Barriers and Facilitators to Hypertension Control Following Participation in a Church-Based Hypertension Intervention Study

Abstract

Purpose:

Hypertension is the primary risk factor for development of cardiovascular complications. Community-initiated interventions have proven effective in reducing cardiovascular disease risk among individuals who might otherwise face barriers to care. The purposes of this study were to gain feedback on a church-based hypertension intervention study and assess barriers and facilitators to hypertension control after participation in the study.

Design:

Qualitative study of 4 focus groups.

Setting:

Focus groups took place at 4 churches in primarily minority neighborhoods of Chicago, Illinois, in summer 2017.

Participants:

Thirty-one community members participated in the focus groups.

Method:

The Community Targeting of Uncontrolled Hypertension (CTOUCH) study was a church-based screening, brief intervention, and referral for treatment program for hypertension. Following the study completion, participants were invited to join a focus group to provide feedback on the study and discuss barriers and facilitators to hypertension control. The authors used the Framework Method to analyze the data.

Results:

Community Targeting of Uncontrolled Hypertension was well received by participants, particularly the awareness of their individual blood pressure and subsequent education on risk modification. The most common facilitators for hypertension control were social support, knowing how to control hypertension, and community resources. The most common barriers to hypertension control were lack of hypertension knowledge, negative primary care experiences, and lack of disease awareness.

Conclusion:

Knowledge of barriers and facilitators can inform areas of success and opportunities for improvement in community-based hypertension programs including future renditions in CTOUCH.

Keywords

hypertension control barriers facilitators community-based intervention qualitative data

Purpose

Thirty-three percent of individuals in the United States are affected by hypertension of which 52% have uncontrolled hypertension.¹ Hypertension is the primary risk factor for premature cardiovascular disease.² While hypertension is a problem for the US population as a whole, significant disparities in hypertension outcomes exist, with minorities having higher rates of morbidity and mortality.^3,4 According to a National Health and Nutrition Examination Survey, 16% of adults with hypertension are unaware of their condition; however, this number is 20% for Hispanics and 30% for adults without insurance.⁵ In Chicago, the highest rates of hypertension are seen in predominantly minority communities, with rates as high as 44% to 58% in some communities in the south and west side, compared to the city-wide average of 28%. The highest rates of hypertension in Chicago are seen among African Americans at 35%.⁶

A systematic review of community-based cardiovascular health interventions in vulnerable populations found those aimed at decreasing blood pressure (BP) to be the most promising.⁷ Churches and faith-based organizations have become an increasingly popular method for conducting community-based health promotion programs and research studies.⁸ Interventions housed in churches can reach broad populations, with the potential to reduce health disparities.⁸

In order to address the disproportionate rates of uncontrolled hypertension and associated morbidity and mortality among minority communities in the city of Chicago, we conducted the Community Targeting of Uncontrolled Hypertension (CTOUCH) pilot study. The CTOUCH study team, composed of emergency medicine physicians, pharmacists, researchers, and students, enrolled 152 community participants across 4 community churches with predominantly African American and Hispanic populations in Chicago, Illinois. The pilot was designed to determine participant acceptability and overall impact of a community-based screening, brief intervention, and referral for treatment program for hypertension (SBIRT-HTNc) on BP improvement/control through patient empowerment and access to primary care follow-up.

Following the pilot study, the authors conducted 4 focus groups for CTOUCH participants—one at each church—on program feedback and barriers and facilitators to hypertension control. Prior literature on barriers and facilitators to hypertension control has focused primarily on African Americans. Studies have found that common facilitators include social support,^9,10 positive relationships with doctors,^9,11 weight loss, unexpected hypertension diagnosis, and family members with hypertension.¹⁰ Common barriers to hypertension control include competing health priorities/comorbidities,^9,12 lack of hypertension knowledge,^9,11 poor access to community resources,⁹ lack of money,¹⁰ lack of motivation to exercise,¹⁰ fear of injury from exercise,¹⁰ stress,¹² habit,¹² time,¹² and taste of healthier foods.¹²

We found far fewer studies that focus on barriers and facilitators for the Hispanic community. One study of Hispanic participants found the greatest barriers to hypertension prevention behaviors were limited resources and cultural expectations and values. Limited resources included health insurance for hypertension screening, money for health food, and time for exercise or cooking healthy meals. Cultural expectations and values referred to valuing social interaction over solitary exercise, not seeking health care, and a preference for traditional foods.¹³

The purposes of the focus groups discussed in this article were to gain feedback on the CTOUCH hypertension intervention study and to identify perceived facilitators and barriers for hypertension control among both African Americans and Hispanics after their participation in the study. As the CTOUCH study was meant to break down barriers for hypertension control, results from this study can help improve community-based hypertension programs, including future renditions of the CTOUCH study, which are culturally sensitive to minority communities.

Design

Community Targeting of Uncontrolled Hypertension Overview

Relationships with 4 churches were initiated in 4 different neighborhoods of Chicago, Illinois, by directly reaching out to community leaders in each congregation. Of the 4 churches, 2 were in predominately African American neighborhoods and 2 were in predominantly Hispanic neighborhoods. Two BP screening events were organized at each congregation to accommodate the different worship services. Information about the screening events was communicated to members of each congregation through bulletin announcements, local flyers, and reminders provided by church leaders at the conclusion of services.

Community members qualified for eligibility screening for the study if they were adults aged 18 years or older who spoke either English or Spanish fluently. Prior to participating in the BP assessment on the day of the screening, all participants were shown a 5-minute standardized consent video explaining all study procedures and were allowed to ask questions before signing a consent form.

Of the 152 community members interested in study participation, only individuals with moderately (≥140/90 mm Hg; n = 46) or severely elevated BP (≥160/100 mm Hg; n = 43) were eligible to participate in the study interventions. Participants with normal BPs (<140/90 mm Hg) on initial screening (n = 63) were congratulated on their BP and received a pedometer and materials on healthy nutrition and exercise.

The study interventions consisted of a BP assessment and a brief customized culturally appropriate video on “What is High Blood Pressure?”. Individuals with severely elevated BPs (≥160/100 mm Hg) additionally viewed a brief collection of echocardiogram images showing early but reversible subclinical changes due to uncontrolled hypertension and had a brief on-site consultation with a clinical pharmacist. Following completion of the intervention, all participants received automated BP monitors (with training on how to use them) and information on Federally Qualified Health Centers located in their respective geographic location for ongoing primary care. Participants were asked to return to the church 3 months after the initial assessment for a follow-up measurement of their BP and were given the opportunity to participate in a focus group.

Setting

Community Targeting of Uncontrolled Hypertension took place at 4 churches in predominantly minority neighborhoods on Chicago’s south and west sides. The neighborhood sociodemographic characteristics for each church partner can be found in Table 1. For all neighborhoods, poverty and uninsured rates were higher than Chicago’s overall average. The percentage of residents with hypertension, the heart disease mortality rate, and stroke mortality rate were higher for most neighborhoods than the city’s average.

Table 1.

Characteristics by Church Partner.

Church	Predominate Race/Ethnicity of Church	Neighborhood^a Characteristics							Number of Participants
Church	Predominate Race/Ethnicity of Church	% African American	% Hispanic	% Household Poverty	% No Health Insurance	% Hyper- tension	Heart Disease Mortality Rate^b	Stroke Mortality Rate^b	Intervention Participants at Baseline (n = 89)	Intervention Participants at 3-Month Follow-Up (n = 60)	Focus Group Participants (n = 31)
1	Hispanic	40.9	52.0	32.2	19.1	21.6	256.7	46.7	18	14	8
2	Hispanic	3.2	80.5	26.2	15.1	31.2	162.6	36.8	20	6	2
3	African American	90.7	2.5	33.0	15.0	38.7	269.8	55.6	26	19	10
4	African American	83.0	11.4	28.6	15.8	35.8	261.0	61.2	25	21	11
Chicago		31.1	28.9	18.9	9.8	27.6	207.1	46.0	–	–	–

^a Neighborhood is based on one of the 77 community area geographical divisions, as defined by the Social Science Research Committee at the University of Chicago. Neighborhood data is from Chicago Health Atlas (https://www.chicagohealthatlas.org/). Accessed November 7, 2018.

^b Per 100 000 population.

Participants

Table 2 shows focus group participant characteristics, based on self-report baseline surveys at the initial CTOUCH study visit, as well as BP readings at the initial and 3-month follow-up visits. Trained research assistants verbally administered the surveys to participants and took their BP readings using automatic BP machines. Participants were predominantly female, African American, and had a history of hypertension.

Table 2.

Focus Group Participant Characteristics.^a

Age, mean (SD)	58.3 (13.1)
% Male	29.0
% African American	71.0
% Hispanic	22.6
% With preferred language of Spanish	22.6
% With history of hypertension (told has high blood pressure and/or is on medication for high blood pressure)	67.7
% With diabetes	29.0
% With tobacco use (currently smoke or live or work with people who smoke every day)	19.4
% in moderately elevated blood pressure (stage I) group	61.3
% in severely elevated blood pressure (stage II) group	38.7
Systolic blood pressure, mm Hg, at baseline, mean (SD)	153.8 (16.6)
Diastolic blood pressure, mm Hg, at baseline, mean (SD)	92.8 (8.9)
Systolic Blood Pressure, mm Hg, at 3-month follow-up, mean (SD)	142.4 (20.3)
Diastolic blood pressure, mm Hg, at 3-month follow-up, mean (SD)	86.7 (10.5)

Abbreviation: SD, standard deviation.

^a N = 31.

Method

Sixty CTOUCH participants attended the 3-month follow-up visit. At this visit, study participants were given the opportunity to participate in a focus group discussion about their experiences with the CTOUCH program and discuss barriers and facilitators to hypertension control in order for this research to potentially improve care for patients with hypertension. Each focus group took place in their respective community church, and there were 31 total participants across the 4 groups. Discussions were audio-recorded, and each participant used a study ID number rather than any names during the focus group. They were moderated by authors Escobar-Schulz, project coordinator for the CTOUCH study, and Del Rios, physician and CTOUCH coinvestigator, who used a semistructured focus group guide (see Online Appendix). Both moderators were females who were bilingual in Spanish. One had prior experience and one was new to moderating focus groups. Two focus groups were in English and two were in a combination of English and Spanish. Each lasted approximately 45 minutes. While CTOUCH participants did receive compensation for their 3-month follow-up visit for the main study, those who agreed to participate in the focus group did not receive any additional compensation.

The study was approved by the University of Illinois at Chicago Institutional Review Board. All participants signed a consent form to participate in the CTOUCH study. Since the focus group discussion was optional and not part of the original consent form, those who were interested in participating in the focus group received a consent addendum form regarding voluntary participation in the focus group.

Analysis

The audio-recordings of the focus groups were transcribed verbatim by trained research assistants. Using the framework analytical approach,¹⁴ each focus group transcript was coded by 3 investigators. The investigators became familiar with the interviews by reading through each transcript and relistening to the audio files if there was a question about any transcript wording. Each investigator independently read through and conducted open coding for all transcripts and then met to develop a working analytical framework with codes and definitions for each transcript. After agreeing on the framework, 2 investigators independently coded each transcript using the working analytical framework. This was completed using the QDA Miner Lite software (v2.0.5; Provalis Research, Montreal, Quebec, Canada). The investigators then met again to determine discrepancies in their coding using the framework and to develop any necessary revisions to the framework. The final framework can be found in the Online Appendix. Next, the investigators summarized the data into a matrix for each theme using Microsoft Excel 2013 (Microsoft Corporation, Redmond, WA). Categories were grouped into subsequent themes, and pertinent quotes were extracted for each theme. Throughout the qualitative analysis process, the investigators met regularly to discuss categories and themes, to reduce discrepancies, and to come to a consensus.

Results

Several themes emerged from the focus groups with CTOUCH participants. Due to the nature of the group, the most common theme was feedback on the CTOUCH program itself. The most common facilitators to hypertension control were social support, knowing how to control hypertension, and available community resources. Even after the CTOUCH intervention, the most common barriers to hypertension control remained a lack of hypertension knowledge, negative primary care experiences, and a lack of disease awareness. Additionally, minor themes surrounding issues navigating health insurance and language/cultural issues emerged in the focus groups located at the predominately Hispanic churches.

Feedback on CTOUCH Program

Participants in the CTOUCH program were overwhelmingly thankful of the program and enjoyed the convenience of having it take place at their church as well as the fact that the program was free.

But just to know that someone cares enough to come up with a program such as this to come out here and help us…It lets us know that people do care about us. And sometimes you feel like, neglected or pushed to the side about your health or they gonna die anyway or whatever the case may be, but to know that someone is going to take out time to come out and inform you and educate you on how to be better to take care of yourself, and your life, this means a lot. (ID 75)

They spoke about their appreciation for the thorough explanations of hypertension and as a result, the large amounts of knowledge that they learned by participating in the program. Specifically, there were several learning tools in the program that participants especially enjoyed. They appreciated receiving a BP monitor as part of the program, which empowered them to check their BP from home whenever they wanted. Participants said that visual education tools, such as colorful graphics that showed where their BP was and where it should be, were easy to follow. Another visual education tool that was appreciated was the ability to see video of a healthy heart compared to an unhealthy heart, which emphasized the severity of uncontrolled hypertension to participants.

Doctor just says, “Oh you have high blood pressure” and just give us medicine, here they explained everything…(ID 6)

Prior to the program, many participants did not know that their BP was high, and the program proved to be “eye-opening.” Participants also commented that the program successfully allowed them to get more in tune to their bodies, better communicate with their doctor, and ultimately allowed them to get their high BP down to controlled levels.

I’m grateful because before I came here, I did not know what the high pressure was, and the risks themselves. Now I know what the risks are. I had it but I did not know it. (ID 4)

Some participants mentioned some areas of improvement for the program. One participant suggested that it would be helpful to have someone come in to share their story. Others suggested that a continued connection to the program would be helpful for current participants and expansion of the program would be beneficial to help other communities.

Facilitators to Hypertension Control

Social support

Social support was a facilitator for participants to help control their hypertension. People identified as providing social support ranged from spouses, adult children, health-care coworkers, the local YMCA, friends, fellow church members, and neighbors. These providers of social support tended to act as a sounding board for whether to see a doctor about hypertension issues and some accompanied participants for exercise. They also provided participants with reminders to take medications, check their BP frequently, go to appointments, and avoid unhealthy foods. Participants also mentioned that it would be helpful to be able to contact someone who could answer any questions they had about hypertension.

My daughter always tells me, she must be knowing something, like if there is something wrong with me, they’re like “call the doctor” or “daddy go lay down and take a rest,” sometimes she always lets me know that something might be wrong. (ID 13)

As a church group, the night that we came in, um…because we know everybody, pretty much on a personal level. The people who had high BP, we were kinda talking to them about “Have you got your blood pressure down? How’s it going?” and checking in, you know what I’m saying? So as a group effort, I think we kinda talk to different ones about how they can help themselves. (ID 8)

Knowledge on how to control hypertension

After partaking in the CTOUCH program, participants gained knowledge on how to control hypertension. Most commonly expressed was the importance of a healthy diet, especially decreasing sodium intake, eating fruits and vegetables, and drinking water as well as getting exercise. Additionally, they discussed the need to decrease stress and not smoke in order to control their hypertension. Participants also understood that medication adherence was very important in controlling their hypertension.

I learned how to eat better, uh, take that salt out of my diet, drink water, no more pop, none of that kind of stuff. Another thing you have to learn-when I do my shopping, I become a label reader. And can[ned] goods, they can take those off the shelf. They are loaded with sodium. Even cereal, you’d be surprised how much salt is in cereal. The sodium content is outrageous. I mean, it’s ridiculous, and I’ve been reading labels. I’m there for two hours. I’m like “can’t buy this, can’t buy this.” But it helps me to understand that I have to watch my intake. That little thing called sodium, it’ll kill you, you know. (ID 58)

Community resources

The most common type of community resource that participants identified as helping them to control their hypertension was places where they could check their BP. This included pharmacies, retail stores, the YMCA, and clinics or health-care facilities. Additionally, participants mentioned exercise opportunities in their community, such as organized, themed runs, and places to exercise, such as the YMCA and tracks. It was very important to participants that these resources be easily accessible in their community (those in walking distance was ideal) and without any costs. Some participants also mentioned other programs in the community that came to their neighborhood to take their BP and provide them with a list of nearby clinic sites, however, these programs seemed to be only for senior citizens.

You know, if I go to the YMCA, if I was gonna workout, they have a blood pressure machine and you can monitor it before you work out or after you work out. (ID 33)

I’m also lucky because I do not have any obstacle because I go to the…clinic and it’s one and a half blocks from my house. I’m walking. (ID 1)

Barriers to Hypertension Control

Lack of knowledge on hypertension and how to control it

While all focus group participants had recently completed the CTOUCH study, there remained a few lingering questions from some participants, which may act as barriers to hypertension control. Some participants were confused about how much sodium to consume and which foods to eat to help lower BP. One requested a list about what to do to control hypertension. There were also questions about medication. Specifically, participants wondered why different people are on different types and numbers of BP medications and the impact of not taking BP medication.

…because I’ve been on this for many years, if you stop taking this for a certain amount of days, or a month, what is the impact or effects of not—if you just stop taking it and you just say in your mind, you know what I am gonna do this on my own. I’m not gonna take this anymore. What and how quickly and how effective would that be? (ID 75)

Participants also remained confused about why BP fluctuates so much and if there was a reason why BP was high in certain circumstances. Additionally, participants wondered at what level BP is serious where a doctor should be consulted. They also wondered about comorbidities, such as whether you can get diabetes from having hypertension.

Finally, some participants mentioned misinformation from online resources, such as searching for information online so that you don’t have to see a doctor. This may lead to someone using the Internet to determine the importance of a health concern and if this concern should be addressed or unaddressed. These gaps in knowledge for participants represent opportunities for future improvements for similar hypertension education programs in the community.

Negative primary care experiences

Participants wanted doctors to provide more extensive explanations about their health, wanted to feel like more than just a number, and wanted personalized care that was customized for them. One participant preferred the care of a nurse over a doctor because nurses explained things while doctors did not. Participants also believed that one of the best aspects of the CTOUCH program was the explanation of hypertension and how to control it, which was much preferred over the limited explanations by doctors.

I feel that, that means if I’m going to the doctor because I have high blood pressure, don’t treat me like everybody else that comes in here that has high blood pressure. You know what I’m saying? Customize it to me, my feelings, my symptoms, whatever’s going on with me. (ID 50)

Some negative primary care experiences were related to the doctor’s BP medication prescription habits. Participants mentioned that doctors were changing their medication to a more costly medication which participants could not afford. Doctors would only change it to a less costly medication if the patients researched the options themselves and requested the switch by the doctor. Participants also commented that doctors would change their dosage or medication type without any explanation of the reasoning behind it, leaving participants frustrated and confused.

The doctor I used to have, every, it seemed like every couple of years she was raising the amount of blood pressure medicine I was getting. It started at like 200, 260, 300, 360. I go like you know what this is costing me? I don’t have insurance at this time. And, and I got on the computer, I looked up all the drugs that are similar to the ones that she had given me. I found another drug that it, it was lower in dosage but was more than half less of the cost. She finally said, “Okay, I’ll lower it”. (ID 2)

Lack of hypertension awareness

Several participants mentioned the challenges with hypertension awareness due to the lack of symptoms associated with the disease. During the study, participants were surprised to learn that they had high BP and stressed the importance of screening in order to diagnose hypertension before it leads to severe health issues such as a stroke. Due to the “silent” nature of hypertension, this lack of awareness poses a barrier to hypertension control because those who are unaware of their condition will not take steps to control it.

…you can’t feel, “Hey, I got-hey, I feel like I got high blood pressure”, you know, it’s you just have it and not be aware of it. (ID 47)

Additional Themes From Predominately Hispanic Churches: Trouble Navigating Health Insurance and Language/Cultural Differences

Focus groups participants at the predominately Hispanic churches additionally discussed issues with navigating health insurance and language/cultural issues. For navigating health insurance, participants specifically expressed difficulty with determining which services and providers were in their insurance network and the challenges with the networks changing frequently. Participants wanted to see this information in a physical book or booklet that was frequently updated. Some were annoyed that their insurance would change or end without the insurance company informing them.

Everything got screwed up the last 5 years. People who had the same doctor, the same everything for a long time even though they’re not inside Obamacare, you know it’s a private plan. They got dumped off the network. (ID 1)

Additionally, participants at the Hispanic churches expressed much frustration about the prevalence of information in English but the lack of information in other languages, especially Spanish. There was also a communication barrier if the participant’s doctor spoke a different language than the participant.

The information in English you can find it everywhere. But there are many people, fortunately we can understand both languages, but everyone cannot understand both languages. So, here we are in a city where there is so much diversity. So just as there is diversity, there should also be diversity in information. (ID 2)

Conclusion

We could not find another study that looked at barriers and facilitators to hypertension control that included both African American and Hispanic participants. Most prior literature focused on a specific demographic group of African Americans, Hispanics, or the elderly individuals. Many of the barriers and facilitators that were most common in our focus groups were also prevalent in prior studies. Specifically, a lack of hypertension knowledge, the complex relationship of hypertension awareness, and the importance of social support, community resources, and primary care experiences have all been mentioned in prior studies as important elements for hypertension control.^9

-12

The best received components of the CTOUCH program were largely those that addressed some of the barriers to hypertension control that patients reported. The CTOUCH program was overwhelmingly well received by participants, especially due to the awareness obtained from learning that they had high BP, the in-depth explanations they received on hypertension, and the empowerment they received from owning their own BP machine so that they could take their BP at home.

To improve CTOUCH and any similar future programs, it is important to take into account remaining knowledge gaps of participants after program completion. The specific hypertension knowledge that was discussed as lacking at the end of the CTOUCH study included questions about healthy eating, medication, BP fluctuations, and when to contact a doctor. These topics should be especially emphasized for future community-based hypertension intervention programs. Additionally, some participants mentioned that they would want CTOUCH to be expanded into additional communities and/or for an additional period of time. While these suggestions are helpful and show the satisfaction of the program with participants, it also brings to light the need for program sustainability. Potential opportunities for sustainability may include weaving the program into existing church events. We plan to report our findings back to participating churches, as knowing community members’ barriers and facilitators to hypertension control would be a helpful starting point for these events. It is also important to partner with local health clinics in order to better improve the health of the community. Future work that includes discussions with local providers to share participant feedback on barriers that are specific to their care could help address treatment issues that were reported by many participants.

There were some limitations in this study. While we believe we spoke to a subset of CTOUCH participants who were representative of the entire group, it is possible that those who participated in the focus groups were different than the group as a whole and may not be fully representative of everyone who participated in the CTOUCH program. Second, while we followed an iterative and collaborative process for agreement between coders during our analysis, we did not calculate an intercoder reliability check value, such as the Holsti’s coefficient.¹⁵ As a result, we cannot quantify our reliability of coding across the multiple coders.

Understanding barriers and facilitators to hypertension control, as well as which program elements participants most appreciated, can inform areas of success and of greater need to improve community-based hypertension programs including any future renditions of the CTOUCH program.

SO WHAT?

What is Already Known on This Topic?

Prior literature on barriers and facilitators to hypertension control has focused on African Americans, Hispanics, or the elderly individuals. Facilitators to hypertension control have included social support, positive relationships with doctors, and unexpected hypertension diagnosis. Barriers to hypertension control have included lack of hypertension knowledge and poor access to community resources.

What Does This Article Add?

We determined barriers and facilitators across minority groups and ages for community members after participation in a hypertension intervention program (CTOUCH) and found similar facilitators and barriers to existing literature. Additionally, CTOUCH participants especially appreciated the program for making them aware of their high blood pressure, in-depth explanations on hypertension, and giving them their own blood pressure machine to use at home.

What Are the Implications for Health Promotion Practice or Research?

Supplemental Material

Supplemental Material, Appendix_All - Barriers and Facilitators to Hypertension Control Following Participation in a Church-Based Hypertension Intervention Study

Supplemental Material, Appendix_All for Barriers and Facilitators to Hypertension Control Following Participation in a Church-Based Hypertension Intervention Study by Sara Heinert, Sandra Escobar-Schulz, Maya Jackson, Marina Del Rios, Sarah Kim, Jennica Kahkejian and Heather Prendergast in American Journal of Health Promotion

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research and/or authorship of this article: University of Illinois at Chicago Department of Emergency Medicine.

ORCID iDs

Sara Heinert, PhD, MPH

Marina Del Rios, MD, MSc

Supplemental Material

Supplemental material for this article is available online.

References

Centers for Disease Control and Prevention (CDC). Table 53. Selected health conditions and risk factors, by age: United States, selected years 1988–1994 through 2015–2016. 2017. https://www.cdc.gov/nchs/data/hus/2017/053.pdf. Accessed February 25, 2019.

Collaboration Global Burden of Disease. Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories, 1990-2017: A systematic analysis for the global burden of disease study 2017. Lancet. 2018;392(10159):1923–1994.

Ferdinand

. Hypertension in minority populations. J Clin Hypertens. 2006;8(5):365–368. doi:10.1111/j.1524-6175.2006.05112.x.

Lackland

. Racial differences in hypertension: implications for high blood pressure management. Am J Med Sci. 2014;348(2):135–138. doi:10.1097/maj.0000000000000308.

Paulose-Ram

Kit

. Characteristics of U.S. adults with hypertension who are unaware of their hypertension, 2011-2014. NCHS Data Brief. 2017;(278):1–8. https://www.cdc.gov/nchs/data/databriefs/db278.pdf. Accessed March 8, 2019.

Chicago Health Atlas. Hypertension. 2017. https://www.chicagohealthatlas.org/indicators/hypertension. Accessed February 21, 2019.

Walton-Moss

Samuel

Nguyen

Commodore-Mensah

Hayat

Szanton

. Community-based cardiovascular health interventions in vulnerable populations: a systematic review. J Cardiovasc Nurs. 2014;29(4):293–307. doi:10.1097/JCN.0b013e31828e2995.

Campbell

Hudson

Resnicow

Blakeney

Paxton

Baskin

Church-based health promotion interventions: evidence and lessons learned. Annu Rev Public Health. 2007;28(1):213–234. doi:10.1146/annurev.publhealth.28.021406.144016.

Flynn

Ameling

Hill-Briggs

et al. Facilitators and barriers to hypertension self-management in urban African Americans: perspectives of patients and family members. Patient Prefer Adherence. 2013;7:741–749. doi:10.2147/PPA.S46517.

10.

Rimando

. Perceived barriers to and facilitators of hypertension management among underserved African American older adults. Ethnic Dis. 2015;25(3):329–336. doi:10.18865/ed.25.3.329.

11.

Lukoschek

African Americans’ beliefs and attitudes regarding hypertension and its treatment: a qualitative study. J Health Care Poor Underserved. 2003;14(4):566–587. doi:10.1353/hpu.2010.0690.

12.

Mansyur

Pavlik

Hyman

Taylor

Goodrick

. Self-efficacy and barriers to multiple behavior change in low-income African Americans with hypertension. J Behav Med. 2013;36(1):75–85. doi:10.1007/s10865-012-9403-7.

13.

Aroian

Peters

Rudner

Waser

. Hypertension prevention beliefs of Hispanics. J Transcult Nurs. 2012;23(2):134–142. doi:10.1177/1043659611433871.

14.

Gale

Heath

Cameron

Rashid

Redwood

. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol. 2013;13(1):117. doi:10.1186/1471-2288-13-117.

15.

Holsti

. Content Analysis for the Social Sciences and Humanities. Reading, MA: Addison-Wesley; 1969.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.11 MB