CALIFORNIA STATE UNIVERSITY, NORTHRIDGE
PLANNING FOR HYPERTENSION EDUCATION AT AN HMO
A thesis submitted in partial satisfaction of the requirements
for the degree of Master of Public Health in Health Education
by
Yvonne V. Siebert
May 1988
The thesis of Yvonne V. Siebert is approved:
Shelia C. Harbet, H.S.D.
Susan C. Giarratano, Ed. D.
Committee Chairperson
CALIFORNIA STATE UNIVERSITY, NORTHRIDGE
ii
ACKNOWLEDGEMENTS
Successful completion of a thesis project often depends upon the support
of others. I would especially like to thank:
Mei-Ling Schwartz, for unselfishly giving of her time and expertise, despite
her demanding schedule.
Dr. Susan Giarratano and Dr. Shelia Harbet, for their constructive advice
and diligent review of this thesis project.
My parents, and my husband Dennis, for their
encouragement, and enthusiasm for all my endeavors.
iii
continuous support,
TABLE OF CONTENTS
ACKNOWLEDGEMENTS
iii
ABSTRACT
vi
Chapter
1.
2.
3.
INTRODUCTION
1
Statement of the Problem
2
Purpose of the Project
3
Limitations of the Project
3
Definition of Terms
3
REVIEW OF THE LITERATURE
5
Rationale Behind Hypertension Education
5
Effectiveness of Hypertension Education
Programs
7
Characteristics of Adult Learners
to a Health Education Program
12
METHODOLOGY
15
Background
15
Needs Assessment
16
Patient Needs Assessment
17
Doctor Needs Assessment
18
Statistical Analysis
20
Development of the Hypertension Education
Curriculum
20
Curriculum Organization Methods
20
Content Specialists' Review
21
Summary
21
iv
4.
5.
6.
RESULTS, DISCUSSION, AND ORGANIZATION
OF THE HYPERTENSION EDUCATION
CURRICULUM
23
Patient Needs Assessment Survey Results
23
Doctor Needs Assessment Survey Results
26
Discussion of Data
30
Organization of the Hypertension Education
Curriculum
32
Scope and Sequence of Topics and
Generalizations
34
HYPERTENSION EDUCATION CURRICULUM
36
Content Outline
37
Topics
42
Bibliography to Curriculum
90
SUMMARY, CONCLUSIONS, RECOMMENDATIONS
92
Summary
92
Conclusions
93
Recommendations
93
BIBLIOGRAPHY
96
APPENDICES
99
A.
Patient Hypertension Needs Survey
100
B.
Doctor Hypertension Needs Survey
103
c.
Cardiac Rehabilitation Education Survey
107
D.
Physician Advisors to Member Health
Education
112
E.
Curriculum Review Committee
114
F.
Doctors' Responses
116
G.
The Findings of the Doctor and Patient
Rating of the Major Hypertension
Topic Areas by Percent
118
v
ABSTRACT
PLANNING FOR HYPERTENSION EDUCATION AT AN HMO
by
Yvonne V. Siebert
Master of Public Health
In Health Education
Hypertension is a disease that
imp~cts
upon many personal lives.
The great magnitude of uncontrolled hypertension and the complications
of hypertension such as, heart attack, stroke, heart and kidney failure rank
hypertension as a major health problem in the United States, demanding
comprehensive hypertension education for patients with this illness.
The purpose 6f this project was to develop a hypertension education
curriculum and program that would provide patients with information and
skills necessary to cope with and manage their illness and to assist staff
in their hypertension education activities at Kaiser Permanente Medical
vi
~1
Center, Panorama City.
The
specific
methods
employed
in
developing the
hypertension
education curriculum include: (1) a review of the hypertension education
literature was conducted to determine the scope of the hypertension problem
in the United States, existing hypertension education curriculum and
programs, and needs assessments for hypertension education with patients
and doctors; (2) two different needs assessment survey forms were developed
and modified for two populations, patients and doctors of Kaiser Permanente
Medical Center, Panorama City to determine their needs and interests
and to justify the need for a hypertension education program; (3) the surveys
were administered to a total of 63 patients attending a health education
class and sitting in clinic waiting rooms in the Medical Center, and to 39
doctors attending a medical staff meeting; (4) the needs assessment survey
data
results,
Administrator,
and
consultation
Physician
with
Advisors
to
the
l\lember
Member
Health
Health
Education
Education,
the
Curriculum Review Committee and the review of the literature were
instrumental in designing a curriculum for the hypertension education
program at Kaiser Permanente Medical Center, Panorama City; (5) the
curriculum, consisting of six major topic areas was developed, using a topic
and generalization approach, and, including objectives, evaluative criteria,
content, learning opportunities and resources; (6) the curriculum was then
validated by professionals practicing in the fields of education, medicine,
health education, dietary and pharmacy; and, (7) recommendations for
implementation and evaluation of the hypertension education program
are given.
vii
{
'
Chapter 1
Introduction
Patterns of disease and medical needs have changed dramatically
in this century.
While acute illness due to infection and deprivation has
receded, the toll of chronic degenerative diseases has grown larger each
year (1:122). Hypertension is a case in point. It is estimated that fifteen
to twenty percent of all adults or about thirty-five million Americans have
hypertension (9:14).
Since the early 1970's the number of adults aware
that they have hypertension has increased from fifty-one to seventy-one
percent (8:43).
Presently, community and national surveys have reported
only fifteen to twenty percent of known hypertensives as being under
adequate blood pressure control (1, 2, 6, 8, 9, 24, 28).
Progress has been made in recent decades in the treatment of
hypertension. Treatment for hypertension includes low fat, low salt diets,
weight loss and/or weight control, stress management, avoidance of tobacco,
exercise, and medication.
There are, however, factors that limit the effectiveness of treatment
of hypertension which includes poor patient compliance to treatment
regimens and lack of patient understanding of their disease and prescribed
treatments.
Education may play an important role in improving patient
compliance and treatment effectiveness (3, 4, 8, 9, 22, 36, 38, 39).
1
Patient education is a process which is viewed as a bridge between
health information and good health practice (39:16). The desired long-term
goals of patient education are to:
1. Promote good health care practices;
2. Increase patients' knowledge of their medical condition;
3. Increase patients' ability to cope with their medical problem and/or
limitations;
4. Encourage patients' responsiblity to maintain their health and
treat their illness; and,
5. Encourage patients' participation as members of the health care
team (30:16).
Patient education is important in all illnesses, but especially in
asymptomatic hypertension.
In order for hypertensive patients to assume
responsibility for their self-care, they need to acquire sufficient knowledge
about the disease and the rationale behind the treatment as well as the
consequences of the treatment (8:44). There is general agreement among
health professionals as to the areas that should be covered by any patient
education program in hypertension. Hypertensive patients need educational
and behavioral intervention ·about hypertension, the disease; medications;
smoking
cessation;
\
alcohol
consumption;
dietary
management;
stress
management; exercise; and, blood pressure monitoring (2, 3, 4, 6, 8, 17,
23, 24,25,28, 34, 38). A hypertension education program may enable patients
to learn to live with their disease, manage their blood pressure, and be
an active partner in taking care of their health.
Statement of the Problem
Based on the number of clinic appointments, Internal-Medicine doctors
2
treat
approximately
Permanente
Medical
300
hypertensive
Center,
patients per month
Panorama
City.
Despite
at
well
Kaiser
staffed
Internal-Medicine and Member Health Education Departments, the Medical
/
Center lacks a structured hypertension education program that will provide
patients with information necessary to cope with and manage their illness.
Purpose of the Project
The purposes of the project are to: (1) conduct a needs assessment
to justify the development of a patient hypertension education program
at Kaiser Permanente Medical Center, Panorama City, and (2) develop
1
a hypertension curriculum that would serve as a framework for the
hypertension education p~ogram.
Limitations of the Project
The following limitations were recognized at the onset of the project:
(1) the hypertension curriculum was designed specifically for hypertensive
patients and teaching staff at Kaiser Permanente Medical Center, Panorama
City; and (2) the data generated from the needs assessment of Kaiser
Permanente patients and doctors and the hypertension program developed
from that data may not be generalizable to other patients and doctors
in other health care settings.
Definition of Terms
The following terms are used throughout the paper. They include:
Asymptomatic
Producing no outward symptoms.
Blood Pressure
The amount of pressure the blood exerts on
the inside walls of the arteries. A blood pressure
is recorded as a fraction. Today, most doctors
accept 120/80 mm HG as the common normal
pressure for adults, although some lower numbers
and values up to 140/90 are included in the
normal range (35:1 08).
3
Systolic blood
pressure
Blood pressure at the point at which the heart
muscle , is contracting or pumping. The tgp
number .in the recorded bl0od pressure reading
(35:108).
Diastolic blood
pressure
'
Blood pressure at the point at which the heart
muscle is relaxed between beats. The bottom
number in 'the recorded blood pressure reading
(35:108).
Compliance
The extent to which a person's behavior (in
terms
of
keeping
appointments,
taking
medications, and executing lifestyle changes)
coincides with his ascribed medical regimen
(17:162).
Health Education
Any designed combination of methods to
facilitate voluntary adaptations of behavior
conducive to health (9).
Hypertension
An unstable or persistent elevation of blood
pressure readings.
Commonly referred to
as high blood pressure (35:110).
Primary hypertension
An elevated blood pressure which does not
have a demonstrable cause. Also referred
to as essential hypertension (35:111).
~-Stepped..,.care
treatment
..
The use of a protocol which begins a treatment program with the mildest standard antihypertensive medications and after careful
evaluation of the patient aqds more potent
standard drugs as necessary to- control the
·blood pressure (32).
The next chapter will present the review of the literature. It will
include an overview of hypertension education with adult populations and
will provide examples of health education interventions that are most likely
to facilitate positive health behavior and promote blood pressure control.
4
Chapter 2
Review of the Literature
The literature review, divided into two sections, provides an overview
of hypertension education with adult populations. The first section examines
the rationale supporting hypertension education. The second section reviews
educational programs in hypertension and their effectiveness on hypertensive
patients.
Rationale Behind Hypertension Education
Hypertension is a very
,unno!i~~9
~-ll~tle
disease. It enters the lives of people
'
and its early presence is usually
'
d~SC()Vered
by accident, generally
during the course of a physical examination for something else.
Its
prevalence rises steady with age and is twice as great in blacks as in whites
(22:765).
Hypertension is considered a "silent killer" because in its early stages
it produces 110 symptoms that require medical attention. The belief that
there must be symptoms prevents many people from having regular medical
checkups.
Blood pressure cannot be felt and a person cannot tell when
it is elevated. It is only !3-fter years of stress on the cardiovascular system
does this illness result in major complications, such as, stroke, heart attack,
heart and l<idney failur.e.
?
- . ____
-·
As a result, hypertension produces premature
disability and death in hundreds of thousands of people each year (17:3).
Myths
and
treatment efforts.
misconceptions
about
hypertension
often
undermine
A survey authorized by the National Heart and Lung
Institute found that twenty-three percent of the population knew what
the term "high blood pressure" meant, while twenty-four percent of the
5
population knew what "hypertension" meant, and a majority assumed that
"hypertensive" meant "high strung, emotional or nervous" (35:1).
Long
and associates found that patients may refer to hypertension as high blood,
the opposite of low blood (anemia); or attribute hypertension to eating
too many spices, or believe that blood pressure elevation is unimportant
unless they have a headache or dizziness (22:768).
Dr. David Satcher, trying to determine the barriers to hypertension
control in the South-Central Los Angeles area discovered these false notions:
1. A feeling
that hypertension
means tenseness or nervousness.
hypertensiv~
Many feel that they only become
after getting excited.
In short, many people think of hypertension as a purely physiological
state rather than an illness with a physiological base.
2. A belief that hypertension is an acute problem and can be cured
by diet and drugs.
This accounts for many people stopping their
medication as soon as they "feel better".
'
-,
"~
3. A belief that hypertension affects only the aged population (35:5).
There are many · misconceptions that surround hypertension.
Many
people with the disease perceive themselves to feel fine and therefore
'
think they are not really sick. The main reason for treating and controlling
hypertension is~ to prevent its consequences that include heart and kidney
failure, stroke, and eventually death.
Patient participation is critical to successful control of hypertension
(23:19).
The treatment, which controls the disease but does 110t cure .. it,
usually consists of a Ufetime regimenof daily medication, and is frequently
combined with adjunctive therapies, such as dietary control of fat and
sodium, exercise, a)1d stress management. Adhering to treatment is often
----------·----~~-~
.---
--~~-·
'· ----
/----
~
.
6
/
difficult and demanding for patients.
Lack of adherence or compliance
to treatment regimens is well documented (1, 9, 13, 17, 18, 28).
Many patients adhere to a treatment program only until their blood
pressure returns to normal. Other patients drop out of treatment programs
due to factors such as family crises, cost of treatment and/or care, long
waiting times in offices or clinics, interference with working hours,
transportation difficulties, side effects from medications, or failure to
understand the disease and their prescribed treatments (37).
Increasing a patient's personal involvment in care may be an effective
'
means of improving compliance. Some patients become involved in their
care when they are taught to monitor their blood pressure, ask more questions
of their physician(s), and/or follow their prescribed treatment regimen.
The idea of
th~
patient making the decision to, control their hypertension
reflects the twin realities that the patient is ultimately in charge and that
the responsibility of the professional as health advisor is to assist the patient
in assuming this role in the decision-making process (17:240).
Hypertension is a condition' that is very complex. Treatment efforts
are successful in controlling hypertension, but myths a.nd misconceptions
about the disease and poor patient compliance to treatment only undermines
treatment efforts.
The facts add up to a appalling lack of patient
information on hypertension.
Hypertension education may provide the
framework for lifelong compliance with the total therapeutic regimen
and permanently affect behavior.
Effectiveness of Hypertension Education Programs
The National High Blood Pressure Education Program (NHBPEP) serves
as a model program for chronic disease education and in developing other
7
cardiovascular risk factor education programs (21:97) The NHBPEP was
organized in 1972 when it became apparent that many of the people who
had hypertension were not aware that they had a problem. There was also
considerable variation in treatment among those who did know about
hypertension and- were under a physician's care. Through articles in national
magazines and newspapers, programs on television, and radio advertisements,
professionals and the general public were informed by the NHBPEP of the
need for detection and control of hypertension.
Most importantly, the
general public was encouraged to have their blood pressure checked.
Data indicate that the public is developing a more accurate understanding of hypertension (1 7, 21 ).
Patients are learning the importance
of treating the problem and are consequently healthier; and health care
profession,als have accepted treatment approaches for managing hypertension
'
'
that include: medication and dietary treatment, weight loss and/or weight
control, exercise, and stress management (2, 3, 4, 6, 8, 17, 23, 24, 25, 26,
34, 38).
In 1974, as part of the NHBPEP Campaign, the National Heart, Lung
and Blood Institute' supported' a coordinated research program designed
to educate the public about control of hypertension. Levine and associates
conducted a diagnostic baseline survey of 305 ambulatory hypertensive
patients at the Johns Hopkins Hospital in Baltimore to determine their
educational needs and interests.
The approach used was based on the
principles that no one educational intervention by itself should be expected
to have a long-lasting impact on behavior change nor should any one or
_..
'
'
>
a combination of interventions be expected to have an identical impact
on different types of behaviors (18:1700).
8
Data from the survey
show,~d
high levels of general knowledge of
hypertension, its treatment, and the possible consequences of nontreatment.
Patients indicated confusion about their own specific treatment
and difficulty incorporating it into their daily schedule.
Patients also
reported a lack of family understanding and support, discouragement and
lowlevels of confidence in their ability to manage the problem.
Based on these survey findings, an educational program consisting
of three interventions including an exit interview, a home visit, and a series
!
of three small group meetings was developed and evaluated on a panel
of 400 outpatients with primary hypertension.
The three interventions
were developed for the following reasons: to clarify and emphasize a
therapeutic regimen; to increase
farr~Hy
support for the patient; and to
increase patient motivation and feelings of self-control (18:700).
,,
The
educational
program
increased
'
reported
compliance
with
medication, improved the proportion of patients losing weight, and improved
appointment keeping. There was also a reported favorable effect on blood
pressure control.
The proportion of patients, w'ith blood pressure under
control in the group assigned to all three interventions
increased by 28
.
~
percent (from 38 percent ot 66 percent), while the proportion in the control
group receiving standard medical therapy with no educational interventions
,_
remained unchanged at 42 percent (18:700).
In the Alameda County High Blood Pressure Program, Bloom and
associates tested the use of two counseling interventions to supplement
physician care (2:39). Before implementing this pilot project the researchers
determined which type of hypertensive patient would benefit most from
working with either of the two counseling interventions: (1) doctors and
9
nurse practitioners in the clinic, or (2) community health workers in the
home. A predictor index was used to assign participants to one of the two
counseling intervention groups (2).
'
'
-
For patients under the care of a private physician, the nurse practitioner provided information and made recommendations to the physician for
changes in the patient's medications. The nurse practitioner directed his/her
efforts to improve and ' facilitate patient compliance to the prescribed
medical regimen.
Unlike _ the nurse practitioner, the community health workers had
\
--
prior experience working in the community. They were high school educated,
-
\
had similar socioeconomic status and were of the same ethnic background
'-
of the patients.
\
The thrust of the health worker's involvement was to
facilitate adherence to medical regimens by removing barriers to compliance.
'
They took blood pressures, clarified misconceptions regarding the use of
folk remedies, assisted clients in using low sodium diets, provided assistance
in arranging for transportation to medical and other appointments, provided
information and made -referrals to social service agencies, or simply
socialized with and acted as a empathetic listener for the patient, reducing
isolation and becoming the link between the patient and the community
(2:43).
The results of the Alameda County study are impressive. The addition
of
a
patient
counseling
component
to
the
medical
management
of
hypertensiqn improved control as measured by change in both systolic and
diastolic blood pressure, increased
-
~ontrol
rate, and increased _the probability
'
(
of being controlled (2:49). The control rate of_the patients had improved
by 40 percent; 10 percent of the improvement could be attributed to
10
physician care and 30 percent to the
couns~ling
approach (2:39). Patients
assigned to the nurse practitioner had a 15.9 percent improvement in blood
pressure control versus a 6.3 percent improvement from the community
health worker (2:50).
In 1978, the
Nurse
Practitioners at the New Bedford Veterans
Administration OutpaJient Clinic developed a small group educational
program for patients with hypertension. The educational program consisted
. of five lectures, each lasting one and a half hours for five consecutive
weeks. The program presented facts about hypertension in a manner that
enabled the patients to identify and internalize the belief that they would
benefit from learning and practicing the presented health information (39:17).
'
.
The New Bedford Veterans Administration program demonstrated
\
that the use of ,small groups promotes a strong initial attractiveness for
individuals and a positive type of cohesiveness among its members (39:16).
Knowles points out the benefits of group education for patient learners
include: (1) a feeling of acceptance and security as, part of a group
tha~
.,
share~
a common concern; (2) active involvement in the process of sharing
consequent common fears, perceptions and attitudes with a homogenous
group; and (3) a greater commitment to integrating needed knowledge into
behavior (38:4).
In order to foster a more total approach to patient learning, Kochar
and Woods found that utilizing multiple disciplines in developing their
hypertension clinic in Milwaukee was beneficial for these reasons: (1) to
increase the number of qualified patient educators; (2) to expose the patient
to an initial contact with ancillary personnel; and (3) to add a variety of
teaching styles and personalities with the aim of further stimulating and
holding the interest of the patient (17:230).
11
To determine the needs of a population prior to the development
of a health education program, needs assessments may be employed to
establish goals, objectives, content, learning opportunities, and instructional
resources (7, 1 0).
Levine and associates conducted a needs assessment
survey in a hypertension clinic at the Johns Hopkins Hospital in Baltimore
to determine the educational needs and interests of ambulatory hypertensive
patients. The needs assessment survey assessed patient's general knowledge
of
hypertension,
its
treatment,
and
the
possible
consequences
of
nontreatment. Based on the needs assessment survey results, a hypertension
education program was developed and evaluated on hypertensive patients
receiving care in the Adult Hypertension Clinic and General Medicine Clinic
of the Johns Hopkins Hospital.
Health
educators
practicing
in
a
rural,
Massachusetts
health
~
maintenance organization were concerned with involving medical staff
in patient education, from initial planning to evaluation.
The health
education staff devised simple needs assessment questionnaires that asked
for the doctor's perceptions of their patient's educational needs in regards
to preselected topics such as diabetes, arthritis, and high blood pressure
(5:1 04). The questionnaires were designed to raise the doctors' awareness
of the needs of patients and to serve as a first step in physician involvement
in patient education. Hypertension emerged as a foremost topic of need
and interest (5:1 04).
The data from the questionnaires was presented to
the medical director and medical staff who supported the idea of developing
a formal hypertension program with the health education staff.
Characteristics of Adult Learners to a Health Education Program
Another important aspect to consider prior to the development of
12
a health education program is to take into consideration the characteristics
of adult learners (14, 15, 16, 38).
Adult learners are motivated to learn
when they recognize a gap between what they know and what they want
to know (3, 15).
Adults are particularly motivated to learn at times of
crises or when problems arise (36:145).
Malcolm Knowles, the father of andragogy or adult learning, contributes
four assumptions about adult learners that distinguish them from children.
Knowles believes that as a person matures:
1. His self-concept moves from dependency to self direction.
He
sees himself as capable of making his own decisions, taking responsibility for consequences, and managing his own life.
2. He accumulates life experiences that are an increasing resource
for learning.
3. His readiness to learn is increasingly oriented to his developmental
tasks and social roles.
4. His time perspective changes and his orientation to learning shifts.
He needs immediate application (rather than postponed application)
of knowledge and his learning is problem-centered rather than
subject-centered (36:144).
Summary
The chronic, asymptomatic nature of hypertension requires active
participation by the patient in management of the disease. However, many
patients are not prepared for the part they must play in their own care.
Health care providers must deliver appropriate and planned education to
ensure that patients understand the disease and its management, know
their specific responsibilites in the treatment, and can participate in their
13
own care.
The studies (NHBPEP, Levine, Alameda County, New Bedford
Veterans Administration) have shown that hypertension education clarifies
and emphasizes
the importance of treatment regimens and increases
patient's motivation and feelings of self control.
For this project, needs assessments were developed specifically for
patients and doctors at Kaiser Permanente Medical Center, Panorama
City after careful review of the literature and consultation with specialists
in Internal-Medicine, Education,
Health Education, and the Curriculum
Review Committee. In addition, the patient and doctor needs were assessed
in order to develop a framework for a program that will provide patients
with information and skills necessary to cope with their illness and to assist
staff in their teaching strategies for these patients.
The next chapter will present the methods and procedures used to
develop, implement and analyze the needs assessment surveys and describe
the methods used to develop the hypertension education curriculum.
14
Chapter 3
Methodology
This chapter presents the procedures utilized to develop, implement,
and analyze the needs assessment surveys.
The methods employed in
designing the hypertension education curriculum that serves as a framework
for the hypertension education program at Kaiser Permanente Medical
Center, Panorama City are presented.
Background
Kaiser Permanente Medical Center, Panorama City is one of several
health maintenance organizations in Southern California. It is an organized
health care system where physicians are employees rather than independent
practitioners, patients and clients are regarded as members and care is
prepaid by insurance or fees.
The Medical Center provides a full range
of medical-care services to a defined population in return for a prepaid,
fixed, annual fee and provides the best possible care to its members at
the least possible cost.
The Member Health Education Department at Kaiser Permanente
Medical
Center,
Panorama
City
offers
classes,
workshops,
individual
counseling, support groups, literature, and audio-visual materials on a wide
range of health topics to its members. The long-term objectives of the
Member Health Education Department are to:
1) reduce the amount of time staff spend repeating common medical
instructions;
2) improve member comprehension and compliance with prescribed
treatment plans;
3) enable merribers to make informed health decisions and become
as self sufficient as possible in managing their health affairs;
15
4) stimulate member interest in positive health practices that reduce
the risks of disease and promote higher levels of wellness; and
5) inform members on how to use health care resources such as facilities, personnel, and medications more appropriately, effectively,
and economically (26).
In pursuant with the Regional Member Health Education Core Program
Requirements, each Medical Center is mandated to provide a hypertension
education program to its members.
Kaiser Permanente Medical Center,
Panorama City does not offer a structured hypertension education program
to its members.
In order to meet the regional mandate, a hypertension
education program was developed.
The steps toward meeting this need
for developing such a program are identified in the following.
NEEDS ASSESSMENT
Prior to the development of the hypertension education program,
two assessments were developed and conducted to: (1) further justify the
need for a hypertension education program, and (2) to identify specific
needs and interests of the hypertensive patient population as well as the
doctors who provide care for the large hypertensive patient population.
Based on information obtained from the review of the literature and
consultation with the Member Health Education (MHE) Administrator and
Physician Advisors to MHE, two different needs assessment surveys were
developed, one for hypertensive patients and the other for doctors who
practice in the Internal-Medicine and Family-Practice Departments at
Kaiser Permanente Medical Center, Panorama City. Copies of each survey
form were distributed to the MHE Administrator and the two Physician
Advisors to MHE (Appendix D and E) for their written and verbal comments
regarding content, clarity and format. Suggestions for revisions were given,
approved changes in the needs assessments were made, then final approval
16
for administration and distribution was obtained from the MHE Administrator
and the Physician Advisors to MHE.
The patient and doctor needs assessment survey forms were designed
by incorporating a similar needs assessment survey format developed for
a Cardiac Rehabilitation class in MHE (Appendix C). The five hypertension
topic areas in the patient and doctor needs assessment surveys were derived
from subject areas identified in the review of the literature regarding
hypertension education and in consultation with the MHE Administrator
and the Physician Advisors to MHE.
Patient Needs Assessment
Based on information obtained from the review of the literature and
consulting with the MHE Administrator and the Physician Advisors to MHE,
the patient needs assessment survey was designed to determine:
1.
Baseline demographic date;
2.
Length of time patient diagnosed with hypertension;
3.
Type of treatment plan prescribed;
4.
Patient information regarding control of their blood pressure;
5.
Patients' interest in learning how to control their blood pressure; and,
6.
Learning needs and interests of patients including: hypertension,
medications, diet and activity, lifestyle risk factors, and communication
with their doctor(s).
Based on the review of the literature and consultation with the MHE
Administrator and the Physician Advisors to MHE, the survey was developed
to include five major hypertension topic areas, three demographic, and
four patient information questions (Appendix A).
The five major topic
areas included: hypertension, medications, diet and activity, lifestyle risk
17
factors, and communication and resources.
Under each of the five topic
areas a set of statements were developed to solicit the patients' responses.
The patients were asked to rate the importance of each statement by using
a
Likert scale (e.g.,
1=very important, 2=somewhat important, 3=not
important at all).
This survey was administered by this Investigator on March 2, 1987,
to a sample of eight adult patients attending an "Eating Right For Your
Heart" class in the MHE Department. The patients completed the survey
in ten to twelve minutes and upon completion they were asked if they
understood the instructions, questions and survey items. All eight patients
said that they understood the instructions, questions and survey items.
Following consultation with the MHE Administrator it was decided that
no changes were to be made in the patient needs assessment survey.
The patient needs assessment survey was administered and collected
by
this
Investigator
to
the
adult
hypertensive
patients
in
the
Internal-Medicine clinic waiting rooms and to the adult patients attending
a "Freedom From Fat" class in the MHE Department during the week of
March 9, 1987.
Doctor Needs Assessment
An assessment form was developed to obtain information from the
doctors who provide care to the hypertensive patient population at Kaiser
Permanente Medical Center, Panorama City.
After consulting with the
MHE Administrator and the Physician Advisors to MHE the doctor needs
assessment survey was designed to determine:
1.
How a hypertension program would benefit the doctors and
their patients;
2.
For whom should the hypertension program be targeted;
18
3.
What were the primary problem areas in normalizing the blood
pressure of patients in their practice;
4.
What was the level of importance of the topic areas to be taught
in the hypertension program;
5.
Was there a need to add, expand, and/or delete topic areas;
and,
6.
Would they refer their hypertensive patients to a hypertension
program offered in MHE.
Information gathered from the review of the literature and consultation
with the MHE Administrator and the Physician Advisors to MHE assisted
in the development of the survey. The survey items included: five major
hypertension topic areas; two multiple choice; one open-ended; and, one
forced choice (yes, no) questions (Appendix B). The five major topic areas
included: hypertension, medications, diet and activity, lifestyle risk factors,
and communication and resources.
Under each of the five topic areas,
a set of statements were developed to solicit the doctors' responses. The
doctors were asked to rate the importance of each statement by using
a
Likert ·scale (e.g.,
1=very important, 2=somewhat important, 3=not
important at all).
The MHE Administrator and the Physician Advisors to MHE carefully
reviewed and approved the sample survey. No pilot testing of the survey
was conducted due to time constraints and preexisting priorities of the
doctors practicing in the Internal-Medicine and Family-Practice Departments
at Kaiser Permanente Medical Center, Panorama City.
A Physician Advisor to MHE administered and collected the needs
assessment surveys at three weekly medical staff meetings during the month
of March, 1987.
The doctors who were unable to complete the surveys
at the medical staff meetings were instructed by the Physician Advisor
19
@ •
to MHE to return the completed surveys to the MHE Department.
Statistical Analysis
Data from the patient and doctor needs assessment surveys were
analyzed using the SPSS: Statistical Package for the Social Sciences (33)
at the California State University, Northridge, Computer Center during
the month of May, 1987.
Descriptive statistic methods (frequency and
means) were used to analyze the data. The subtopic item percentage means
were collapsed to derive the mean percent for each of the five major topic
areas for the patients and doctors. Inferences were made from the data
to determine the major topic areas that were rated as "very important"
by patients and doctors to be included in the hypertension education
curriculum and program.
DEVELOPMENT OF THE HYPERTENSION EDUCATION CURRICULUM
Curriculum Organization Methods
The hypertension education curriculum is organized by a topic and
generalization approach.
A topic is a subdivision of an outline, theme or
thesis. The five major topic ar·eas that were identified in the hypertension
needs assessment for the doctors and patients included: (1) overview of
hypertension; (2) medications; (3) diet and activity; (4) lifestyle risk factors;
and, (5) communication and resources.
In conjunction with each major topic, a generalization is stated.
Generalizations
are
unifying
statements
that
provide
a
focus
and
summarization of the content to be covered under each topic area (7).
The desired patient-oriented behaviors, related to and following the
generalizations, are presented in the instructional objectives within each
20
topic area. The evaluative criteria stated with each instructional objective
is used to determine the extent to which patients attain the specified
behaviors
identified
in
the
instructional
objectives
e.g.,
knowledge
attainment, psychomotor skills, (7:109).
The learning opportunities describe the means for achieving the instructional objectives (7:52).
Learning opportunities describe those things
patients (learners) do in order to accomplish the instructional objectives
(7:51).
Resources were identified within each topic area to assist the health
professionals in obtaining current information from literature, pamphlets,
films, posters, and videos to aid in their teaching strategies and lesson
planning.
Content Specialists Review
The hypertension education curriculum, comprised of five major topic
areas, was validated by the Curriculum Review Committee (Appendix E).
This committee consisted of six individuals who practice in the fields of
Health Education, Dietary, Pharmacy, and Medicine at Kaiser Permanente
Medical Center, Panorama City. Upon receiving a copy of the curriculum,
these six individuals were asked to review, write comments and suggestions,
recommend revisions, regarding the content, clarity and format of the
curriculum. In addition, these six individuals were asked to identify additional pertinent resources and learning opportunities to augment the
curriculum.
Summary
Two needs assessment surveys were developed and administered to
two groups to justify the need for planning a hypertension education program
21
at Kaiser Permanente Medical Center,
Panorama City.
The surveys
identified specific needs and interests of the hypertensive patient population
and the doctors who provide care for the hypertensive patient population.
The responses to the surveys were analyzed using descriptive statistical
methods (frequency and means). The results of the needs assessment surveys
were used to define and organize the hypertension education curriculum
and to serve as a framework for the hypertension education program. The
hypertension education curriculum is organized by topics, generalizations,
instructional objectives, evaluative criteria, learning opportunities, and
resources.
Physician
Advisors to MHE and other content specialists
representing key Medical Center Departments including Health Education,
Dietary, and Pharmacy, served to validate the content of the hypertension
education curriculum.
The next chapter will present the results of the needs assessment
surveys and discuss these findings.
22
Chapter 4
Results, Discussion, and Organization of the
Hypertension Education Curriculum
This chapter presents the results and discussion of the patient and
doctor needs assessment surveys and how they guide in the development
of the hypertension education curriculum and program for Kaiser Permanente
Medical Center, Panorama City.
Patient Needs Assessment Survey Results
This section presents the results of the patient needs assessment
survey (Appendix A).
Forty three patients sitting in the Internal-Medicine
Clinic waiting rooms and twenty patients attending a "Freedom From Fat"
class in the Member Health Education Department were administered the
survey. A total of 63 patients from these two settings completed the survey.
These patients were between 29 and 78 years of age and were predominantly
Caucasian, (82.5 percent, n=52).
The remaining respondents were Black
(4.8 percent, n=3), Hispanic (7 .9 percent, n=5), Native American (1.6 percent, n=l), Asian (1.6 percent, n=l), and Iranian (1.6 percent, n=l).
The
majority, 54 percent (n=34) of the patients were male, 46 percent (n=29)
were female.
English was the primary language spoken for all patients
surveyed.
The patients who require services at Kaiser Permanente Medical
Center, Panorama City have on the average, a minimum of a ninth grade
education. They live in and around the East San Fernando Valley, which
includes the cities of Arleta, North Hollywood, San Fernando, Pacoima,
and Sylmar.
23
Descriptive statistic methods (frequency and means) were used to
analyze the data to determine priority areas and topics to be covered in
the
hypertension
education
curriculum
and
program
from
the
needs
assessment survey.
A summary of the results of the patient needs assessment survey
is discussed below. The first question, asking how long have the patients
been diagnosed with hypertension, resulted in the following data. Of the
63 patients:
(a) 15.9 percent (n=10) had been diagnosed within the last year.
(b) 6.3 percent (n=4) had been diagnosed within one to three years.
(c) 27 percent (n=17) had been diagnosed within three to five years.
(d) 50.8 percent (n=32) had been diagnosed more than five years ago.
The second question queried the patient as to what kind of treatment
plan they are presently prescribed.
The patients could identify as many
treatment plans that applied to them in this question; therefore, the total
responses for this item for each patient could be greater than 100 percent.
The patients responded:
(a) 30.2 percent (n=19) were on a diet control (low fat, low sodium)
treatment plan.
(b) 38.1 percent (n=24) were treated with medications.
(c) 52.4 percent (n=33) were on a diet and medication treatment plan.
(d) 17.5 percent (n=ll) were on a diet and exercise treatment plan.
In response to the third question, asking the patients if they were
well informed about controlling their hypertension, the following data were
obtained:
(a) 46 percent (n=29) felt that they were well informed.
(b) 54 percent (n=34) felt that they were not well informed about
24
controlling their hypertension.
The patient who answered "yes" to the third question was then asked,
"Where did you receive your information?"
(a) 44 percent (n=28) received information from their doctors.
(b) 12.7 percent (n=8) from a nurse.
(c) 28.6 percent (n=18) from written materials.
(d) 3.2 percent (n=2) from television and radio.
The patients who responded "no" to the third question were then asked,
"Would you be interested in learning how to control your high blood pressure?"
Of the 54 percent (n=34) of patients feeling that they were not well informed
about controlling their high blood pressure, 60 percent (n=21) were interested
in learning how to control their high blood pressure.
In response to the fourth question, "If a high blood pressure program
was offered at Panorama City would you attend?"
Ninety-two percent
(n=58) said that they would attend such a program.
Accordingly, if the
patient answered "yes" to the fourth question they were asked, "When would
be the best time to attend the program?" More than half, 58.7 percent
(n=37) responded that they would prefer to attend the program between
the hours of 10 AM and 12 Noon.
The patients rated the five major hypertension topics in the "very
important" column in mean percentages that ranged from 78.9 to 93.6;
4.3 to 15.1 in the "somewhat important" column; and, 0.4 to 5.9 in the "not
important at all" column. Table 1 reveals the combined patient and doctor
rating of the five major hypertension topics. Appendix G reveals the findings
of the patient and doctor rating of the five major hypertension topics by
subtopic item mean percentages and mean percentages.
25
Doctor Needs Assessment Survey Results
This section presents the results of the doctor needs assessment survey
(Appendix B).
Thirty nine doctors who practice at Kaiser Permanente
Medical Center, Panorama City responded to the survey.
The majority
of the doctors who participated in the survey were Caucasian, (90 percent,
n=35),
primarily
Internal-Medicine
male,
and
(80
percent,
Family-Practice
n=31),
and
have
Departments for
practiced
in
approximately
five to twenty years.
Descriptive statistic methods (frequency and means) were used to
analyze the data to determine priority areas and topics to be covered in
the
hypertension
education
curriculum
and
program
from
the
needs
assessment survey. A summary of the results is discussed below.
The initial section of the survey consisted of four questions covering
areas such as benefits of a
hypertension education program, target
population, prime problems in normalizing blood pressure of patients, and
doctor referral of patients to a hypertension education program in MHE.
The first two questions are multiple choice, instructing the doctors to select
as many answers that apply to them; therefore, the total responses per
item could be greater than 100 percent.
The first question asking the doctors how a hypertension program
could benefit the doctors and their patients resulted in the following data:
(a) 87 percent (n=34) thought that a program could improve their
patients' adherence to their prescribed treatment regimen.
(b) 59 percent (n=23) felt that a program could decrease the amount
of time they spent educating patients in their office.
(c) 56 percent (n=22) thought that a program would increase patients'
confidence in managing their blood pressure.
(d) 10 percent (n=4) indicated that a program would be good for public
26
(l
relations; could increase patients' general knowledge about hypertension; and, that a program has the potential to fragment and
disorganize patient care.
In response to the second question, asking the doctors what type of
patients should the hypertension program be targeted, the doctors responded:
(a) 69 percent (n=27) indicated that the program should be targeted
to patients diagnosed with hypertension within the past year.
(b) 46 percent (n=18) felt that the program should be targeted to
patients diagnosed within one to three years.
(c) 30 percent (n=12) felt that the program should be targeted to
patients diagnosed within three to five years.
(d) 33 percent (n=13) thought that the program should be targeted
to patients diagnosed with hypertension for more than five years.
(e) 59 percent (n=23) indicated that the program should be targeted
to patients on antihypertensive medications.
(f) 44 percent (n=17) indicated that the program should be targeted
to patients on a diet and/or exercise regimen.
The third item, an open-ended question, asked, "What are the prime
problem areas in normalizing the blood pressure of patients in your practice?"
Of the 39 doctors who responded to this question, the responses included
(Appendix F):
(a)
7. 7 percent (n=3)-
noncompliance to diet
(b)
10.2 percent (n=4)-
noncompliance to medications
(c)
12.8 percent (n=5) -
noncompliance to lifestyle changes
(d)
5.1 percent (n=2)-
noncompliance to weight loss
(e)
5.1 percent (n=2) -
patients do not keep appointments
(f)
5.1 percent (n=2)-
daily blood pressure variation
(g)
2.5 percent (n=1)-
difficulty in obtaining a nonstressed
blood pressure reading to get a current
reading
(h)
12.8 percent (n=5)-
teaching
at home
27
self-blood
pressure
monitoring
'
(i)
12.8 percent (n=5)-
poor health habits
(j)
2.5 percent (n=1)-
ineffective medication
(k)
5.1 percent (n=2)-
smoking cessation
(I)
2.5 percent (n=1)-
not enough time to see patients
(m)
2.5 percent (n=1)-
patients are afraid to discuss problems
that may affect their blood pressure
(n)
2.5 percent (n=1)-
economics
(o)
10.2 percent (n=4)-
poor patient understanding of hypertension
The final question asked the doctors, "Would you refer patients to
a hypertension education program in Member Health Education?"
Their
responses were:
(a)
87 percent (n=34) "yes"
(b)
13 percent (n=5) "no"
The doctors rated the five major hypertension topics in the "very
important" column in mean percentages that ranged from 39.0 to 75.6;
17.3 to 31.1 in the "somewhat important" column; and, 6.2 to 11.3 in the
"not important at all" column. Table 1 reveals the combined doctor and
patient rating of the five major hypertension topics. Appendix G reveals
the findings of the doctor and patient rating of the five major hypertension
topics by subtopic item mean percentages and mean percentages.
28
Table 1
Combined Doctor and Patient Rating of Major Hypertension
Topic Areas From the Needs Assessment Surveys by Mean Percentages
N(doctors
= 39)
N (Patients
= 63)
Number Rating Description:
1
2
3
= Very
Important
= Somewhat Important
= Not Important At All
XD = Mean percent of Doctors
XP
= Mean
percent of Patients
Major ToEic Areas
1
2
3
Overview of
Hypertension
XD 71.8
XP 90.9
19.2
8.7
8.9
0.4
2.
Medication
XD 75.6
XP 84.5
17.3
13.8
7.0
1.6
3.
Diet and Activity
XD 62.6
XP 93.6
31.1
4.3
6.2
2.0
1.
4.
Lifestyle Risk
Factors
XD 67.3
XP 78.9
25.0
15.1
7.6
5.9
5.
Communication
and Resources
Xn
29.7
13.3
11.3
3.8
39.0
XP 82.8
29
Discussion of Data
Data generated from the doctor and patient needs assessment surveys
indicated that a majority of the respondents perceived hypertension education
to be an important aspect in patient care and in the treatment of the disease.
This is consistent with other research findings that show that patient education plays a key part in the treatment of the disease because it promotes
good health practices; and increases patients' knowledge and ability to
cope with the disease (8, 22, 27, 39).
A majority of the doctors (86 percent, n=34) felt that the development
of a hypertension program in Member Health Education would improve
their patients' adherence to their prescribed treatment regimens; would
decrease the amount of time they spent educating patients in their office;
and would increase their patients' confidence in managing their blood
pressure. Most doctors (64 percent, n=25) felt that the hypertension program
should be targeted to patients diagnosed within the past year and on
antihypertensive medications.
Likewise, a majority (87 percent, n=34)
of the doctors responded that they would refer patients to a hypertension
education program in Member Health Education.
A majority (50.8 percent, n=32) of the patients had been diagnosed
with hypertension for more than five years.
In addition, these patients
were presently being treated with antihypertensive medications and dietary
prescriptions.
More than half of the patients (54 percent, n=34) felt that
they needed more information on hypertension and would attend a hypertension education program offered in the Member Health Education Department.
The results from the doctor and patient needs assessment surveys
clearly justified the need to develop a hypertension education curriculum
30
that would assist patients in decision-making, and psychomotor skill and
knowledge acquisition about hypertension at Kaiser Permanente Medical
Center, Panorama City.
According to the results of the survey, requesting doctors and patients
to rate the hypertension education topic areas, the following was determined.
Decision making issues that were found to be of high interest and a necessary
part of the curriculum related to: taking medications and eating and planning
low fat, low salt and calorie meals.
The psychomotor skills that needed to be included in the curriculum
were:
blood
pressure
monitoring
and
practicing
stress
management
techniques.
The doctor and patient rating of the five major topic areas showed
that the patients rated the topic areas in higher mean percentages than
the doctors. The patients reported that all topic areas were very important
to know.
Based on the doctor and patient survey results, verbal and written
feedback from the Physician Advisors to MHE, MHE Administrator, and
written suggestions from doctors participating in the survey, it was suggested
that the "Communication and Resources" topic (Appendix A, B) should
be deleted and replaced with a blood pressure monitoring topic. The general
consensus from this group indicated that if patients had the knowledge
and psychomotor skills to monitor their blood pressure, they would have
better control over their disease. Also, time constraints, and the doctors'
rating of the "Communication and Resources" topic resulted in very low
mean percentages (39.0-very important, 29. 7-somewhat important, 11.3
not important at all) further justified the deletion of the "Communication
31
and Resources" topic.
Finally, the major topic and subtopic areas selected for the hypertension education curriculum and program were determined through the review
of the literature, the needs assessment data obtained from the doctors
and patients, and consultation with the Physician Advisors to MHE, MHE
Administrator, and the Curriculum Review Committee.
The major topics included in the hypertension education curriculum
and program are: (l) overview of hypertension; (2) blood pressure monitoring;
(3) medication treatment; (4) dietary management; and, (5) stress management.
A sixth major topic "Patient-Provider Communication" (identified
in the survey form as "Communication and Resources") will also be included
as an alternate or an integral part of the curriculum should time warrant
in the hypertension education program.
The subtopic areas cover an overview of hypertension, treatment
approaches, directions for blood pressure monitoring, and managing diet
and stress.
Organization of the Hypertension Education Curriculum
Based on the results from the doctor and patient needs assessment
surveys, and through consultation with the Physician Advisors to MHE,
MHE Administrator, and the Curriculum Review Committee, the hypertension
education curriculum is organized using five major and an alternate or
sixth topic.
The first topic discusses an overview of the hypertension
education program. It provides the patients with an insight into their disease,
identifies the anatomy involved in the regulation of blood pressure, points
out the cardiovascular •risk factors and complications of hypertension, and
identifies treatment approaches for hypertension.
32
The second topic focuses on the importance of blood pressure monitoring. It provides the patient with the information and skills necessary to
monitor their blood pressure.
The third topic, medication treatment, focuses on the treatment
approach for hypertension.
This topic is designed to inform patients of
the effects, side effects and the role of medication in the control of
hypertension.
It also stresses the importance of following a medication
regimen.
The fourth topic provides information on personal management of
the diet.
This topic covers a wide range of material that includes:
appropriate and inappropriate food intake; the relationship between salt,
potassium and hypertension; ways to lower fat intake and the difference
between saturated and unsaturated fats; the benefits of weight loss and/or
weight control; personal reasons for eating; reading food labels; calculating
fat calories; and meal planning using dietary exchange lists.
The fifth topic on stress management covers the benefits of exercise
for weight loss and/or weight control, blood pressure control and stress
management;
positive
and
negative
stress
and
how
it
affects
the
cardiovascular system; and ways to integrate stress management techniques
into daily living.
The alternate or sixth topic focuses on patient-provider communication.
This topic assists the patient to have a better working relationship with
their doctor(s). In so doing, the patient will have a better understanding
of the goals of treatment, will know when to call their doctor(s), and will
know what symptoms to report.
33
,,
Scope and Sequence of Topics and Generalizations
The scope and sequence of the six major topics is provided below:
Topic 1: Overview of Hypertension
Health Generalization:
Comprehension of the meaning of hypertension,
factors and the possible complications that affect
and can result from hypertension, may enable
a hypertensive patient to participate more
effectively in the control of their disease.
Topic 2: Blood Pressure Monitoring
Health Generalization:
Knowledge and skills of blood pressure monitoring
may enable a patient-participant to better control
their hypertension.
Topic 3: Medication Treatment
Health Generalization:
Patient compliance to a medication regimen may
be increased by developing an understanding of
the type, effects, side effects, and the role of
hypertensive medications.
Topic 4: Dietary Management
Health Generalization:
Patient-participant understanding of appropriate
and inappropriate food intake may be influential
in controlling hypertension and reducing cardiac
risk factors.
Topic 5: Stress Management
Health Generalization:
Patient-participant understanding of the adverse
effects of stress and tension on the cardiovascular
system
may
be
influential
in
controlling
hypertension and reducing cardiac risk factors.
Topic 6: Patient-Provider Communication
Health Generalization:
Individual perceptions and levels of knowledge
may affect patient-provider communication.
The hypertension education curriculum is also organized by instructional objectives, using the cognitive, psychomotor and affective domains,
evaluative criteria, learning opportunities and resources.
opportunities and
resources
The learning
were determined by consulting with the
34
'
Curriculum Review Committee (Appendix E) and reviewing the literature.
To summarize, the needs assessment surveys substantiated the need
to develop a hypertension education curriculum and program for hypertensive
patients and staff actively involved in hypertension education activities
at Kaiser Permanente Medical Center, Panorama City. The hypertension
education curriculum consists of information on hypertension, blood pressure
monitoring, medication treatment, dietary and stress management, and
patient-provider communication.
generalizations,
instructional
The curriculum is organized by topics,
objectives,
evaluative
criteria,
learning
opportunities and resources.
The following chapter will present the Hypertension Education Curriculum. Chapter 6 will include the summary, conclusions and recommendations
for this project.
35
Chapter 5
Hypertension Education Curriculum
This chapter presents the hypertension education curriculum which
was based upon data obtained from the doctor and patient needs assessment
surveys, review of the literature, and in consultation with the Physician
Advisors to MHE, MHE Administrator and the Curriculum Review Committee
at Kaiser Permanente Medical Center, Panorama City.
The curriculum
was developed to serve as a framework for the hypertension education
program and to assist staff involved in hypertension education activities.
The topics in the curriculum include: (1) An Overview of Hypertension,
(2)
Blood
Pressure
Monitoring,
(3)
Medication
Management, and (5) Stress Management.
Treatment,(4) Dietary
A sixth topic, Patient-Provider
Communication, will also be included as an alternate or an integral part
of the curriculum should time warrant in the hypertension education program.
36
CONTENT OUTLINE
1.
Overview of Hypertension Program
A.
Overview of Hypertension
B.
Definitions
1.
2.
3.
4.
C.
Classification of High Blood Pressure
1.
2.
3.
4.
D.
Normal blood pressure
Mild hypertension
Moderate hypertension
Severe hypertension
Anatomy involved in regulation of blood pressure
1.
2.
3.
Brain
Heart
Kidneys
E.
Prevalance of hypertension
F.
Complications of hypertension
G.
Cardiovascular risk factors
1.
2.
H.
Unmodifiable risk factors
Modifiable risk factors
Treatment approaches for hypertension
1.
2.
3.
4.
5.
II.
Blood pressure
Systolic blood pressure
Diastolic blood pressure
Hypertension
Dietary treatment
Weight loss
Stress management
Exercise
Medication treatment
Blood Pressure Monitoring
A.
Importance of blood pressure monitoring
37
B.
Definitions
1.
2.
3.
4.
5.
6.
C.
Measuring devices
1.
2.
D.
III.
Mercury
Aneroid
Blood pressure equipment
1.
2.
3.
E.
Artery
Blood pressure
a.
systolic blood pressure
b.
diastolic blood pressure
Blood volume
Sphygmomanometer
Stethoscope
Vein
Arm cuff, sphygmomanometer
Stethoscope
Samples, costs, availability
Demonstration/directions for blood pressure measurement
Medication Treatment
A.
Diuretics
1.
2.
3.
B.
Sympatholytics
1.
2.
3.
c.
Mode of action
Possible side effects
Examples of sympatholytics
Vasodilators
1.
2.
3.
D.
Mode of action
Possible side effects
Examples of diuretics
Mode of action
Possible side effects
Examples of vasodilators
Beta Blockers
1.
2.
3.
Mode of action
Possible side effects
Examples of beta blockers
38
E.
Calcium Entry Blockers
1.
2.
3.
F.
Reasons why some people are tempted to stop taking their
medications.
G.
Following a medication regimen
H.
Tips for medication taking
1.
2.
3.
4.
IV.
Mode of action
Possible side effects
Examples of calcium entry blockers
Diuretics
Beta Blockers
Calcium Channel Blockers
Potassium Supplements
Dietary Management
A.
Primary risk factors for heart disease
1.
2.
High blood cholesterol
Hypertension
B.
Salt intake
C.
Potassium
D.
Fiber
1.
2.
3.
4.
5.
6.
Where it is found
Qualities of fiber
Water soluble fiber/insoluble fiber
Sources of fiber
Methods of cooking fiber
Dietary recommendations
E.
Reading product labels
F.
Eating Out
1.
2.
G.
Four Simple Rules
Types of restaurants
Food Exchange System
1.
Definition of food exchange system
39
2.
H.
Meal Planning- 1200 calories/day
1.
2.
3.
4.
I.
2.
3.
4.
2.
3.
4.
5.
Diet
Exercise
Behavior modification
Specific dietary factors
Behavior modification: hints for losing weight
Ways to maintain ideal body weight
1.
2.
N.
Losing/gaining cycles
Fad diets
Common fad diets
Concepts of smart dieting
1.
M.
Behavaior theory
Weight loss factors
1.
2.
3.
L.
Follow prescribed meal plan
Avoid foods high in sugar, saturated fat and cholesterol
Avoid alcohol
Lose weight if overweight
General Obesity
1.
K.
Breakfast
Lunch
Dinner
Night snack
Guidelines for following meal/diet plan
1.
J.
Categories of food exchange system
a.
free foods
b.
foods to avoid
1\'Iilk exchange - List 1
c.
Vegetable exchange - List 2
d.
e.
Fruits exchange - List 3
f.
Breads/starch exchange - List 4
Meats/proteins exchange - List 5
g.
Fats exchange - List 6
h.
Determining ideal body weight
Setting realistic goals
Preventing backsliding
1.
2.
Definition of backsliding
Dealing with backsliding
40
V.
VI.
Stress Management
A.
Definition of stress
B.
Stressful situations
C.
Physiologic or bodily changes that accompany stress
D.
Symptoms of uncontrolled stress
E.
Stress management
Patient-Provider Communication
A.
Working with your doctor
1.
2.
3.
4.
B.
Understanding treatment goals
Asking questions
Know when to call your doctor and what symptoms to
report
Follow-up visits
Kaiser Permanente Medical Center resources
1.
2.
3.
4.
5.
6.
7.
Dietary Department
Freedom From Fat
Alcohol Clinic
Stress Management Classes
Counseling Services
Smoking Cessation Program
Member Health Education Learning and Resource Center
41
OVERVIEW OF HYPERTENSION
TOPIC 1:
Health generalization:
Objectives:
Comprehension of the meaning of hypertension, factors and the possible complications that affect and can result from hypertension, may enable a hypertensive
patient to participate effectively in the control of their disease.
Following instruction, the group participant will be able to:
1.
Define the meaning of blood pressure. (Knowledge)
Evaluative criteria:
The group participant will be able to accurately identify the correct definition
of blood pressure on a multiple choice test item.
2.
Identify the components that make up blood pressure. (Knowledge)
Evaluative criteria:
The group participant will be able to accurately identify systolic and diastolic
blood pressure as the components that make up blood pressure on a multiple
choice test item.
3.
Define the meaning of hypertension. (Knowledge)
Evaluative criteria:
The group participant will be able to accurately identify the correct definition
of hypertension on a multiple choice test item.
4.
Identify three organs involved in the regulation of blood pressure. (Knowledge)
Evaluative criteria:
The group participant will be able to accurately identify the brain, heart and
kidneys as the three organs involved in the regulation of blood pressure on a
multiple choice test item.
5.
Recall three complications of hypertension. (Knowledge)
Evaluative criteria:
The group participant will be able to accurately identify three complications of
hypertension on a multiple choice test item.
6.
Identify cardiovascular risk factors associated with hypertension. (Knowledge)
Evaluative criteria:
The group participant will be able to accurately identify four modifiable cardiovascular risk factors associated with hypertension on a multiple choice test
item.
.1::1:-..?
TOPIC 1:
OVERVIEW OF HYPERTENSION (cont.)
TOPIC CONTENT
4>c:.:>
SUGGESTED LEARNING OPPORTUNITIES
1.
A.Overview of Program
This program will provide information on hypertension, blood pressure monitoring, medications and lifestyle management. The information
will be provided by a doctor, nurse
practitioner, dietician, pharmacist
and social worker. The program will
be held on 4 consecutive weekdays
2.
for 2 hours ea. After attending the
program the hypertensive patient
and family member will have additional skills in decision-making and
behavior control.
B. Definitions
1. Blood pressure
3.
The force of blood pressing
against the blood vessel wall
(7:132).
2. Systolic blood pressure
a. The highest pressure pushing
the blood in the arteries when
the heart is pumping or contracting (16:808).
b. The top number in the recorded blood pressure measurement.
Instructor will begin the session by posing
the following questions to stimulate discussion:
What does blood pressure mean to you?
What is hypertension?
The group will view a film, "What Goes Up".
Following the film the instructor will review the main ideas in the film. The participants will be encouraged to ask questions.
Participant questions will be answered by
group .and/or instructor.
The instructor will show a human skeleton
with the anatomy attached and point out the
heart, brain, kidneys as the organs involved in the regulation of blood pressure.
Participants will be encouraged to ask
questions, look at and feel the anatomy
and skeleton.
SUGGESTED RESOURCES
BOOKS
1. Learning to Live With
Hypertension. 1985. Boston:
Medicine In The Public
Interest (MIPI) Publication.
2. Kochar, M.S. and Woods, K.D.
Hypertension Control for
Nurses and Other Health
Professionals. 1985. 2nd
Edition. New York:
Springer Publishing Co.
pp. 132-135.
BOOKLETS
1. "High Blood Pressure"
a flipchart and/or booklet
Robert J. Brady
Routes 197, 450
Bowie, MD 20715
2. "Help Yourself to Health:
Living with High Blood
Pressure"
American Osteopathic Asscn.
212 East Ohio Street
Chicago, ILL 60611
TOPIC 1:
OVERVIEW OF HYPERTENSION (cont.)
TOPIC CONTENT
.:::.
.:::.
SUGGESTED LEARNING OPPORTUNITIES
3. Diastolic blood pressure
a. The lowest pressure in the
arteries when the heart is
relaxed or filling with blood
(16:808).
b. The bottom number in the
recorded blood pressure meament.
4. The instructor will ask the group the
4. Hypertension
a. hyper= too much
following questions to stimulate disb. tension = force
cussion:
c. Too much force or tension on
the artery walls (9:5).
What are some of the complications you
d. A condition in which the flow
know of that are from hypertension?
of blood consistently exerts
too much pressure against the
What are some of the risk factors you
walls of arteries (5:168).
have control over that are associated with
C.Classification of High Blood
hypertension?
Pressure
High blood pressure is usually classified according to the diastolic pressure, that is, the pressure at which
point the heart is relaxed or filling
with blood.
SUGGESTED RESOURCES
FILMS
1. "What Goes Up"
16 mm film, color,
12 minutes
Local American Heart
Association
TOPIC 1:
OVERVIEW OF HYPERTENSION (cont.)
TOPIC CONTENT
""'
C)1
Normal blood pressure: diastolic
pressure below 90mm Hg.
Mild hypertension: diastolic pressure
between 90 and 104 mm Hg.
Moderate hypertension: diastolic
pressure betwen 105 and 114 mm Hg.
Severe hypertension: diastolic pressure of 115mm Hg or more.
D.Anatomy involved in the regulation of blood pressure
1. Brain
2. Heart
3. Kidneys
E. Prevalence of Hypertension
1. Approximately 50 million
Americans or one in every five
individuals (7:133)
2. More men than women
3. More blacks have hypertension
than whites
F. Complications of Hypertension
1. Heart attack
2. Congestive Heart Failure
3. Stroke
G. Cardiovascular Risk Factors
1. Unmodifiable risk factors (9:25)
a. family history
b. male
SUGGESTED LEARNING OPPORTUNITIES
SUGGESTED RESOURCES
TOPIC I:
OVERVIEW OF HYPERTENSION (cont.)
TOPIC CONTENT
~
0')
SUGGESTED LEARNING OPPORTUNITIES
c. over 40 years old
d. diabetic
2. Modifiable risk factors (9:26)
a. high blood pressure
b. cigarette smoking
c. high blood cholesterol level
d. overweight
e. a lot of stress and tension in
life
H.Treatment Approaches for Hypertension
High blood pressure can be lowered
in a number of ways. Treating high
blood pressure is very individualized
so a patient may be on one or several
treatment regimens. Here is a list of
treatment approaches doctors may use
for hypertensive patients:
1. Dietary treatment (low sodium,
low fat/cholesterol)
2. Weight loss
3. Stress Management (relaxation
techniques: biofeedback, yoga,
Tai Chi)
4. Exercise
5. Medication treatment
SUGGESTED RESOURCES
TOPIC II: BLOOD PRESSURE MONITORING
Health generalization:
Knowledge and skills of blood pressure monitoring may enable a patient-participant
to better control their hypertension.
I
I
I
Objectives:
Following instruction, the group participant will be able to:
1.
Define the meaning of blood pressure. (Knowledge)
Evaluative criteria:
The group participant will be able to accurately identify the correct definition of blood pressure on a multiple choice test item.
2.
Identify the components that make up blood pressure. (Knowledge)
Evaluative criteria:
The group participant will be able to accurately identify systolic and diastolic
blood pressure as the components that make up blood pressure on a multiple
choice test item .
3.
Recall the equipment used to measure blood pressure. (Knowledge)
Evaluative criteria:
The group participant will be able to accurately identify the stethoscope and
blood pressure cuff as the equipment used to measure blood pressure on a
multiple choice test item.
4.
Demonstrate blood pressure measurement. (Psychomotor skill)
Evaluative criteria:
Following guided demonstration, the group participant will be able to accurately demonstrate blood pressure measurement on another group participant.
.:..
-:J
~
TOPIC II.
BLOOD PRESSURE MONITORING (cont.)
TOPIC CONTENT
00
"""
SUGGESTED LEARNING OPPORTUNITIES
A.Importance of blood pressure monitoring
1. High blood pressure may go undiscovered for years unless it is
detected in a routine blood pressure reading or physical examination.
2. The only way to diagnose and
treat high blood pressure accordingly is from blood pressure measurements.
3. Blood pressure measurement is a
useful way to determine a person's blood presure control if they
are being treated with medications,
diet and weight loss.
B. Definitions
1. Arteries
1.
Blood vessels which carry blood
away from the heart to the
various parts of the body.
2. Blood Pressure
The force of blood pressing
against the blood vessel wall.
a. Systolic blood pressure
2.
The highest pressure pushing
the blood in the arteries when
the heart is pumping or contracting. The top number in
SUGGESTED RESOURCES
BOOKS
Instructor will begin the session by showing
a video, "The Self Measurement of Blood
Pressure. Following the video the instructor will review the main points presented in
the video. The group will be encouraged to
ask questions.
The instructor will present to the group the
equipment used to measure blood pressure
(i.e., stethoscope, blood pressure cuff). Instructor will explain the difference between
the aneroid and mercury measuring devices.
1. Kochar, M.S. and Woods, K.D.
Hypertension Control for
Nurses and Other Health
Professionals, 1985. 2nd Edition. New York: Springer PubbUshing Co. pp. 198-199
2. Oparil, S.
Hypertension, 1986. Chicago:
Budlong Co.
TOPIC II:
BLOOD PRESSURE MONITORING (cont.)
TOPIC CONTENT
""'
tC
3.
4.
5.
6.
C.
1.
2.
SUGGESTED LEARNING OPPORTUNITIES
the recorded blood pressure
3.
measurement (16:808).
b. Diastolic blood pressure
The lowest pressure in the
arteries when the heart is
relaxed or filling with blood.
The bottom number in the recorded blood pressure measurement (16:808).
Blood volume
The amount of blood circulating
within the body. In normal adults
of average weight, blood volume
is 10-12 pints (17).
Sphygmomanometer
An instrument for measuring
blood pressure.
Stethoscope
4l.
An instrument for listening to
sounds within the body.
Vein
A series of vessels of the
vascular system which carries
blood from various parts of the
body back to the heart (17).
Measuring Devices- 2 basic types:
Mercury (glass tube with HG)
Aneroid (graduated circular dial)
SUGGESTED SOURCES
Instructor will ask a group participant to come
to the front of the room and be seated at the
VIDEO
table and chair. Instructor will demonstrate to 1. "The Self Measurement of
the group blood pressure measurement on the
Blood Pressure"
participant. While the instructor is demon~~~videocassette, 14 minutes
strating this skill, she explains, outloud, each
step involved in measuring blood pressure.
E. Ruley, M.D.
Dept. of Nephrology
After this task is completed the instructor
National Medical Center
will pass out stethoscopes and blood pressure
111 Michigan Ave., N. W.
cuffs to several participants and ask these
people to return demonstrate blood pressure
Washington, D.C. 20010
measurement on another group member. Instructor will ask the group to trade partners so
other group members will be able to practice
blood pressure measurement. The group will be
encouraged to ask questions.
Instructor will present to the group a human
skeleton with the anatomy attached and point
out the heart, radial and brachial arteries.
She will ask the group to point out and feel
for their radial and brachial arteries. She will
help out group members who are unable to find
their radial and brachial arteries.
TOPIC II:
BLOOD PRESSURE MONITORING (cont.)
TOPIC CONTENT
en
0
D.Blood Pressure Equipment
1. Arm cuff
2. Stethoscope
3. samples, costs, availability
E. Blood Pressure Measurement
1. A blood pressure reading requires
two measurements:
a. systolic blood pressure
b. diastolic blood pressure
2. Blood pressure is recorded as
a fraction, with the systolic
pressure expressed over the
diastolic pressure. For example,
a blood pressure reading 130/70
means that the systolic pressure
is 130 and the diastolic pressure
is 70 (17).
3. A blood pressure is read as
"130 over 70".
4. General instructions for blood
pressure measurement:
a. Sit down, support arm on
table. Have forearm flexed,
and palm upward.
b. Palpate the brachial artery for
stethoscope placement.
c. Place the deflated cuff
smoothly and snugly, with the
lower margin approximately
SUGGESTED LEARNING OPPORTUNITIES
SUGGESTED RESOURCES
TOPIC II:
BLOOD PRESSURE MONITORING (cont.)
TOPIC CONTENT
c:.n
......
SUGGESTED LEARNING OPPORTUNITIES
one inch above the antecubital
space (elbow).
d. Place the stethoscope diaphragm
firmly and flatly over
the brachial artery. The tips of
the stethoscope should be
turned forward in the ears.
e. Feel or palpate the radial
artery and inflate the cuff
rapidly to at least 30mm Hg
above the point at which the
radial pulse disappears. A
minimum of 220 mm Hg is used
as a guide for the lowest inflation point in adults.
f. Deflate the cuff at the rate
of 2 to 3 mm Hg/sec.
g. As the pressure falls, listen
for the first thumping sounds
through the stethoscope. When
the sounds are heard, read the
gauge. The pressure at which
sounds begin is the systolic
blood pressure.
h. Continue to let the air out of
the cuff. The thumping sounds
become fainter. When the
sounds disappear you have the
diastolic blood pressure. Let
SUGGESTED RESOURCES
TOPIC II:
BLOOD PRESSURE MONITORING (cont.)
!
TOPIC CONTENT
SUGGESTED LEARNING OPPORTUNITIES
SUGGESTED RESOURCES
the air out of the cuff rapidly
and completely. If a second
measure is to be taken, wait
one or two minutes (6).
,.
I
!
c.n
t:-.:1
MEDICATION TREATMENT
TOPIC III:
Health generalization:
Objectives:
Patient compliance to a medication regimen maybe increased by developing an understanding of the type, effects, side effects, and the role of hypertensive medications.
Following instruction, the group participant will be able to:
1.
Identify three of the five classes of antihypertensive medications. (Knowledge)
Evaluative criteria:
The group participant will be able to accurately identify three classes of antihypertensive medications when given a list of seven classes of medications on a
multiple choice test item.
2.
Identify the mode of acltion of three classes of antihypertensive medications. (Knowledge)
Evaluative criteria:
The group participant will be able to accurately identify three classes of antihypertensive medications and correctly associate the mode of action to each medication when given a two column list with five items to each column.
3.
Recall two possible side effects associated with five commonly prescribed antihypertensive medications.
(Knowledge)
Evaluative criteria:
The group participant will be able to accurately identify five commonly prescribed antihypertensive medications and two side effects associated with each
of the medications when given a two column list with ten items to each
column.
4.
Recall six reasons why some people are tempted to stop taking their blood pressure medications.
(Knowledge)
Evaluative criteria:
The group participant will be able to accurately identify six reasons why some
people are tempted to stop taking their blood pressure medications when given
a ten item list on a multiple choice test item.
5.
Identify three criteria for following a medication regimen. (Knowledge)
Evaluative criteria:
The group participant will be able to accurately identify three criteria for following a medication regimen on a multiple choice test item.
<:.11
w
TOPIC III:
MEDICATION TREATMENT (cont.)
TOPIC CONTENT
SUGGESTED LEARNING OPPORTUNITIES
A.
1. A pharmacist will start out the session by
Diuretics
1. Mode of action: (9:52)
~
"""
by asking the group the following questions
to assess their knowledge of previous topic:
Lowers blood pressure in the
blood vessels by washing
What does blood pressure mean to you?
excess salt and water from
the body. This reduces the
amount of fluid circulating
What is hypertension?
in the bloodstream, which
reduces the pressure in the
What are the complications of hypertension?
arteries.
2. Possible side effects:
The pharmacist will tell the group that there
a. low potassium levels, nausea,
are several measures to control hypertension.
muscle cramps, weakness
These measures include: diet changes in
b. low sodium levels, thirst,
sodium, fat; weight loss; exercise; stress
decreased sweating, confusion
management; and, medication therapy.
3. Examples of Diuretics
a. Lasix
2. The pharmacist will pass out a handout on the
b. Diuril
different classes of antihypertensive medicac. Hydrodiuril
tions. He will ask the group to refer to a
d. Aldactone
flipchart that has written in bold print the
B. Sympatholytics
classes of hypertensive medications and the
1. Mode of action: (9:53)
medications that fall under each class. The
Acts on different parts of
pharmacist will lecture on the five classes
the nervous system. Some
of medications, explain the mode of action
of these drugs work by
of these medications, and give examples of
reducing the amount of
possible side effects from these medications.
blood the heart pumps with
The class will be encouraged to ask questions.
each beat as well as reducing the
heart rate.
SUGGESTED RESOURCES
BOOKS
1. Learning to Live With
Hypertension 1985. Boston:
Medicine In The Public Interest (MIPI) Publication
BOOKLETS
1. "Facts About Medication
for Blood Pressure"
Hypertension Program
Health Services Div.
P. 0. Box 968
Sante Fe, NM 86503
POSTER
1. "Don't Skip Your Blood
Pressure Medication"
High Blood Pressure
Information Center
120/80 NIH
Bethesda, MD 20205
FILMSTRIP
1. "Antihypertensives" 35mm
filmstrip with audiocassette
or LP record
Trainex Corp.
P. 0. Box 116
Garden Grove, CA
TOPIC III:
MEDICATION TREATMENT (cont.)
TOPIC CONTENT
C.11
C.11
SUGGESTED LEARNING OPPORTUNITIES
3. Pharmacist will stress the importance of
Others relax the blood vessels
taking medications. He will pass out the
indirectly by blocking nervous
Learning to Live With Hypertension
system signals that cause them to
handbook and refer patients to read chapter
tighten up and contract. When the
7.
small blood vessels or arterioles
contract, blood pressure rises. By
preventing contraction, these drugs 4. The pharmacist will show a filmstrip called
reduce blood pressure.
"Antihypertensives." After the filmstrip, the
pharmacist will review the main ideas pre2. Possible side effects:
a. depression
sented and answer any questions posed by the
group.
b. drowsiness
c. diarrhea
3. Examples of Sympatholytics
5. The pharmacist will ask the group the fola. Reserpine
lowing question to stimulate discussion:
b. Aidomet
What are some of the important things to
c. Ismelin
C. Vasodilators
know about when taking your blood pressure
1. Mode of action: (9:53)
medications?
These drugs work by relaxing
the blood vessels directly. These
drugs cause the muscular walls of
the blood vessels (vaso-) to widen
(dilate) which lowers the pressure
in them.
2. Possible side effects:
a. headache
b. dizziness
SUGGESTED RESOURCES
TOPIC III:
MEDICATION TREATMENT (cont.)
TOPIC CONTENT
CJ1
0')
c. nausea
d. diarrhea
3. Examples of Vasodilators:
a. Apresoline
b. Loniten
c. Persantine
D. Beta Blockers
1. Mode of action: (9:53)
These drugs inhibit or reduce
the production of a hormone,
called angiotensin, that is
involved in regulating blood
pressure
2. Possible side effects:
a. facial rash
b. dizziness
c. headache
3. Examples of Beta Blockers
a. Captopril
b. Inderal
c. Lopressor
E. Calcium Entry Blockers
1. Mode of action: (7:80)
These drugs slow down the entry
of calcium into the cell. Too
much calcium in the cell causes
the muscle in the blood vessels
to tighten or contract, thus
causing a rise in blood pressure.
SUGGESTED LEARNING OPPORTUNITIES
SUGGESTED RESOURCES
TOPIC III:
MEDICATION TREATMENT (cont.)
TOPIC CONTENT
SUGGESTED LEARNING OPPORTUNITIES
SUGGESTED RESOURCES
...
~
2. Possible side effects:
a. headache
b. dizziness
c. flushing
3. Examples of Calcium Entry
Blockers
a. Calan
b. Procardia
c. Cardiazem
F. Reasons why some people are tempted
to stop taking their medications
(9:47)
1. Most people with hypertension do
2.
3.
4.
5.
not feel sick, they believe they do
not need medication.
A lot of people do not understand
that high blood pressure is a serious
problem if it is not treated.
Some people do not want to trade
the feeling of wellness for feeling
poorly from side effects of the
medications.
Once their blood pressure is lowered
some people think that they are
cured and no longer need the medication to control their blood pressure.
Some are discouraged by having to
take drugs indefinitely.
-:.
TOPIC III:
MEDICATION TREATMENT (cont.)
TOPIC CONTENT
o:.ro
00
SUGGESTED LEARNING OPPORTUNITIES
SUGGESTED RESOURCES
6. Some people do not like to take
drugs in general, they "subconsciously forget" to take their
medications.
7. Some people may have other medical
conditions as well, and if they feel
poorly, they may blame it on the
medicine for blood pressure.
8. Some people believe that hypertension affects those who are nervous
or tense, some people do not take
their pills unless they feel nervous
or tense.
9. People get confused because they
have so many prescription drugs to
take.
10. Scheduled times of drugs are not
convenient.
11.
Medicine is too expensive.
12. They simply forget and no one helps
to remind them to take their medicine.
G. Following a medication regimen (9:49)
1. Take medications at the times and
in the amounts prescribed to you.
2. Never stop taking medications unless
told to do so.
3. Know when to take your medications
and with what.
.,
TOPIC III:
MEDICATION TREATMENT (cont.)
TOPIC CONTENT
01
~
SUGGESTED LEARNING OPPORTUNITIES
4. Find out the times that you should
not take your medication. If ill or
after heavy exercise, medication is
contraindicated.
5. Ask your doctor what to do if you
forget a pill or if you take too many.
H. Tips for medication taking:
1. Diuretics
-Eat foods that are high in potassium
content, or take potassium supplement prescribed by your doctor.
-Reduce salt intake or use a salt substitute.
-Notify your doctor if you are currently taking medicines for appetite
control, asthma, colds, coughs, hay
fever, or sinus, since they may tend
to increase your blood pressure.
2. Beta Blockers
Notify your doctor if you are currently
taking medications for appetite control, asthma, colds, hay fever, or sinus
since they may tend to increase your
blood pressure.
3. Calcium Channel Blockers
Drinking alcohol may make side effects such as dizziness, lightheadedness, or fainting feeling much
worse and may cause a serious drop
SUGGESTED RESOURCES
TOPIC III:
MEDICATION TREATMENT (cont.)
TOPIC CONTENT
0')
0
SUGGESTED LEARNING OPPORTUNITIES
in blood pressure. Check with your
doctor before drinking alcohol beverages.
4. Potassium Supplements
-Take this medication immediately
after meals or with food to lessen
possible stomach upset or laxative
action.
-Since salt substitutes and low-salt
milk may contain potassium, do not
use them unless told to do so by
your doctor.
SUGGESTED RESOURCES
TOPIC IV:
DIETARY MANAGEMENT
Health generalization:
Objectives:
Patient-participant understanding of appropriate and inappropriate food intake may
be influential in controlling hypertension and reducing cardiac risk factors.
Following instruction, the group participant will be able to:
1. Describe the relationship between salt and hypertension. (Interpretation)
Evaluative criteria:
m
......
The group participant will be able to describe the relationship between salt and
hypertension during a small group discussion with a registered dietician and other
group participants.
2. Identify five foods that are high in sodium content. (Knowledge)
The group participant will be able to accurately identify five foods high in soEvaluative criteria:
dium content on a multiple choice test item.
3. Explain the relationship between sodium and potassium in dietary treatment for hypertension. (Interpretation)
Evaluative criteria:
The group participant will be able to explain the relationship between sodium
and potassium in dietary treatment for hypertension during small group discussion with a registered dietician and other group participants.
4. Identify whether a fat is saturated or unsaturated. (Knowledge)
Evaluative criteria:
The group participant will be able to accurately identify whether a fat is saturated or unsaturated on a multiple choice test item.
5. Identify three ways to lower fat intake. (Knowledge)
Evaluative criteria:
The group participant will be able to accurately identify three ways to lower
fat intake on a multiple choice test item.
6. Describe two ill effects of obesity and how it affects a person with hypertension. (Interpretation)
Evaluative criteria:
The group participant will be able to accurately describe in writing two ill
effects of obesity and how it affects hypertension.
TOPIC IV:
DIETARY MANAGEMENT (cont.)
7. Identify two benefits of weight loss and/or control for hypertensive patients. (Knowledge)
Evaluative criteria:
The group participant will be able to accurately identify two benefits of weight
loss and/or control for hypertensive patients on a multiple choice test item.
8. Explain how excess alcohol consumption affects the cardiovascular system. (Interpretation)
The group participant will be able to accurately explain how excess alcohol
Evaluative criteria:
consumption affects the cardiovascular system during small group discussion
with a registered dietician and other group participants.
en
9. Recall information regarding the relationship of weight reduction to fat, fiber, and sugar. (Knowledge)
The group participant will be able to accurately identify whether an item is a
Evaluative criteria:
fat, fiber or sugar and recall if the item should be increased or decreased during
weight reduction on a multiple choice test item.
t-.:1
10. Identify three strategies for maintaining a weight reduction plan. (Knowledge)
Evaluative criteria:
The group participant will be able to accurately identify three strategies for
maintaining a weight reduction plan on multiple choice test item.
11. Plan a nutritionally adequate diet using the six dietary exchange lists. (Comprehension)
The group participant will be able to plan nutritionally adequate diets for breakEvaluative criteria:
fast, lunch and dinner when given food models by a registered dietician.
TOPIC IV:
DIETARY MANAGEMENT (cont.)
TOPIC CONTENT
SUGGESTED LEARNING OPPORTUNITES
SUGGESTED RESOURCES
Transparencies
O"l
~
Instructor uses transparencies to cover content
A. Primary Risk Factors
and discusses risk factors for heart disease.
For Heart Disease
1. High blood cholesterol
a. Normal range 160-260 mg/dl
b. 30% of 2 million deaths are
result of coronary heart disease
c. LDL-responsible for depositing
cholesterol in arteries
d. HDL-remove cholesterol and
transport to liver
e.Recommended dietary changes
-choose lean meats, poultry
or fish
-decrease overall use of
meat and when used remove
fat and skin
-roast, bake or broil rather
than fry foods
-reduce all fats
-reduce weight
-exercise regularly
Lecture to cover content.
2. Hypertension
a. 70% of people have hypertension
b.Systolic/upper or larger
number (pressure in arteries
after heart pumps blood)
-Primary risk factors
-Coronary arteries
-Normal artery
-Partially obstructed artery
-Obstructed artery
-Heart damage and clots
-Dietary action against
blood cholesterol
-Dietary changes to decrease use of meat
TOPIC IV:
DIETARY MANAGEMENT (cont.)
TOPIC CONTENT
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SUGGESTED LEARNING OPPORTUNITES
c. Diastolic/lower number
(lowest pressure in arteries)
d. Sodium controls body fluids
-fluid retention- result
hypertension
e. Sodium equals salt
B. Salt eaten in 4 ways
Instructor refers to transparencies and explains
1. salt shaker
to participants.
2. salt in cooking
3. salt in foods
4. salt in soft water
5. recommended changes
Instructor discusses alternatives of cooking
a. 2-4 gm sodium/day
without salt by referring to transparencies.
b. use herbs, spices, table wine,
basil, chili, chives, cinnamon,
coriander, curry powder, garlic powder, onion powder,
oregano, paprika
C. Potassium
Lecture to cover content.
1. A vital mineral in the body, a
chemical partner to sodium
2. Relationship between sodium
and potassium:
a. Potassium with sodium is involved in the maintenance of
normal water balance
b. Diuretics cause more salt
and water to pass out of the
SUGGESTED RESOURCES
Transparencies
-Salt eaten in 4 ways
-Salt in foods
-Seasoning food without the
use of salt
-Cooking with wine
""
TOPIC IV:
DIETARY MANAGEMENT (cont.)
TOPIC CONTENT
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c.n
body to control blood pressure, but potassium is also
washed out with the salt
c. More foods high in potassium
must be eaten to replace the
loss of potassium
d. Foods high in Potassium
-bananas, oranges, raisins
-tomatoes, squash, spinach
-poultry, beef, fish
D. Fiber
1. Found in fruits, vegetables
and whole grains
2. Complete carbohydrates
3. Water soluble and insoluble
fiber
4. Qualities of fiber:
a. controls blood cholesterol
b. controls heart disease
c. a natural laxative
d. controls intestinal problems
e. aids in weight control
5. Sources of fiber
-fruits, vegetables, peas,
beans, breads and cereals
made from whole grains
6. Steam, bake or boil vegetables and fruits
SUGGESTED LEARNING OPPORTUNITIES
SUGGESTED RESOURCES
Lecture to cover content.
Show group participants high fiber foods by
using cartons of cereal, crackers, legumes,
and food models of fruits and vegetables.
Visual demonstration
-Cartons of foods
-Food models of fruits and
vegetables
Explain how fiber is reduced and calories increased by different methods of cooking.
TOPIC IV:
DIETARY MANAGEMENT (cont.)
TOPIC CONTENT
C)
C)
SUGGESTED LEARNING OPPORTUNITIES
7. Recommendations
a. 3 servings fruit/day
b. 2 servings vegetables/day
c. raw salad daily
e. dried beans or legumes 3
times/week
f. use whole grain bread/cereals
Lecture to cover content.
E. Reading Product Labels
1. Packaged foods
2. Ingredients listed in descendExplain how ingredients are listed on proing order
3. Identification of saturated
duct labels. The first 3 ingredients listed
fats
are the highest in calorie content and should be
-lard, coconut or palm oil
avoided. Show cartons of food to demonstrate
label reading.
4. Artificial sweetners
-Aspartame, Saccharin
Nutra Sweet, Equal
Lecture to cover content and refer to transF. Eating Out
1. Four Simple Rules
parency.
-Dining out in style
a. Reduce food portions
-order ala carte
-share a meal
-order side dish as main
entree
b. Reduce fat
-avoid fried foods
-decrease use of gravy and
dressing
SUGGESTED RESOURCES
Transparency
-Reading Product Labels
Visual demonstration
-Cartons of food
-Sweet 'N Low, Equal,
TOPIC IV:
DIETARY MANAGEMENT (cont.)
TOPIC CONTENT
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-avoid creamy sauces
c. Reduce sugar
-avoid desserts
-order fresh fruit
-avoid after dinner mints
d. Reduce salt
-avoid sauces and gravy
-avoid cured or smoked meat
and fish
2. Types of restaurants
a. Fast Food Chains
b. Coffee Shops
c. Other restaurants
G. Food Exchange System
1. A list of groups of measured
foods of the same nutrients
that can be substituted in your
meal plan for variety
2. Categories of food exchange
system
a. Free foods
b. Foods to avoid
c. Milk Exchange List 1
d. Vegetable Exchange List 2
e. Fruits Exchange List 3
f. Breads/Starch Exch. List 4
g. Meats/protein Exch. List 5
h. Fats Exchange List 6
SUGGESTED LEARNING OPPORTUNITIES
SUGGESTED RESOURCES
Divide the class into 3 groups and pass out
restaurant menus. Have the groups pick out
a healthy menu and provide feedback.
Handout
-"Fast Food Guide"
-"What Are Exchange
Lists?"
Explain categories of food exchange system
and refer to transparency.
Transparency
-The six major exchange
lists
TOPIC IV:
DIETARY MANAGEMENT (cont.)
TOPIC CONTENT
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SUGGESTED LEARNING OPPORTUNITIES
3. Free foods have very few
Show packages of sugar substitutes, cans of
calories
low sodium, low calorie soda.
a. Examples: (LS =low salt)
LS catsup, LS horse radish, LS
mustard, diet soda (2 cans/day)
lemon lime, cranberries, raw
vegetables e.g. lettuce, radish,
chinese cabbage, and other
free foods e.g. herbs & spices
4. Foods to avoid. Contain concentrated sugar and empty calories.
a. Examples: desserts, preserves,
soda, sugar, honey and corn
syrup, alcohol
Show food models and carton of milk, also
5. Milk Exchange/Substitute
List #1
refer to meal planning booklet. Explain the
a. nonfat milk & milk products difference between nonfat milk and lowfat
b.lowfat milk
milk.
c. buttermilk
d. nonfat powdered milk
e. nonfat yogurt (plain)
SUGGESTED RESOURCES
Visual demonstration
-Packages of sugar substitutes
-cans of low sodium, low
calorie soda
Transparencies
-Milk Exchange List
-Vegetable Exchange List
Visual demonstration
-Food models of milk and
vegetables
TOPIC IV:
DIETARY MANAGEMENT (cont.)
TOPIC CONTENT
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SUGGESTED LEARNING OPPORTUNITIES
6. Vegetable List #2
Show food models for serving size
a. Emphasis on high fiber food
because such foods breakdown into sugar at a slower
rate than other foods which
helps maintain a constant
blood sugar level because
it takes longer to digest
and absorb. Examples are
cabbage, broccoli, brussel
sprouts, cauliflower and all
the greens
7. Fruit Exchange List # 3
a. fresh fruit, dried fruit and
Instructor will show food models for portion
juices
size. Refer to meal planning book for all the
b. Emphasize those with high
food groups.
fiber. Examples are all fruits
with edible skin and/or seeds
(pear, apple, peach, apricots
and berries)
8. Bread Exchange List #4
Show food models for portion size
a. bread exchange is not only
foods thought of as bread
b. List includes potatoes, cereal,
crackers, dried beans and other
flour products, starchy vegetables, prepared foods and desserts.
Instructor will show the patients cartons of
SUGGESTED RESOURCES
Transparencies
-Fruit exchange list
-Bread exchange list
-Meat exchange list
Handouts
"Meal Planning for 2 GM
Sodium Diabetic Diet"
Visual demonstration
TOPIC IV:
DIETARY MANAGEMENT (cont.)
TOPIC CONTENT
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SUGGESTED LEARNING OPPORTUNITIES
c. Emphasize these with high
cereals, wrappers of breads and tell them
fiber. Examples are whole
the sources.
wheat, pita bread, 7 grain
cracked wheat bread, bulgur, lns1tructor will ask patients if they are already
oat bran cereal, heart of
using these products.
bran cereal, potato with skin
and kashi
9. Meat Exchange List # 5
Lecture to cover content, refer to transparency.
a. This list contains food rich
in protein.
b. Examples: lean red meat, fish,
poultry (skinless), dried
beans, peas and lentils
c. medium fat meats: ground
beef, eggs & peanut butter
d. High Fat meats: corn beef,
brisket, veal breast, cold
cuts, hot dogs - high fat
meats are high in saturated
fat and should be avoided
e. prefer the lean red meat list
to be used most of the time
because you will have less
Instructor will ask patients portion size of
of the animal fat
meal they are used to eating and provide feedf. Do not eat more than 2
back.
eggs/week
g. Do not eat red meat more
than 3 times/week
SUGGESTED RESOURCES
-cartons of cereals, wrappers of breads
Transparencies
-High Fat Meat Exchange
List
-Fat Exchange List
Visual demonstration
-Pat of margerine
TOPIC IV:
DIETARY MANAGEMENT (cont.)
TOPIC CONTENT
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SUGGESTED LEARNING OPPORTUNITIES
h. Eat skinless chicken, fish, turkey, tofu, dried beans and
lentils
10. Fat Exchange List #6
a. Examples oil, margerine, sour
cream, walnuts, salad dressing
b. Preferred intake: polyunsat- Instructor will refer to food models for
urated fats such as sesame
portion size also discuss the sources and
seeds, safflower, sunflower, avaHability factor.
corn or sesame oil, margerine
made from above oil with no
lard as a part of ingredients
c. Include monounsaturated fats
e.g. olive oil, canola oil and
peanut oil
d. Avoid: butter, bacon fat, sour
cream, coconut oil, cashew
nut and palm oil because they
are high in saturated fats
e. Best distritution of fats is:
10% polyunsaturated
10% monounsaturated
10% saturated fats
H. 1. Meal planning- 1200 Cal/Day Actual meal planning will be done using food
Breakfast- 360 cal
models and transparencies. Participants will
1 fruit - 1 orange
help to plan menu. Make the patient aware of
1 meat- !c lowfat cottage
the diet sheet.
cheese
SUGGESTED RESOURCES
Transparencies
-1200 Cal Menu Plan
Breakfast- 360 cal
TOPIC IV:
DIETARY MANAGEMENT (cont.)
TOPIC CONTENT
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2 bread - 1 cp/cracked wheat
1 biscuit, shredded wheat
1 fat - 1 tsp margerine
1 milk - 1 cup nonfat milk
Free Food - coffee, tea or
Sanka
2. Lunch- 405 cal
soup- chicken broth
2 meat - 2oz roast turkey
2 bread - 2 slices whole wheat
pita bread
1 fat - 2 tsp mayo
1 veg - ! cup alfalfa sprouts
2 slices tomato
1 fruit - 1 apple
Free Food - lettuce and coffee
or tea or lowcal soda
3. Dinner - 360 cal
2 meat- 2 oz broiled fish
2 bread - t cup kernel corn
t cup brown rice
1 fat - 1 tsp margerine
1 veg - t cup broccoli
1 fruit - 1 orange
Free Food -lettuce, coffee or
tea, low cal dressing
SUGGESTED LEARNING OPPORTUNITIES
SUGGESTED RESOURCES
Instructor will ask 2/3 patients to subsitute
the foods they would prefer to eat instead of
wlhat was planned by the group.
-1200 Cal Menu Plan
Lunch 405 cal
Instructor will repeat same strategy as was
done for breakfast.
Visual demonstration
Foods models: fruit, bread,
cottage cheese, margerine
nonfat milk, turkey, lettuce
alfalfa sprouts, tomato
Instructor will refer to transparancy and ask
the group to plan the menu, and give suggestions.
Transparencies
-1200 Cal Menu Plan
Dinner 360 cal
Ask 2/3 patients to change the menu to their
personal liking.
TOPIC IV:
DIETARY MANAGEMENT (cont.)
TOPIC CONTENT
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SUGGESTED LEARNING OPPORTUNITIES
4. Night Snack - 80 cal
1 milk- 1 cup nonfat milk
Lecture to cover content.
I. Some Guidelines:
1. Follow your prescribed meal
plan
2. Avoid Foods high in sugar content
·
3. Avoid foods high in saturated
fat and cholesterol
4. Avoid alcohol
5. Lose weight if you are overweight
J. GENERAL OBESITY
1. Behavior Theory
Lecture
a. Behavior Theory states that Overhead Transparencies
there are 3 events why we
eat
-Stimulus- desire to eat
-Behavior- eat
-Event- fullfilling, relief of
hunger, satisfaction
b. Looking at the stimulus:
for example- depression, anger, happiness, celebration,
social availability of food,
change of environment, fatigue, smell of food, sight of
food
SUGGESTED RESOURCES
Visual demonstration
Transparencies
-Factors affecting the
Stimulus
-Problems associated with
overeating
-BMR and Dieting
TOPIC IV:
DIETARY MANAGEMENT (cont.)
TOPIC CONTENT
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SUGGESTED LEARNING OPPORTUNITIES
c. After the event of eating due
to the stimulus, it can result
in overeating which leads to:
-weight gain
-poor self-control
-loss of figure
-back problems
-higher risk of medical problems associated with obesity/weight gain
K. Weight Loss Factors
Lecture to cover content, refer to transparency.
1. Losing/Gaining Cycle:
This cycle is very discouraging
and can be dangerous to your
health
-weight gain is associated with
structural damage to the heart
and arteries; so reducing and
gaining can result in an increased risk of heart and blood
vessel diseases
-repeated restrictive dieting
makes the body change- there
is a decrease in metabolism
due to the restriction of calories, and the body becomes
more efficient in storing energy in the fat cells
SUGGESTED RESOURCES
TOPIC IV:
DIETARY MANAGEMENT (cont.)
TOPIC CONTENT
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SUGGESTED LEARNING OPPORTUNITIES
2. Fad Diets
Fad diets that work on fast
weight loss with minimum work
effort are poor choices:
-based on an unbalanced diet
and/or unscientific principles.
3. Common Fad Diets
Lecture to cover content, refer to
a. Diet Pills- to depress aptransparency.
petite, or cause a loss of
water, or help the body burn
up fat at a faster rate
* Dangerous to your health
b. Fasting or Skipping Mealsless calories taken in so
weight loss is inevitable
* Possible nutritional deficiencies, and may eat more
calories at another meal
c. Formula Diets- meets the
RDA in all nutrients except
calories
* lacks fiber, does not teach
good eating habits, and is
very hard to stay on
d. Rotation Diet- changes in the
caloric level at various meals
which allows for weight loss
SUGGESTED RESOURCES
Transparencies
-Common Fad Diets
Transparencies
-A Matter of Balance
-Low Fat Diet
TOPIC IV:
DIETARY MANAGEMENT (cont.)
TOPIC CONTENT
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SUGGESTED LEARNING OPPORTUNITIES
* Changes in the calorie level
causes changes in the body's
metabolic rate
e. Fit for Life Diet- only eating
certain foods at specified
times,
*based on an unbalanced diet
and unscientific principles,
similar to the Beverly Hills
Diet
L. Concepts of smart dieting:
Leeture to cover content, refer to
Weight Loss is a combination of transparencies.
of moderate caloric restriction,
making smart food choices, exercise, and behavior modifications
1. diet- balanced and healthy
from the different food groups
2. exercise- needs to be a part of
your lifestyle to help in weight
reduction
3. behavior modification- ways of
thinking which influence diet
and exercise, and helps in
weight reduction
4. Specific dietary factors
a. Reducing fat consumptionwatching the amount of high
SUGGESTED RESOURCES
TOPIC IV:
DIETARY MANAGEMENT (cont.)
TOPIC CONTENT
-3
-3
fat foods. Decrease overall
fat use and increase complex
CHO use = reduction of risk
factors for heart disease
b. Increasing fiber consumption found in complex CHO,
both soluble and insoluble
fiber
-Controls blood cholesterol
-A natural laxative
-Provides a feeling of satiety for help in weight
control
-Methods of cooking
c. Decrease sugar consumption
Sugar provides only calories
with no nutrients
-Some evidence shows the relationship between sugar and
promoting binge eating
-Most sweets are high in
sugar and fat, which can
compound the problems in a
person on a diet
SUGGESTED LEARNING OPPORTUNITIES
SUGGESTED RESOURCES
Transparencies
-Dietary Fiber
-Hints for losing weight
TOPIC IV:
DIETARY MANAGEMENT (cont.}
TOPIC CONTENT
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SUGGESTED LEARNING OPPORTUNITIES
5. Behavior ModificationLecture to cover content, refer to
transparencies.
Hints for losing weight:
a. -plan a pause between bites
-prepare the next bite only
after finishing the current
bite
-do not have something on
fork while food is in your
mouth
-put your fork down between
bites
-all of these are done to slow
down eating for satiety, for
your body to tell you that you
have had enough
b. Eat for the right reasons-examine "stimulus" which
causes eating
-eat at only one place in the
house- which can help to eliminate false eating cues
c. Leave something on your
plate
-select something before
meal and leave a little left
on your plate. Try to make
this a habit.
SUGGESTED RESOURCES
Visual demonstration
-Fiber Food packages
-Food models: apple,
potato, pie, ice cream
TOPIC IV:
DIETARY MANAGEMENT !(cont.)
TOPIC CONTENT
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SUGGESTED LEARNING OPPORTUNITIES
d. Watch out for eating occations-preplan what to eat
-try to find other things to do
e. Look for ways to be more
active
-a deficit of 3500 calories a
week for 1 lb. of wt. loss or
500 calories a day
-walking- between lunch, park
futher away, etc.
f. Reward yourself-non-food rewards for losing
weight and controlling behavior
-continued good effort
M. Ways to maintain Ideal Body
Lecture to cover content, refer to
transparencies.
Weight
1. Determining Ideal Body
Weight
a. Men- 106 pounds for first 5'
6 pounds for each additional
inch
b. Women- 105 pounds for first 5'
5 pounds for ech additional
inch
SUGGESTED RESOURCES
Transparencies
-Determining Ideal Body
Weight
-Quality of Weight Loss
TOPIC IV:
DIETARY MANAGEMENT (cont.)
TOPIC CONTENT
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SUGGESTED LEARNING OPPORTUNITIES
2. Setting realistic goals
Participants will take a quiz to assess their
a. QUIZ- Why do you want to
personal reasons for trying to lose weight.
lose weight?
Participants will assess their
personal reasons for trying to
lose weight by rating the situations to the degree of importance, and then choose 3
of the most important reasons.
b. Plan to lose 1 lb. per week;
this includes using diet, exercise and positive thinking.
c. Have a reason for making the
committment for losing
weight.
d. Frustration and weight loss:
-takes patience and time, early
part of weight loss is mainly
water due to protein breakdown. Eventually will lose
less water and more fat, although pound per week weight
loss might be less.
-Support system: groups, family
and friends, community resources like Weight Watchers
or TOPS, books, restaurants
SUGGESTED RESOURCES
Transparencies
-Preventing backsliding
TOPIC IV:
DIETARY MANAGEMENT (cont.)
TOPIC CONTENT
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SUGGESTED LEARNING OPPORTUNITIES
SUGGESTED RESOURCES
Participants will take a quiz on backsliding
N. Preventing backsliding
to assess situations that cause them to backslide.
1. QUIZ- What makes you
backslide?
Participants will assess the
situations that can cause
them to backslide. Each situation is rated, and the
questions are divided into
different causes of backsliding.
2. Backsliding can start with one
single situation, which can
lead to a total collapse of
committment to change.
3. Dealing with backsliding
a. Learn your high risk situations from the quiz- a high
risk is any situation which
poses a threat to your sense
of control which increases
the chance of relapse.
-negative emotions and
moods- feeling of frustration, stress and fear
-negative physical statepain or injury, both physical
and psychological
-private positive emotionsdesires or actions which pro-
""
TOPIC IV:
DIETARY MANAGEMENT (cont.)
TOPIC CONTENT
(X)
t-.:1
SUGGESTED LEARNING OPPORTUNITIES
duce pleasure
-personal control- focusing
on testing willpower
-urges or temptations- responses to sudden inclinations, or wanting to return
to old habits
-interpersonal conflictrelationships which can cause
some negative feelings
-social influences- individual or group actively using
pressure to influence another
-interpersonal positive (emotions)- social situations that
bring pleasure
-errors in thinking- not thinking through or distorting the
information in the senses
-unsupportive environmentlack of support from the
physical or social environment
-lack of skills- not being able
to challenge or change the
ways of thinking/or irrational beliefs. Goals should
be reasonable.
SUGGESTED RESOURCES
TOPIC IV:
DIETARY MANAGEMENT (cont.)
TOPIC CONTENT
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c..:>
-unbalanced lifestyle- not
giving yourself enough time
to do something for yourself
4. Be prepared to cope- know
what to do and take a positive
action. Mentally remind yourself of why you made the commitment.
5. Practice being prepared to cope
with mental rehearsal so that
you can feel good about the situation. Decide in advance how
to handle a high risk situation.
6. Use skills or techniques for
coping- positive self-talk, exercise, meditation etc.
7. Avoid "Tunnel Vision" or always
focusing on temptation- think
positive and with motivation,
stop yourself from giving up.
8. Learn to recover from your
first slip- focus on what you
have learned and how to prevent it from happening in the
future, and remember your reason for wanting to lose weight.
SUGGESTED LEARNING OPPORTUNITIES
SUGGESTED RESOURCES
TOPIC V:
STRESS MANAGEMENT
Health generalization:
Objectives:
Patient-participant understanding of the adverse effects of stress and tension on the
cardiovascular system may be influential in controlling hypertension and reducing
cardiac risk factors.
Following instruction, the group participant will be able to:
1. Identify two positive and two negative stressful situations a person may encounter in their daily lives.
(Knowledge)
Evaluative criteria:
00
.;:..
The group participant will be able to accurately identify two positive and two
negative stressful situations a person may encounter in their daily lives on a
multiple choice test item.
2. Identify five physiologic or bodily changes that accompany stress. (Knowledge)
The group participant will be able to accurately identify five physiologic
Evaluative criteria:
changes that accompany stress on a multiple choice test item.
3. Recall five symptoms of uncontrolled stress. (Knowledge)
The group participant will be able to accurately identify five symptoms of unEvaluative criteria:
controlled stress on a multiple choice test item.
4. Identify three methods of integrating stress management techniques into daily living. (Knowledge)
Evaluative criteria:
The group participant will be able to accurately identify three methods of
integrating stress management techniques into daily living on a multiple
choice test item.
5. Demonstrate a stress management technique. (Psychomotor skill)
Evaluative criteria:
Following guided demonstrations of deep breathing and stretching exercises,
the group participant will be able to accurately return demonstrate deep breathing and stretch a particular muscle group.
TOPIC V:
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STRESS MANAGEMENT (cont.)
TOPIC CONTENT
SUGGESTED LEARNING OPPORTUNITIES
A. Definition of Stress
Stress is any situation that
creates an uncomfortable feeling, tension, or strain in a person.
B. Stressful situations may be positive or negative, and it is an individual feeling. Positive: marriage, pregnancy, giving birth,
new job; negative: death of a
friend or family member, new job
C. Physiologic, or bodily changes
accompanying stress (1:68)
1. muscular tension
2. increased heart rate
3. increased breathing
4. increased blood pressure
5. cold hands or feet
6. anxiety
D. Symptoms of uncontrolled stress:
1. irritability
2. overreaction to trivial frustrations
3. increased smoking, drinking,
and drug abuse
4. change in sleeping habits
5. restlessness, coupled with
general fatigue
Questions and Answers
Lecture to cover content.
Instructor will ask the class:
-What does your body feel like when you
are under stress or tension?
-How do you handle your stress?
-What are some stress management techniques you use that meets your lifestyle?
The social worker will pass out the handout
"Plain Talk About Stress".
She will discuss with the group signs and symptoms of stress, stress management and how to
incorporate stress management into one's life.
The group will be encouraged to discuss, ask
questions, make comments.
Physical therapist will lecture briefly about
the benefits of exercise. She will demonstrate
types of aerobic and isotonic exercise.
The room will be cleared of tables and chairs.
The group will have the opportunity to practice
isotonic and aerobic exercises (running in place,
dynamic walking, or running in the room in a
circle and raising arms up and down while running.
SUGGESTED RESOURCES
TOPIC V:
STRESS MANAGEMENT (cont.)
TOPIC CONTENT
SUGGESTED LEARNING OPPORTUNITIES
SUGGESTED RESOURCES
6. memory lapses and decreased
concentration
7. tension headaches, indigestion
E.Stress Management (7:258)
1. Look at the problem or stress-
00
en
ful situation. Recognize your
limits.
2. What are your responses to
stress?
Are they in your best personal
and health interest?
3. Adapt to the stressful problem
by thinking about and acting
on alternatives or solutions.
4. Learn to relax by:
a. Transcendental Meditation
b. Yoga
c. Guided imagery
d. Tai Chi
e. Exercise
The social worker will ask the group
the follwoing questions to stimulate
discussion:
-What does stress mean to you?
-How do you feel when you are feeling
stressed?
-Practice/demonstration of stress management technique.
BOOKS
Learning to Live With
Hypertension pp. 29-30.
1985. Boston: Medicine In
Public Interest (MIPI) Publication.
The Relaxation Response
Benson, H. (1984)
New York: Times Books
The Relaxation Book;
An lllustrat~d Self-Help
Book Rosen, G. Prentice
Hall.
TOPIC VI:
PATIENT-PROVIDER COMMUNICATION
Health generalization:
Objectives:
Individual perceptions and levels of knowledge may affect patient-provider communication.
Following instruction,, the group participant will be able to:
1. Develop an awareness that communication between physician and patient can influence_ the outcome
of the treatment. (Receiving)
The group participant will be able to accurately identify 4 criteria for
Evaluative criteria:
effective treatment to take place with their physician on a multiple choice
test item.
00
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2. Identify resources available at Kaiser Permanente Medical Center, Panorama City for the long-term
management of hypertension. (Knowledge)
The group participant will be able to accurately identify 4 resources avaiEvaluative criteria:
lable at Kaiser Permanente Medical Center, Panorama City for the long-term
management of hypertension on a multiple choice test item.
TOPIC VI:
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PATIENT-PROVIDER COMMUNICATION (cont.)
TOPIC CONTENT
SUGGESTED LEARNING OPPORTUNITIES
SUGGESTED RESOURCES
A. Working With Your Doctor
1. It is essential that you and
your doctor have a good relationship so that you can work
out a treatment program that
suits you both.
2. Effective treatment of hypertension or any condition depends in part on both of you
agreeing on the same course
of action, which can happen
only if you understand the
goals of treatment.
3. Be sure that your doctor explains things to you clearly,
in terms that you understand.
4. Ask questions of your doctor,
no matter how silly you think
your questions are.
5. Know when to call your doctor,
what symptoms to report and
what to do if either the doctor
or you are away.
6. Follow-up visits are crucial to
make sure that your blood
pressure stays down.
The instructor will invite 2 physicians
who will discuss and share with the group
the following themes: a) the importance of the
the patient taking an active role as a patient/consumer in their health care, and b)
patient-physician roles.
BOOK
Learning to Live With
Hypertension 1985. Boston:
Medicine In the Public
Interest (MIPI) Publication.
The group will be expected to listen, ask
questions, raise issues, and share personal
•experiences in the discussion.
The instructor will divide the class into 2
groups. One group will be instructed to role
play a situation that illustrates the patient
taking an active role in their health care
when visiting their doctor (e.g.: asking questions, having the doctor explain a treatment
in terms that he/she might better understand,
etc.)
The other group will be observi.ng this roleplay situation, takng notes, listening.
After the first group finishes the scenario,
the 2 groups will change roles- group 1 observes,
group 2 role-plays- but the scenario changes.
This time group 2 plays an inactive patient
"'
TOPIC VI:
00
tO
PATIENT-PROVIDER COMMUNICATION (cont.)
TOPIC CONTENT
SUGGESTED LEARNING OPPORTUNITIES
7. Living with hypertension can
be tedious, especially at first,
but in the long run, it need not
be costly or uncomfortable.
8. Discuss any difficulties that
you are experiencing from
your hypertension with your
doctor.
9. Make a list of questions for
your doctor before you visit
with him so that you are prepared (9).
B. Kaiser Permanente Resources:
1. Dietary department
2. Freedom From Fat
3. Alcohol clinic
4. Smoking Cessation Program
5. Stress Management classes
6. Counseling services
7. Member Health Education
Learning and Resource Center
consumer, asks no questions of their doctor,
is meek.
SUGGESTED RESOURCES
Following the scenarios a discussion will take
place. The instructor asks the group:
What are some of the things you observed when
the patient took an active role when communicating with their doctor?
When the patient was inactive and meek?
The instructor will pass out brochures about
Kaiser Permanente Medical Center, Panorama
City resources, will discuss the resources available and give out names and phone numbers for
members to call when/if they feel the need to
use the resources.
"'
BIBLIOGRAPHY TO CURRICULUM
1.
Bloomfield, Harold and Kory, R. The Holistic Way to Health and
Happiness. 1978. New York, Simon and Schuster.
2.
Glanz, Karen, and Scholl T. Intervention Strategies To Improve Adherence Among Hypertensives: Review and Recommendations. Patient
Counseling and Health Education. 1984. _1(1). pp.14-26.
3.
Griffin, Laura, and Kee. J. Primary Hypertension: Suggestions for
a Preventive Approach. Family and Community Health. February,
1986. ~(4). pp. 59-67.
4.
Havlik, Richard, et al. Weight and Hypertension. Annals of Internal
Medicine. 1983. ~(5). (Part 2). pp. 855-859.
5.
Johnson, Sharon. Facts on Hypertension. Working Woman. October,
1985. pp. 168-170.
6.
Kochar, Mahendr, et al. Hypertension Control: A Multidisciplinary
Team Approach. Family and Community Health. May, 1981. _1(1).
pp. 1-109.
7.
Kochar, Mehendr and Woods, K. Hypertension Control for Nurses
and Other Health Professionals. 1985. 2nd Edition. New York: Springer
Publishing Company.
8.
Krause, Marie and Mahan, L. Food, Nutrition and Diet Therapy. 1979.
Sixth edition. Philadelphia: W. B. Saunders Company.
10.
Levine, David. Health Education for Behavioral Change - Clinical
Trial to Public Health Program. The Johns Hopkins Medical Journal.
November, 1982. 151(5). pp. 215-219.
11.
Levine, David, et al. Data-Based Planning for Educational Interventions Through Hypertension Control Programs for Urban and Rural
Populations in Maryland. Public Health Reports. March-April 1982.
~(2). pp. 107-112.
12.
Levine, David, et al. Health Education for Hypertensive Patients.
Journal of American Medical Association. April 20, 1979. 241(16).
pp. 1700-1703.
-
13.
Liebman, Bonnie. The Sodium-Hypertension Connection. Nutrition
Action. December, 1982. pp. 5-11.
90
14.
Long, Madeline, et al. Hypertension: What the Patients Need to
Know. American Journal of Nursing. May, 1976. ~(5). pp 765-770.
15.
McDonald, Mary and Grimm, R. Compliance With Hypertension Treatment. Postgraduate Medicine. June, 1985. 1_]_(8). pp. 233-242.
16.
Mitchell, Ellen. Protocol for Teaching Hypertensive Patients.
American Journal of Nursing. May, 1977. pp. 808-809.
17.
Oparil, Suzanne. Hypertension. 1986. Chicago: Budlong Press Company.
18.
Rankin, Sally and Duffy, K. Patient Education: Issues, Principles
and Guidelines. 1983. Philadelphia: J. B. Lippincott Company.
19.
Simonds, Scott. Member Health Education in Kaiser Permanente
Medical Care Program in Southern California Region. A Consultation
Report. August, 1976.
20.
Special Communication: Patient Behavior for Blood Pressure Control:
Guidelines for Professionals. Journal of American Medical Association.
June, 1979. 241(23). pp. 2534-2537.
21.
Wyka, Cheryl, et al. Group Education for the Hypertensive. Cardiovascular Nursing. January-February, 1980 . .!&.(1). pp. 1-5.
91
Chapter 6
Summary, Conclusions and Recommendations
Summary
Hypertension represents a public health concern and impacts upon
many personal lives. The treatment for hypertension, which includes dietary
and
medication treatment, weight loss and/or weight control, stress
management, and exercise, is therapeutic; but patient noncompliance to
the recommendations for treatment only limits the benefits of treatment.
Hypertension education, if appropriately planned, may provide the framework
for life-long compliance with the total treatment regimen and permanently
affect health and behavior.
The major purpose of this project was to develop a hypertension
education program that would meet the needs of adult hypertensive patients
and the staff actively involved in hypertension education activities.
A
needs assessment was developed and conducted to justify the need for a
hypertension education program and to identify specific needs and interests
of the hypertensive patient population as well as the doctors who provide
care for the patient population at Kaiser Permanente Medical Center,
Panorama City.
Information obtained from the review of the literature,
patient and doctor needs assessment surveys, and in consultation with the
Physician Advisors to MHE, MHE Administrator and the Curriculum Review
Committee,
were
instrumental in
designing a hypertension education
curriculum for the hypertension education program as well as the Medical
Center.
The curriculum content was validated by a panel of experts practicing
92
in the fields of Education, Medicine, Health Education, Dietary and
Pharmacy.
Written and verbal feedback obtained through this validation
process was used to select content areas and refine the curriculum.
In the following, the conclusions drawn, and the recommendations
for implementation and evaluation of the hypertension education program
will be given.
Conclusions
The following conclusions were drawn from this project:
1. Needs assessments may be developed and administered to ascertain
the needs and interests of both patients and doctors regarding hypertension.
2. Needs assessment surveys may be used to define appropriate content,
objectives, learning opportunities, and resources for the hypertension
education curriculum.
3. The positive responses from the Physician Advisors to MHE, MHE
Administrator, and the Curriculum Review Committee affirm the
usefulness of the hypertension education curriculum as a resource tool
for the health professionals responsible for teaching hypertension
education.
4. It was determined that the development of an educational program
to meet the needs and interests of adult hypertensive patients at Kaiser
Permanente Medical Center, Panorama City was needed.
5. A hypertension education curriculum could be developed integrating
the learning and developmental needs of adults at Kaiser Permanente
Medical Center, Panorama City.
Recommendations
Upon completion of this project, it is recommended that the program planner,
prior to implementing the hypertension education program, should:
1. Develop and administer a formal in-service training program to prepare
the health professionals to assume their teaching responsibilities for
the hypertension education program.
2. Develop marketing and promotional methods to encourage hypertensive
patients and significant others to attend a hypertension education
program. A flier and/or brochure should be designed, with an
eye-catching logo, to include the topics that will be covered in the
93
program, date, time, location, and phone number for pre-registration
for the program. Copies of the flier and/or brochure should be displayed
in the IVIHE Department and around the main lobby of the Medical Center
(e.g., admitting counter, display bulletin near the main elevator, the
bulletin board in the pharmacy, and in the various waiting rooms in
the Medical Center). They should be inserted into the prescription
package by the pharmacy clerk, for all patients who fill their hypertensive
prescriptions. In addition, they should be distributed to the doctors
to give to their hypertensive patients to refer them to the hypertension
education program.
3. Reserve a large classroom, comfortable for 15 to 20 people, for each
session of the program. The classroom should be well ventilated,
carpeted, and should be equipped with tables, chairs, chalkboard, and
a movie screen. Restrooms and telephones should be within walking
distance of the classroom and accessible for handicapped individuals.
There should be adequate lighting and electrical outlets for a movie
projector, overhead projector, and video cassette recorder.
4. Request a doctor to reserve time to teach a session of the program,
"Overview of Hypertension", to increase patient attendance and referral.
Recommendations for Curriculum Development
It is recommended that the individual responsible for use of the curriculum
for the hypertension education program, needs to:
1. Request health educators, pharmacist, dietician, and doctors,ideas and
resources for learning opportunities and strategies to supplement the
hypertension education curriculum.
2. Plan an evaluation of the hypertension education program by using the
evaluative criteria specified in the curriculum and by including the
following levels of evaluation, (a) Process, and (b) Outcome
(a) Process evaluation
1.
Have the patients complete a written questionnaire to determine their
level of satisfaction with each of the class sessions, and to determine
whether the session attended was helpful, informative, and held at a
convenient time of day. This could be completed at the end of each
session or during the final session.
2. During the blood pressure monitoring session, have the patients return
demonstrate blood pressure monitoring on another patient after
instruction from the nurse practitioner. The nurse practitioner should
have a checklist with instructions on blood pressure monitoring to
determine whether the patient is demonstrating blood pressure monitoring
accurately.
3. During
the
stress
management session,
94
have
the
patients return
demonstrate a relaxation technique after instruction from the health
professional. The health professional should have a checklist with
instructions on relaxation techniques to determine whether the patient
is demonstrating a relaxation technique correctly.
(b) Outcome evaluation
1. Develop and administer a pre-and post-test to assess patient knowledge
acquisition of hypertension, the disease; blood pressure monitoring;
medications; and diet and stress management. Administer the pre-and
post-tests that are appropriate to the age and reading level of the
patients. The pre-test should be administered at the beginning of the
first session and the post-test should be given at the conclusion of the
last session.
2. Determine
session by
determine
relaxation
smoking or
patient compliance to lifestyle changes on a 3 month follow-up
using a checklist developed by the MHE Department to
whether the patient is: (a) engaging in exercise, (b) using
techniques, (c) engaging in blood pressure monitoring, (d)
not smoking, and (e) following a medication regimen.
3. Measure behavior change over time by having the patient fill out a
baseline data sheet at the beginning of the program, and three months
after the program. The behavior changes to be measured will include:
(a) medication compliance, (b) blood pressure changes, (c)smoking
cessation, (d)exercise, and (e) stress management.
In summary, the conclusions drawn, and the recommendations given
for the program planner(s), aid in the implementation and evaluation of
the hypertension education program at Kaiser Permananente Medical Center,
Panorama City.
95
BIBLIOGRAPHY
1.
Alderman, Michael and Melcher, L. A Company Instituted Program
To Improve Blood Pressure Control In Primary Care. Israel Journal
of Medical Science. February-March 1981. 1.1(2-3). 122-128.
2.
Bloom, Joan, et al. Improving Hypertension Control Through Tailoring:
A Pilot Study Using Selective Assignment Of Patients To Treatment
Approaches. Patient Education and Counseling. August 1987. 10.
39-51.
3.
Braithwaite, Jane and Morton, B. Patient Education For Blood Pressure
Control. Nursing Clinics of North America. June 1981. _li(2). 321-329.
4.
Bullen, Margaret. What Patients With Hypertension Should Know
About Their Medication. Drugs. 1980. ~· 373-379.
5.
Davis, Paul. Interdisciplinary Team-Building For Hypertension-Patient
Education In An HMO. In: H.Cleary, J.Kichen, and P. Ensor (Eds),
Advancing Health Through Education- A Case Study Approach. 1985.
Palo Alto: Mayfield Publishing Company.
6.
Pass, Marion. The Role of Health Education In Hypertension Control.
Family And Community Health. May 1981. _!(1). 73-83.
7.
Fodor, John and Dalis, G. Health Instruction: Theory And Application.
1981. Third Edition. Philadelphia: Lea and Febiger.
8.
Galli, Maryann. Promoting Self-Care In Hypertensive Clients Through
Patient Education. Home Healthcare Nurse. March-April 1984.
43-45.
9.
Glanz, Karen and Scholl, T. Intervention Strategies To Improve
Adherence Among Hypertensives: Review And Recommendations.
Patient Counseling And Health Education. 1984. _!(1). 14-26.
10.
Green, Lawrence, et al. Health Education Planning- A Diagnostic
Approach. 1980. Palo Alto: Mayfield Publishing Co.
11.
Griffin, Laura and Kee, J. Primary Hypertension: Suggestions For
A Preventive Aproach. Family And Community Health. February
1986. ~(4). 59-67.
12.
Hill, Donna and Madison R. A Health Education Program For Weight
Reduction In A Hypertension Clinic. Public Health Reports. May-June
1980. ~(3). 271-276.
13.
Kerr, Jean. Adherence And Self Care. Heart And Lung. January
1985. _!i(l). 24-30.
96
14.
Knowles, Malcolm. The Adult Learner: A Neglected Species. 1973.
Houston: Gulf Publishing Company.
15.
Knowles, Malcolm. The Modern Practice Of Adult Education. 1980.
Chicago: Follett Publishing Company.
16.
Knox, Alan. Helping Adults Learn. 1986. San Francisco: Jossey-Bass
Inc., Publishers.
17.
Kochar, Mahendr and Woods, K. Hypertension Control For Nurses
And Other Health Professionals. 1985. 2nd Edition. New York: Springer
Publishing Company.
18.
Levine, David, et al. Health Education For Hypertensive Patients.
Journal Of The American Medical Association. April1979. 241(16).
1700-1703.
-
19.
Levine, David, et al. Data-Based Planning For Educational Interventions Through Hypertension Control Programs For Urban And
Rural Populations in Maryland. Public Health Reports. March-April
1982. 97(2). 107-112.
20.
Levine, David. Health Education For Behavior Change - Clinical
Trail to Public Health Program. The Johns Hopkins Medical Journal.
November 1982. 151(5). 215-219.
21.
Levy, Robert and Admire, J. Hypertension Education: A Federal
Perspective. Family And Community Health. May 1981. _!(1). 97-109.
22.
Long, Madeleine, et al. Hypertension: What Patients Need To Know.
American Journal of Nursing. May 1976. 1.§_(5). 765-770.
23.
McCombs, Jane, et al. Critical Patient Behaviors In High Blood
Pressure Control. Cardiovascular Nursing. July-August 1980. 1..§_(7).
19-23.
24.
McDonald, Mary and Grimm, R. Compliance With Hypertension
Treatment. Postgraduate Medicine. June 1985. 11.(8). 233-242.
25.
McKenney, James. Methods Of Modifying Compliance Behavior
In Hypertensive Patients. Drug Intelligence And Clinical Pharmacy.
January 1981. _!l. 8-13.
26.
Member Health Education Learning And Resource Center (Handout)
1983. Kaiser Permanente Medical Center, Panorama City, CA.
27.
Mitchell, Ellen. Protocol For Teaching Hypertensive Patients.
American Journal of Nursing. May 1977. 808-809.
28.
Moore, Michael. Step-Care Approach To Improving Hypertensive
Patient Compliance. American Family Physician. July 1982. ~(1).
155-160.
97
29.
Morisky, Donald, et al. The Relative Impact Of Health Education
For Low-And-High-Risk Patients With Hypertension. Preventive
Medicine. 1980. 9. 550-558.
30.
Morisky, Donald, et al. Health Education Program Effects On The
Management of Hypertension In The Elderly. Archives Of Internal
Medicine. October 1982. 142. 1835-1838.
31.
Morisky, Donald, et al. Five-Year Blood Pressure Control And Mortality
Following Health Education For Hypertensive Patients. American
Journal Of Public Health. February 1983. 73(2). 153-161.
32.
National Institute of Health: Hypertension Detection and Follow-up
Program of the National Heart and Lung Institute (pamphlet), Bethesda,
Maryland, 1973.
33.
Nie, H., et al. SPSS: Statistical Package For the Social Sciences.
1975. 2nd Edition. New York: McGraw-Hill Book Company.
34.
Ogbuokiri, Justina. Self Monitoring Of Blood Pressure In Hypertensive
Subjects And Its Effects On Patient Compliance. Drug Intelligence
And Clinical Pharmacy. June 1980 • ..!..!· 424-427.
35.
Oparil, Suzanne.
36.
Rankin, Sally and Duffy, K. Patient Education: Issues, Principles
And Guidelines. 1983. Philadelphia: J.B. Lippincott Company.
37.
Smith, Dorothy and Germain, C. Care Of The Adult Patient. 197 5.
4th Edition. Philadlephia: J.B. Lippincott Company.
38.
Wyka, Cheryl, et al. Group Education For The Hypertensive. Cardiovascular Nursing. January-February 1980 . ..!..Q_(1). 1-5.
39.
Wyka, Cheryl, et al. Long-Term Evaluation Of Group Education
For High Blood Pressure Control. Cardiovascular Nursing. May-June
1984. ~(3). 13-17.
Hypertension. 1986. Chicago: Budlong Press Company.
98
APPENDIX A
Kaiser Permanente Medical Center, Panorama City
Patient Hypertension Needs Survey
99
KAISER PERMANENTE MEDICAL CENTER
PANORAMA CITY
PATIENT HYPERTENSION NEEDS SURVEY
Dear Patient,
The Member Health Education Department at Kaiser Permanente, Panorama City is interested in finding out what you know about high
blood pressure and whether you would like further information about
management and control. Please take a few moments to fill out this
questionnaire. Your help is greatly appreciated.
Sincerely,
The Hypertension Program Planning Committee
GENERAL INFORMATION
DIRECTIONS: For the following series of questions, please check the
most appropriate answer in the blank space to the right of the
statement.
1. How long have you been diagnosed with high blood pressure?
a) within the last year
b) 1 - 3 years
c) 3 - 5 years
d) more than 5 years
2. What kind of treatment plan are you presently on?
a)
b)
c)
d)
e)
diet control (low fat, low sodium)
medications
diet and medications
diet and exercise
other (please fill-yo-here)
3. Do you feel you are well informed about controlling your high
blood pressure?
a) Yes
b) No
If yes, where did you get your information?
a) doctor
b) nurse
c) written-ffiaterials
100
d) TV, radio
e) other (please-fill in here)
If no, would you be interested in learning how to control
your high blood pressure?
a) Yes
b) No
4. If a high blood pressure program was offered at Panorama City
would you attend?
a) Yes
b) No
If yes, when would be the best time for you to attend the program?
a)
b)
c)
d)
10 - 12 noon
3 pm - 6 pm __
- 9 pm - -
1
4
7
-
5. Your age
6. Your sex
Male
Female
7. Your ethnic background:
a)
b)
c)
d)
e)
f)
Caucasian (White)
Black
Native American
Hispanic
Asian
-Other (please state)
DIRECTIONS: Following is a list of statements which describe infor~
mation that may be important to you in managing your high blood
pressure. Please read each statement. Using the number description listed below, decide HOW MUCH EACH STATEMENT APPLIES TO YOU.
List the number associated with the description in the space next
to the statement.
1 =
v~RY
IMPORTANT; 2 = SOMEWHAT IMPORTANT; 3 = NOT IMPORTANT AT ALL
1. HIGH BLOOD PRESSURE OVERVIEW
a) What is high blood pressure?
b) What causes high blood pressure'?
c) What risk factors are associated with high blood pressure.
101
RATE
(l
d) Lifestyle changes that are important to control high blood
pressure.
e) Other interests (please fill in here)
2. MEDICATION
a) Medications commonly prescribed to control high blood
pressure.
b) Common side effects of high blood pressure medications.
c) How medications work to lower high blood pressure.
d) Tips for taking medications.
e) Other interests (please fill in here)
3. DIET AND ACTIVITY
a) The relationship between sodium (salt), potassium, medication
treatment and high blood pressure.
b) How to develop healthy eating habits.
c) How saturated, unsaturated fats and cholesterol affect blood
pressure and the cardiovascular system.
d) Ways to lower fat and cholesterol levels.
e) Reducing calories and meal planning.
f) How being overweight affects blood pressure.
g) Safe and unsafe exercises for patients who have high blood
pressure.
h) Other interests (please fill in here)
----------------------
4. LIFESTYLE RISK FACTORS
a) The effects of smoking on the cardiovascular system.
b) How excess alcohol consumption affects the cardiovascular
system.
c) How excessive stress or tension may affect blood pressure.
d) Ways of using stress management techniques into my daily
living.
e) Other interests (please fill in here)
5. COMMUNICATION AND RESOURCES
a) How I can take an active role as a patient/consumer in my
health care.
b) The importance of appointment keeping.
c) The importance of informing my doctor of any concerns,
problems I may have regarding high blood pressure.
d) How to effectively communicate with my doctor(s).
e) Kaiser Permanente resources available for managing high
blood pressure.
f) Other interests (please fill in here)
102
'
APPENDIX B
Kaiser Permanente Medical Center, Panorama City
Doctor Hypertension Needs Survey
103
KAISER PERMANENTE MEDICAL CENTER
PANORAMA CITY
HYPERTENSION NEEDS SURVEY
Dear Doctor:
Each medical center throughout the region is mandated to provide a
hypertension program to its members. Prior to our developing such a
program at Panorama City, we would like to find out how it would be
of benefit to you and what you would like to see included in the
program. Please take a few moments to fill out this questionnaire
and return it to the Member Health Education Department by March 27,
1987.
Thank you for your input.
Sincerely,
The Hypertension Program Planning Committee
104
1. How could a hypertension program benefit you and your patients?
Please circle all that apply.
a) improve your patients' adherence to the prescribed regimen
b) decrease the amount of time you spend educating patients in the
office
c) increase patients' confidence in managing their blood pressure
d) have no effect on my patients' blood pressure control
e) don't know
f) other (please state)
2. What type of patients should the hypertension program be targeted?
Please circle all that apply.
a)
b)
c)
d)
e)
f)
patients
patients
patients
patients
patients
patients
diagnosed as having hypertension
diagnosed as having hypertension
diagnosed as having hypertension
diagnosed as having hypertension
on antihypertensive medications
on a diet/exercise regimen
within the last year
within 1 - 3 years
within 3 - 5 years
for more than 5 years
3. What are the prime problem areas in normalizing the blood pressure
of patients in your practice?
(please state)
4. Would you refer patients to a hypertension program in Member Health
Education?
Please circle the appropriate answer.
a) Yes
b) No
DIRECTIONS: Please rate the importance of the content areas that
you want your patients to know more about. Use the following
numbers to fill in the blank spaces under RATE at the right of
the questions.
1 = VERY IMPORTANT;
2 = SOMEWHAT
IMPORTA..~T;
3 = NOT IMPORTANT AT ALL
L
OVERVIEW OF HYPERTENSION
RATE
a)
b)
c)
d)
What is hypertension?
What causes hypertension?
What risk factors are associated with hypertension?
Lifestyle changes that are important to control hypertension.
105
e) Other interests (please state)
2. MEDICATION
a)
b)
c)
d)
e)
Medications commonly prescribed to control hypertension.
Common side effects of antihypertensive medications.
How medications work to lower hypertension.
Tips for taking medications.
Other interests (please state)
3. DIET AND ACTIVITY
a) The relationship between sodium, potassium, medication
treatment and hypertension.
b) How to develop healthy eating habits.
c) How saturated, unsaturated fats and cholesterol affect blood
pressure and the cardiovascular system.
d) Ways to lower fat and cholesterol levels.
e) Caloric restriction and meal planning.
f) How obesity affects blood pressure.
g) Safe and unsafe exercises for hypertensive patients.
h) Other interests (please state)
4. LIFESTYLE RISK FACTORS
a) The effects of smoking on the cardiovascular system.
b) How excess alcohol consumption affects the cardiovascular
system.
c) How excessive stress or tension may affect hypertension.
d) Ways of integrating stress management techniques into daily
living.
e) Other interests (please state)
5.
COMMU~ICATION
AND RESOURCES
a) How patients can take an active role in their health care.
b) The importance of appointment keeping.
c) The importance of informing their doctors of any concerns,
problems they may have regarding hypertension.
d) Kaiser Permanente resources available for managing hypertension.
e) Other interests (please state)
106
APPENDIX C
Cardiac Rehabilitation Education Program
Department Of Member Health Education
Panorama City
Patient Health Needs Survey
107
Q
CARDIAC REHABILITATION EDUCATION PROGRAM
DEPARTMENT OF MEMBER HEALTH EDUCATION
PANORAMA CITY
PATIENT HEALTH NEEDS SURVEY
II
CONFIDENTIAL
II
Having a heart attack can be an upsetting experience, particularly for the person who previously had few known health problems.
The purpose of this survey is to find out what you and your
family need to know and do, in order to deal·with this unexpected
event.
We appreciate your taking time to share your ideas and feelings with us.
If there is any question on the survey that you
don't wish to answer, or that doesn't apply, just leave it blank.
Please mail this survey back in the enclosed, stamped envelope.
108
'
Q '
General Condition:
1.
With regard to heart disease, I want more information on:
(Please check all that apply.)
a.
How the heart works
b.
What causes heart disease
c.
How to recognize the early warning signs and
symptoms of a heart attack
d.
What should be done if those symptoms occur
e.
What a heart attack is
f.
How a heart attack is diagnosed
g.
How the body repairs the damaged heart muscle
h.
How long the healing process takes
i.
Who to call to answer questions during the
recovery period at home
j.
What can be done to prevent another heart
attack from occuring
k.
Who to call and what to do in the event of a
heart attack occuring
1.
Other interests (Please state)
Medication:
2.
I want to learn the following information about the medications
that were prescribed:
(Please check all that apply.)
a.
The reason why certain drugs were prescribed
b.
The names of each of the prescribed medications
c.
How to recognize common side effects associated
with each drug
d.
wnat should be done if the side effects occur
e.
Tips for remembering to take the medication
109
3.
f.
What to do if a dose is missed
g.
When to discontinue taking the drugs
What problems might interfere with taking the medications?
Activities of Daily Living:
4.
In scheduling activities during the recovery period at home,
it would be helpful to have information on:
(Please check all that apply and circle the topics that are
most important to you.)
a.
Activities that are safe
b.
Activities to avoid
c.
Energy saving shortcuts
e.
Taking a shower or bath
f.
Cooking meals
g.
Doing household chores
h.
Having sexual relations
i.
Riding in a car
j.
Shopping for groceries
k.
Working in the yard
l.
Driving a car
m.
Going to social activities
n.
Returning to work
o.
Possible hazards that could trigger an attack
p.
Other (please state)
110
5.
What difficulties might occur at home in trying to follow the
prescribed daily activity plan?
Diet Activity
6.
With regard to the prescribed diet and level of activity, I
want to learn more about:
(Please check all that apply.)
a.
What foods and drinks are healthy for your heart
b.
When and why is it important to reduce the amount
of sodium (salt) in you diet
c.
What cholesterol is and how it affects your
heart and blood vessels
d.
The difference between saturated and unsaturated
fats
e.
Why weight reduction is important in reducing
the risks of another heart attack
f.
How you develop healthy eating habits that will
help you lose weight and keep it at desired
levels
g.
Which activities are safe and which activities
should be avoided during convalescence at home
7.
h.
How you take your pulse and count the pulse rate
i.
Other diet and activity questions (Please state)
What might keep you from following your prescribed diet and
activity at home?
111
APPENDIX D
Physician Advisors to l\1ember Health Education
at Kaiser Permanente Medical Center, Panorama City
112
Physician Advisors to Member Health Education
at Kaiser Permanente Medical Center, Panorama City
Steven Rubin, M.D.
Internal-Medicine
Virginia Ambrosini, M.D.
Internal-Medicine
113
APPENDIX E
Curriculum Review Committee
at Kaiser Permanente Medical Center, Panorama City
114
Curriculum Review Committee
at Kaiser Permanente Medical Center, Panorama City
Mei-Ling Schwartz, M.P.H.
Member Health Education Administrator
Karen Sussman, M.P.H.
Health Education Specialist
Deepi Singh, M.S., M.P.H., R.D.
Nutrition Educator
Member Health Education
Holly Masui, Pharm.D.
Pharmacist
Steven Rubin, M.D.
Internal-Medicine
Virginia Ambrosini, M.D.
Internal-Medicine
115
APPENDIX F
Doctors' Responses to Question,
"What are the prime problem areas in normalizing the
blood pressure of patients in your practice?"
116
Doctors Responses to Question,
"What are the prime problem areas in normalizing the
blood pressure of patients in your practice?"
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
Difficulty in obtaining a nonstressed blood pressure reading to get a
current reading
Ineffective medication
Smoking cessation
Stopping smoking
Patients will not change diet
Noncompliance to diet
Non compliance to diet
Patients will not take prescribed medications
Noncompliance to medications
Patients do not follow medication regimen
Patients will not take their medications
Patients refuse to change lifestyle
Noncompliance to changes in lifestyle
Nonadherence to changes in lifestyle
Patients do not want to change their lifestyle for blood pressure control
Noncompliance to recommended changes in lifestyle
Patients will not lose weight
Noncompliance to weight loss
Patients do not keep scheduled appointments
Noncompliance to appointment keeping
Daily blood pressure variation
Blood pressure changes
Teaching blood pressure monitoring
Inability for patients to learn how to take blood pressure
Teaching self-blood pressure monitorng at home
Patients want to know about blood pressure monitoring; but they have
difficulty learning to take a blood pressure
Teaching patients how to take their blood pressure
Poor health habits
Health habits are not conducive to health
Patients refuse to change their poor health habits
Unhealthy habits of living
Poor health habits
Not enough time to see patients
Patients are afraid to discuss problems that may affect their blood
pressure
Economics
Poor patient understanding of high blood pressure as a disease
Patient lack of knowledge of hypertension
Difficulty in understanding hypertension/high blood pressure
Lack of patient-education/knowledge of hypertension as a lifelong
problem
117
APPENDIX G
The Findings Of The Doctor And Patient Rating
Of The Major Hypertension Topic Areas
118
THE FINDINGS OF THE DOCTOR AND PATIENT RATING OF THE MAJOR HYPERTENSION TOPIC AREAS BY PERCENT
NUMBER OF RESPONDING:
DOCTORS (N=39)
PATIENTS (N=63)
NUMERICAL RATING DESCRIPTION:
1 = VERY IMPORTANT
2 = SOMEWHAT IMPORTANT
3 = NOT IMPORTANT AT ALL
Xn
= MEAN PERCENT OF DOCTOR RATING PER MAJOR TOPIC AREA
XP = MEAN PERCENT OF PATIENT RATING PER MAJOR TOPIC AREA
"""
"""
tO
MAJOR TOPIC AREAS
1
2
3
D
66.7
93.7
17.9
6.3
15.4
D
82.1
85.7
15.4
14.3
2.6
D
61.5
90.5
25.6
9.5
12.8
D
76.9
93.7
17.9
4.8
5.1
1.6
71.8
90.9
19.2
8.7
8.9
0.4
OVERVIEW OF HYPERTENSION
A.
What is hypertension?
p
B.
What causes hypertension?
p
C.
Risk factors associated with hypertension.
p
D.
Lifestyle changes to control hypertension.
p
X'D
XP
1
2
3
MEDICATION
1-'
t-.::1
0
A.
Common antihypertensive medication
prescribed.
D
p
79.5
87.3
17.9
12.7
2.6
B.
Common side effects of medications.
D
p
79.5
88.9
15.4
9.5
5.1
1.6
C.
How medications work to control hypertension.
D
p
56.4
87.3
28.2
11. 1
15.5
1.6
D.
Tips for taking medications.
D
p
87.2
74.6
7.7
22.2
5.1
3.2
XD
75.6
84.5
17.3
13.8
7.0
1.6
-XP
1
2
3
DIET AND ACTIVITY
A.
Relationship between sodium, potassium,
meds., and hypertension.
D
71.8
96.8
25.6
1.6
2.6
1.6
B.
How to develop healthy eating habits.
D
53.8
93.7
30.8
4.8
15.4
1.6
p
p
....
....
~
c.
Effects of fats/cholesterol on cardiovascular system.
D
61.5
96.8
25.6
1.6
12.8
1.6
D.
Ways to lower fat and cholesterol levels.
D
p
76.9
95.2
20.5
3.2
2.6
1.6
Caloric restriction and meal planning.
D
61.5
92.1
35.9
6.3
2.6
1.6
E.
p
p
F.
How obesity affects blood pressure.
D
59.0
90.5
38.5
6.3
2.6
3.2
G.
Safe and unsafe exercises for hypertensives.
D
53.8
90.5
41.0
6.3
5.1
3.2
XD
62.6
93.6
31.1
4.3
6.2
2.0
p
p
XP
"12:
1
2
3
LIFESTYLE RISK FACTORS
I-'
1:-:>
1:-:>
A.
Effects of smoking on the cardiavascular system.
D
p
66.7
77.8
28.2
12.7
5.1
9.5
B.
Effects of alcohol on the cardiavascular system.
D
p
33.3
74.6
51.3
15.9
15.4
9.5
c.
Effects of stress and tension on hypertension.
D
p
82.1
81.0
12.8
15.9
5.1
3.2
D.
Integrating stress management techniques
into daily living.
D
p
87.2
82.5
7.7
15.9
5.1
1.6
XD
67.3
78.9
25.0
15.1
7.6
5.9
XP
1
2
3
COMMUNICATION AND RESOURCES
~
A.
How patients can take an active role in
their health care.
D
p
51.3
77.8
38.5
15.9
10.3
6.3
B.
Importance of appointment keeping.
D
p
46.2
74.6
43.6
19.0
10.3
6.3
c.
Informing doctors of problems, concerns
that regard hypertension.
D
p
30.8
82.5
43.6
14.3
25.6
3.2
D.
How to effectively communicate with my
doctors(s). Patients' responded only.
p
84.1
12.7
3.2
Kaiser Permanente resources available for
managing hypertension.
D
p
66.7
95.2
23.1
4.8
10.3
'XD
39.0
82.8
29.7
13.3
11.3
3.8
t--:1
~
E.
XP