davis DT, Bustamante A, Brown CP, Wolde-

Tsadik G, Savage EW, Cheng X, Howland I,

et al. The urban church and cancer control: a

source of social influence in minority communities.

Public Health Rep 1994;109:500–6.

[46] Suarez L, Lloyd L, Weiss N, Rainbolt T, Pulley L.

Effect of social networks on cancer-screening be-

havior of older Mexican-American women. J Natl

Cancer Inst 1994;86:775–9.

[47] Kong BW. Community-based hypertension control

programs that work. J Health Care Poor Under-

served 1997;8:409–15.

[48] Kong BW. Community programs to increase hyper-

tension control. J Natl Med Assoc 1989;81(Suppl):

13–6.

[49] National Kidney Foundation. Healthy hair starts

with a healthy body [pamphlet]. Detroit, MI:

National Kidney Foundation of Michigan, 1999.

[50] Carter BL, Elliot WJ. The role of pharmacists in the

detection, management, and control of hyperten-

sion: a national call to action. Pharmacotherapy

2000;20:119–22.

[51] Carter BL, Barnette DJ, Chrischilles E, Mazzotti

GJ, Asali ZJ. Evaluation of hypertensive patients

after care provided by community pharmacists in a

rural setting. Pharmacotherapy 1997;17:1274–85.

[52] Erickson SR, Slaughter R, Halapy H. Pharmacists’

ability to influence outcomes of hypertension

therapy. Pharmacotherapy 1997;17:140–7.

[53] Mehos BM, Saseen JJ, MacLaughlin EJ. Effect of

pharmacist intervention and initiation of home

blood pressure monitoring in patients with uncon-

trolled hypertension. Pharmacotherapy 2000;20:

1384–9.

[54] Bogden PE, Abbott RD, Williamson P, Onopa JK,

Koontz LM. Comparing standard care with a

physician and pharmacist team approach for

uncontrolled hypertension. J Gen Intern Med

1998;13:740–5.

[55] Hill MN, Bone LR, Levine DM. Community Out-

reach. In: Oparil S, Weber MA, editors. Hyperten-

sion: a companion to Brenner and Rector’s Kidney.

Philadelphia: WB Saunders Co; 1999. p. 415–9.

[56] Robertson A, Minkler M. New health promotion

movement: a critical examination. Health Educ Q

1994;21:295–312.

[57] Miller NH, Hill MN. Nursing clinics in the

management of hypertension. In: Oparil S,

Weber MA, editors. Hypertension: a companion

to Brenner and Rector’s Kidney. Philadelphia: WB

Saunders Co; 1999. p. 409–14.

[58] Hypertension Detection and Follow-up Program

Cooperative Group. Five-year findings of the hyper-

tension detection and follow-up program. JAMA

1979;242:2562–71.

[59] Schron EB, Davey JA, Jensen JM, Probstfield JL.

The systolic hypertension in the elderly program:


implications for nursing practice and research.

Progr Cardiovasc Nurs 1989;4:138–45.

[60] Schultz JF, Sheps SG. Management of patients with

hypertension: a hypertension clinic model. Mayo

Clin Proc 1994;69:997–9.

[61] Hill MN, Miller NH. Compliance enhancement:

a call for multidisciplinary team approaches. Cir-

culation 1996;93:4–6.

[62] DeBusk RF, Miller NH, Superko HR, Dennis CA,

Thomas RJ, Lew HT, et al. A case-management

system for coronary risk factor modification after

acute myocardial infarction. Ann Intern Med 1994;

120:721–9.

[63] Friedman RH, Kazis LE, Jette A, Smith MB,

Stollerman J, Torgerson J, et al. A telecommunica-

tions system for monitoring and counseling patients

with hypertension: impact on medication adherence

and blood pressure control. Am J Hypertens 1996;

9(4 Pt 1):285–92.


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