The Impact of DASH (Dietary Approach to Stop Hypertension) on African American

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A clinical practice change project has been designed and implemented to educate patients about a dietary approach to stop hypertension (DASH). This practice change project increased patients’ knowledge and willingness for dietary change to reduce their blood pressures.

According to the American Heart Association (AHA, 2015), hypertension is one of the leading health issues contributing to cardiovascular disease that is a leading cause of morbidity and mortality. Understanding that hypertension is a risk factor that can be modified, 54% of an estimated one million adults diagnosed with hypertension are poorly controlled (Center for Disease Control, 2017). Healthcare providers are at the forefront of counseling patients on preventive services (Jarl et al., 2014). Educating patients on a lifestyle modification, such as DASH has demonstrated a proven strategy to reduce the blood pressures of patients diagnosed with hypertension. The literature strongly suggests that interventions are needed for adherence to DASH diet among patients diagnosed with hypertension (Jarl et al., 2014).

Patients were recruited from an outpatient clinic at a private historically black university in Washington, D.C. The participants consisted of African American patients between the age of 18 and 65 diagnosed with hypertension at a primary care clinic in Washington D.C. A pre-posttest and food frequency questionnaire designed by DASH was utilized to gain knowledge of patients before and after DASH education session. The practice change was guided by the Pender’s health promotion model and The ACE star model of knowledge. Patient’s blood pressures were measured before and after the implementation of DASH education session.

Health education can reduce chronic disease mortality and morbidity (Jarl et al., 2014). Although some studies describe how providers provide health education, few studies have examined how doctors, physician assistants, and nurse practitioners differ in health education delivery. Patients with chronic disease receive health education from physician assistants and nurse practitioners more frequently than physicians, but none of the three categories of clinicians consistently offered health education. Possible reasons include variations in preparation, different positions per form of provider within a clinic, or increased clinical demands on providers. More data collection is needed to understand the causes of these differences and potential opportunities to provide patients with condition-specific education (Ritsema et al., 2014).

Education meetings alone or in conjunction with other interventions can improve patients’ knowledge and increase patient outcomes. Using a pre-posttest and DASH food frequency questionnaire to evaluate needs, educators can develop programs that address learners’ information needs and issues more effectively and ultimately help patients (Ebell et al., 2011).

Background of the Project

African Americans are at an increased risk for developing HTN at an early age due to a gene that increases their sensitivity to salt (American Association for the Advancement of Science [AAAS], 2004; Rigsby, 2011). This population is disproportionately affected by HTN when compared to other ethnicities (Rigsby, 2011). As a result, African Americans with HTN have an increased rate of stroke (80%) and heart disease (50%) when compared to other ethnicities (AAAS, 2004). Asante (2015) reported that 84% of African Americans did not understand HTN and chronic diseases related to lack of therapy. Hypertension occurs when the force of the blood flowing through a person’s blood vessels is consistently too high (AHA, 2017). The Center for Disease Control (CDC, 2018) defines normal blood pressure (BP) as a systolic B/P less than120 mmHg and diastolic B/P less than 80 mm Hg. Hypertension is the leading preventable cause of premature death worldwide (Mills et al., 2016). The principal health issue of four or more office visits to health care providers in the U.S. is for HTN with an estimated direct and indirect cost of $51.billion (CDC, 2019).

According to Healthy People 2020, their goal is to increase compliance and control of hypertension among adults from 43.7% to 61.2% by 2020. This initiative would take place with increased coordinated health promotion and disease prevention to improve patients’ outcomes. This would significantly increase controlled blood pressures compared to the years 2005-2008 (Healthy People, 2020).

Adopting DASH diet, a mixed diet of fruits, vegetables, nuts, whole grains, lean fish, poultry, and low-fat dairy foods, contributes to lower blood pressure (National Heart, Lung, And Blood Institute [NHLBI], 2015). The diet requires reducing less saturated fat, total fat, and cholesterol. In a randomized control experiment, the diet decreased BP (Appel et al., 1997). Participants adopting DASH diet, systolic blood pressure decreased by an average of 7.7 mm Hg, and average blood pressure decreased by 3.6 mm Hg (Blumenthal et al., 2010).

According to Kim and Andrade (2016), there are major health issues that contributed to non-adherence to dietary recommendations and that non-adherence rates are on the decline. Many barriers prevent patients from adhering to a healthy diet, although DASH has proven to reduce blood pressures among patients (Viera et al., 2007). There are currently barriers during office visits with patients, such as time restraints, that contribute to limited resources available to educate patients (Matyas et al., 2011). Another barrier would be motivating patients to modify their diets for better hypertension control (Samadian et al., 2016).

The primary objective of this DPI was to investigate if a DASH education intervention for patients would impact patient outcomes by reducing hypertension in African American patients at a primary health clinic in Washington, D.C. If it succeeded, the program could be adopted at the facility as well as in other medical locations. Moreover, the community’s health in Washington and across the United States as a whole would improve substantially. The explanation of the problem was helpful to understand the root cause and then recommend a change.

Problem Statement

It was not known if or to what degree the implementation of a DASH would impact the patients’ blood pressures compared to no intervention among African American patients diagnosed with hypertension in an outpatient clinic in Washington, D.C.

High blood pressure (HBP) prevalence in African Americans in the US is among the world’s highest (Maraboto & Ferdianand, 2020). Many of non-Hispanic African American men and women have high blood pressure. High blood pressure also occurs earlier in life and is typically more extreme for African Americans (Maraboto & Ferdianand, 2020). While some of the causes are natural and do not necessarily represent cause for health concerns, others are related to unhealthy lifestyle habits. By addressing them, healthcare providers should be able to alleviate some of the problems in the community with limited investment.

Uncontrolled hypertension (HTN) in the USA is particularly prevalent and devastating among Black people who are more vulnerable than people from other racial/ethnic groups to the effects of this disease (Maraboto & Ferdiannand, 2020). Moreover, the findings of many research studies in this population are frequently underrepresented in cardiovascular clinical trials, restricting their ability to apply them accurately. In this analysis, the information will be summarized that is currently available regarding risk factors, manifestations, complications, and HTN management in this often difficult-to-treat population (Maraboto & Ferdiannand, 2020). This practice change project sought to better understand how increasing patient’s knowledge on DASH diet is the best approach for treating patients with hypertension (Maraboto & Ferdianand, 2020).

Purpose of the Project

The purpose of this quantitative quasi-experimental project was to determine if or to what degree the implementation of a Dietary Approach to Stop Hypertension education intervention for patients would impact the patients’ blood pressure when compared to no intervention among African American patients diagnosed with hypertension in an outpatient clinic in Washington, D.C. The independent variable was defined as DASH diet and the dependent variable were patient blood pressures, healthy food selections and knowledge about DASH after the implementation of DASH diet education sessions. The independent variable was measured using a validated food frequency questionnaire, and the dependent variables were evaluated using a sphygmomanometer and a food frequency tool. This purpose statement aligns to the PICOT components from previous courses.

Clinical Question

The different factors that affect the relatively high likelihood of African Americans developing hypertension are well-known, but their specific effects on blood pressure have not been studied adequately. This knowledge is vital because, while some factors are challenging to control, others, such as food consumption habits, are easier to adjust. The current contribution of African American diets to the community’s cardiovascular health is unclear. However, DASH has been researched extensively and found to be effective across most demographics (Siervo et al., 2015). As such, it may result in blood pressure improvements in the target population once they become more aware of it.

To what degree does the implementation of a Dietary Approach to Stop Hypertension education intervention impact blood pressure of patients diagnosed with hypertension when compared to no intervention among African American patients in an outpatient clinic in Washington, D.C.? This practice change project took place over a four-week period and aimed to reduce the development and increase the management of HTN among African Americans. Questions for the clinical project were designed to show the correlation between the problem and differences in both populations.

The following clinical question guides this quantitative project:

CQ: Does the implementation of a Dietary Approach to Stop Hypertension education intervention impact African American patients diagnosed with hypertension at a primary health clinic in Washington, D.C. over four weeks?

The independent variable was defined as DASH diet and the dependent variable were patient blood pressures, healthy food selections and knowledge about DASH after the implementation of DASH diet education sessions.

Advancing Scientific Knowledge

This DPI increased strategies to help patients control their blood pressure (BP) by lowering systolic and diastolic. The goal was to implement education programs for patients in the clinic setting to increase hypertension management and increase patient outcomes. Dramatic improvement in public health could be gained from enhanced hypertension control (AHA, 2015). The effectiveness and implementation of DASH intervention by providers will also add to ways to effectively increase community efforts to achieve blood pressure control throughout the population, especially among African Americans.

The theoretical framework chosen for this DPI was Nolan Pender’s health promotion model and the ACE star model of knowledge. According to Petirin (2015), Pender’s health model focuses on changing patients’ unhealthy behaviors and improving patient outcomes. This was directly in line with educating patients about using a DASH diet by increasing their knowledge about dietary intake and the effects it can have on their blood pressure. Pender’s model can change this behavior and improve patient outcomes by better managing their hypertension.

This DPI practice change project can further advance Pender’s health promotion model by showing successful hypertension management and control. Pender’s health promotion model could be applicable as a theoretical framework to identify major determinants of adherence to hypertension control recommendations. The findings of this DPI represented more legitimacy surrounding self-care practices in hypertension if there is a large enough sample size.

The conceptual-theoretical-empirical (CTE) structure is a system of nursing knowledge that requires attention to elements of substance and process as well as considerable thought, careful planning, and commitment to evidence-based practice that typically changes nursing practice and sets the standard for providing quality patient care (Fawcett &Desanto-Madeya, 2012). The project implementer (PI) utilized the Health Promotion Model (HPM) by Nola Pender and the ACE star model of knowledge transformation to guide this project. Pender’s health promotion model (HPM) is a widely used model to plan for and change unhealthy behaviors and promote health (Petirin, 2015).

Using the health promotion model was more advantageous than other strategies since the HPM aims to improve the health condition of patients and their families. For this DPI project, the primary goal was to provide an alternative HTN management method with a DASH diet and lifestyle practices to reduce patients’ blood pressure. The positive project results will help people diagnosed with HTN manage the condition with dieting and exercise, which will enable them to live long, healthy lives.

Significance of the Project

African Americans are identified as a high-risk population for the treatment and management of HTN. This is a multifactorial problem that requires a comprehensive education and treatment program. There are disparities in health care and access to care in African Americans (AHA, 2017). To effectively treat and impact this population, an educational intervention aimed at diet and lifestyle modifications and HTN management is required. A multidisciplinary patient-centered medical approach that incorporates the healthcare provider, nurses, case managers, pharmacists, and dieticians will have the most significant impact on improving patient outcomes.

The significance of this DPI project was to increase patients’ knowledge and behaviors toward change to help reduce HTN cases among African American individuals who are at a higher risk of developing HTN. HTN does not always require medical intervention, and quantitative data have provided sufficient evidence that indicates the condition can be managed and prevented using other measures, such as dieting and change to healthier lifestyle practices. The DPI project positive results can contribute to the prevention of hypertension in the community and globally, which will significantly reduce the mortality of cardiovascular-related complications around the world.

Changing clinical practice is a challenging task and can be best demonstrated by the time gap between evidence and usage in practice and the widespread use of low-value treatment. Established frameworks concentrate primarily on obstacles to new information learning and implementation. However, improvements to clinical practice not only entail learning new practices but also unlearning old and obsolete information. This DPI practice change aimed to explain the experience of having to leave old dietary habits in the past and its association with new learning. When a change is introduced, whether through the introduction of new directives or self-imposed changes, patients face different struggles to successfully change their health management practices (Gupta et al., 2017).

Health associations encourage healthcare providers to engage in patients’ blood pressure management services (CDC, 2017). Lifestyle improvements include weight control, exercise, and diet guidelines for HTN management (Matyas et al., 2011). Because of a lack of knowledge, many patients do not obey the guidelines. Education of patients regarding improvements in lifestyle may have a big influence on their confidence in DASH diet education regarding HTN (Matyas et al., 2011). Kwan et al. (2013) reported that a lack of education is a common factor that patients do not adopt dietary education.

Lifestyle improvements with a heavy emphasis on dietary activity focus on the treatment of HTN based on CDC guidelines (2017). The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (2014) has increased its focus on the shift in the lifestyle of hypertension prevention and treatment and listed DASH diet on hypertension algorithm lifestyle medication.

Rationale for Methodology

The participants for this DPI project were from a primary health clinic in Washington, D.C. The initial group consisted of individuals who are all from the primary care clinic, African American, and have been diagnosed with hypertension. The quantitative DASH pre-post-test and food frequency approach was used to measure the relevant variables (Harrison, 2014). In addition, patients’ blood pressure was measured before and after provider-to-patient counseling of DASH diet to see if there is a correlation between increasing patient knowledge and decreasing patient blood pressure.

The best approach for this DPI project was a quantitative pre-posttest to answer the clinical question. Taking the pre-test and completing DASH food frequency tool at the beginning, patients are not expected to know the answers to all the questions; however, they should be expected to utilize previous knowledge to predict rational answers. When taking the same test called a post-test at the end of a DASH education, participants should be expected to answer more questions correctly and have better food selections based on an increase in knowledge and understanding.

Investigators can assess reliability by comparing the answers respondents give in one pretest with answers in another pretest. Then, a survey question’s validity is determined by how well it measures the concept(s) it is intended to measure. Both convergent validity and divergent validity can be determined by first comparing answers to another question measuring the same concept, then by measuring this answer to the participant’s response to a question that asks for the exact opposite answer (Dimitrov & Rumrill, 2003). The findings can then be used to evaluate the response and determine whether it is accurate.

Nature of the Design

The focus for this quasi-experimental design DPI project was to administer a DASH five-question pre-and-post measuring patients’ knowledge and a DASH food questionnaire before and after DASH education to determine its effectiveness. Everyone was granted free access to the pre posttest and DASH food questionnaire tool; access and usage of the tool was granted by the National Institute of Health. By observing the differences between the patients’ actions and health outcomes before and after the intervention, the researcher can assess its effectiveness, answering the research question.

The selected design was the best design for the project because it covers all the dimensions of the problem and was helpful in recommending a practical solution and answering the clinical question. By using pre-post test questions and DASH food questionnaire tool to evaluate needs, educators can develop educational programs that address the information needs and issues of learners more effectively and ultimately help patients (Ebell et al., 2011). A pre-post-test by design and DASH food questionnaire was used for the DPI project because it covered all topics that the participants learned during DASH education sessions.

For this DPI project, African American patients diagnosed with HTN were the main participants. They were asked a series of questions to measure their knowledge of HTN, DASH diet and food intake. This practice change project goal was to broaden their knowledge on the best approaches regarding the effectiveness of a DASH diet, thus improving patient outcomes with improved management of HTN. Patients’ blood pressures were measured before and after the provider to patient DASH education, DASH food questionnaire and pre-posttest.

The design mandates a selection of a considerable quantity of patients so that quantitative statistics may be used with a high degree of confidence. With that said, resource limitations reduce the number of people that may be recruited. As such, the participants were selected from one medical facility using a convenience sampling method. The intervention was also used at that location, as all of the participants were its patients, and the effort could be organized without significant difficulty. Similarly, the data gathering was performed with tools available onsite.

Definition of Terms

Below is a list of terminologies encompassed in the DPI project. It relates to providers educating patients on the adoption of DASH diet to guide them in managing their hypertension.

Hypertension: Is blood pressure greater than 120/80 mm Hg? It is also known as high blood pressure and is responsible for increasing pressure on the blood vessels (AHA, 2017).

Sodium: A major cation of extracellular fluid in human cells (Chobanian et al., 2003). Iodized sodium chloride is commonly known as salt and is used in food. It is found in many foods as it is essential for the nerve and muscle function in the human body.

Dietary Approach to Stop Hypertension (DASH): Designed to help treat, manage, or prevent hypertension. DASH diet is a meal plan that is designed to lower blood pressure (Challa et al., 2020). The diet comprises fruits, vegetables, and low-fat dairy products.

Pender’s Health Promotion Model: A health promotion model that defines health as a positive dynamic state instead of terming it as the absence of disease. It is also directed at enhancing a patient’s level of well-being (Petirin, 2015).

Conceptual Theory Empirical: It is relative to the conceptual framework providing concrete and specific results through various theoretical frameworks derived from empirical tests from experiments (McConnel, 2015).

ACE Star Model of Knowledge: Describes five significant points in the transformation of knowledge into practice (Stevens, 2013). It begins at the top point, where discoveries are made, and it serves as the focal point of the project.

DASH Questionnaire: Consists of five questions related to the patients’ adherence to a DASH-compliant diet. Developed and tested by Apovian et al. (2010), who found it correlated strongly with other well-established tools.

Assumptions, Limitations, Delimitations

This DPI project assumed that all participants would answer DASH pre and post-test questions and DASH food frequency questionnaire honestly and would be engaged in DASH educational sessions. However, there are no guarantees that the responses would be accurate, as a variety of biases can manifest that will be described below. The second assumption is that the project represents the broader African American community accurately. The participants initially did not exhibit any particularly significant self-reported deviations from the standard dietary habits in their community or within the sample.

Limitations included no assurance that participants would provide the right answers for the questionnaires. A number of potential biases was present, including social desirability bias, culture bias, and acquiescence bias. Additional limitations were the use of a convenience sampling of 20 participants reducing the generalizability of no control group, and the time frame to conduct the DPI project was only four weeks. As such, the confidence level is substantially lower than it would be for a larger sample, and the intervention may not have had enough time to demonstrate its effects entirely.

Delimitations include only using one primary care clinic, and all participants were African American; no other ethnic group was asked to participate in the DPI project. The outpatient clinic patient population was made up of 95% African Americans. The clinic was chosen because of time and resource limitations, as the educational program would have to be implemented separately for each facility. The sample makeup was chosen because only patients at the clinic were recruited due to the difficulty in contacting other people. Due to COVID-19 and the related lockdown, most off-site participants were not willing to attend in-person educational meetings, and the project was abandoned as a result.

Summary and Organization of the Remainder of the Project

In the United States, the prevalence of hypertension in blacks is among the highest in the world. Blacks develop hypertension at a younger age, their average blood pressure is much higher compared to whites, and they suffer worse severity of the disease (AHA, 2017). As a result, African Americans have 1.3 times higher rates of nonfatal stroke, 1.8 times, of fatal stroke, 1.5 times, of heart disease-related death, 4.2 times, of end-stage kidney disease, and 1.5 times, of heart failure; overall, hypertension mortality and its effects are four to five times more common in African Americans than in whites (CDC, 2015). A combination of genetic and, most likely, environmental factors is responsible for the increased prevalence of hypertension and excessive target organ damage (AHA, 2017).

Further research state that approximately 26% of the global population is suffering from hypertension, and the prevalence of the problem is expected to increase by 29% since 2025. And the risk is higher among developing nations. The problem is not only tremendous at the public level, but it will cost the nation in the form of public health burden. Along with the leading cause of stroke and heart diseases, hypertension is also a third-ranking cause of death across the world (Yang, 2019). Because of the overall increase in hypertension threats, this DPI project emphasizes the prevention and control of hypertension in the selected population sample.

A healthy diet and portion control are promoted by DASH diet. It supports the introduction into your daily diet of more fruits and vegetables, whole-grain foods, fish, poultry, nuts, and fat-free or low-fat milk items (DASH, 2013). Foods high in saturated fat, cholesterol, trans fats, candy, sugary beverages, sodium (salt), and red meat should be reduced (DASH, 2013). Owing to family background, some individuals have high blood pressure (DASH, 2013). For some, it may be to blame for unhealthy diets, lack of exercise, or another medical problem. People who have hypertension also take medication. However, diet and exercise, even if it is part of your family background, can help lower high blood pressure (DASH, 2013).

A pre-and post-test, defined as a before & after assessment and DASH food frequency questionnaire, was used to measure whether the anticipated improvements would take place in the participants from DASH education. This was the simplest evaluation design appropriate for the DPI project. A standard test questionnaire was applied (pre-test or baseline) and re-applied after a given time or at the end of the program (post-test or end line). The pre-and post-tests and DASH food frequency tool was given in writing.

The value of hypertension understanding continues to be emphasized by existing recommendations on hypertension management. To improve treatment effectiveness, more effort should be made to increase patient knowledge and patients’ willingness to comply with physical examinations (Harrison, 2014). As clinicians, if we want to convince patients to concentrate on their long-term wellbeing, we need to build a relationship of confidence. By sharing as much of our information as possible, the trust will be strengthened (Harrison, 2014).

African Americans are identified as high-risk HTN treatment and management populations (AHA, 2017). This is a multi-factor challenge involving a robust education and care program. In African Americans, there are inequalities in health insurance and access to treatment. An educational intervention to modify diet and lifestyle and manage HTN is needed to treat this population effectively. Increased screening and more rigorous recommendations in this population are required. The most significant effect on better patient outcomes would be the multidisciplinary patient-centered medical approach involving a primary care professional, nurse, case managers, pharmacists, and dietitians. The DPI project took place over a four-week period of time. The next chapter will further discuss the review of literature, the methodology in which the DPI project was utilized, the purpose of the DPI project, and practice implications from the results. The primary objective of this DPI was to investigate if a DASH education intervention for patients would improve the management of patients diagnosed with HTN at a primary health clinic in Washington, D.C. The project was informed by the significant research and evidence base surrounding the approach, which is discussed in chapter 2.

Literature Review

The purpose of this project is to investigate the effect of educating patients about a dietary approach to stop hypertension. The main goal of the project is to increase the willingness and knowledge of patients for dietary change to reduce blood pressure. The target patients are from an outpatient clinic in Washington D.C. The literature review will be addressing specific themes that entail a dietary approach to stop hypertension. The literature review will be arranged in sub-sections with each sub-section addressing a specific theme.

A literature search was performed using Cumulative Index and Allied Health Literature (CINAHL), American Heart Association, Google Scholar, Medline, and PubMed. Keywords included HTN, DASH diet, patient knowledge, African Americans, lifestyle modification, provider education, and various combinations of the aforementioned. The search focused on evidence-based nursing articles and quantitative studies that had human peer-reviewed, used the English language, was full text, and within the last fifteen years. The search criteria were used to obtain the current body of literature and ascertain if an evidence-based practice change was supported.

The literature search resulted in approximately 60 articles. Articles were reviewed for relevance to PICO, inclusion, and exclusion criteria, and 20 articles remained. The level of evidence was determined from (Fineout-Overholt’s, 2015) evidence hierarchy (1) Level I: Evidence from systematic review or meta-analysis of all random clinical trials (RCT), (2) Level II Evidence obtained from well-designed RCTs, (3) Level III Evidence obtained from well-designed controlled trials without randomization, (4) Level IV Evidence from well-designed case-control and cohort studies, (5) Level V Evidence from systematic reviews and descriptive and qualitative studies (6) Level VI Evidence from single descriptive or qualitative studies, and (7) Level VII Evidence from the opinion of authorities and/ or reports of expert committees. The studies with evidence rated I through IV were utilized. Inclusion criteria used to select articles included studies that focused on lifestyle modification or nonpharmacological management of HTN, knowledge and education, management, or self-management in reference to or combination of HTN in African Americans, education for patients, and patients’ attitudes toward change. Exclusion criteria included participants under 18 years of age.

Background

Early-onset HTN is a significant contributor to a shortened life expectancy of African American men (AHA, 2017). Hypertension is one of the leading factors for cardiovascular disease and is the leading risk factor for the overall global burden of diseases. Evidenced data has demonstrated that lifestyle modification and changes are known to reduce blood pressure (BP) (AHA, 2015). The purpose of this chapter is to provide an integrative review of literature identifying the best evidence-based literature to support lifestyle modification interventions in hypertensive African Americans to increase knowledge and decrease blood pressure.

Existing literature about hypertension and its leading causes and effects on African Americans is empirically reviewed to support the findings of the project. Hypertension is the third leading cause of death across the world and causes numerous other diseases. It is also a risk factor for cardiovascular diseases (CVD) and numerous other premature mortalities across the world as well as in the United States. Dietary Approach to Stop Hypertension is proposed to the sample population. DASH is an eating plan that is carefully designed to control or lower high blood pressure. DASH plan prefers potassium, calcium, and magnesium-rich foods to patients. Patients are selected from the historically black university between the age of 16-85. A healthy diet along with medical treatment is also discussed to solve the problem. Data from old literature and demographic trends are also used to support research claims. Data collected from clinical questionnaires is also interpreted with the help of available literature and research.

Theoretical Foundations

The Nola Pender’s health promotion model (HPM) and the ACE star model of knowledge transformation will be utilized to guide this project. Pender’s health promotion model (HPM) is one of the widely used models to plan for and change unhealthy behaviors and promote health (Petirin, 2015). The use of evidence-based practice (EBP) and national guidelines improve the quality of patient care and close the gap between quantitative patient outcomes and practice (Dontje, 2007). The conceptual-theoretical-empirical (CTE) structure is a system of nursing knowledge that requires attention to elements of substance and process as well as considerable thought, careful planning, and commitment to evidence-based practice that typically changes nursing practice and sets the standard for providing quality patient care (Fawcett et al., 2012). An EBP model or theory is used to guide the process of translating quantitative evidence into clinical practice. The clinical problem identified was hypertension in African American adults. The PICO question identified for this EBP is as follows; in African American patients diagnosed with hypertension, does an educational overview regarding a Dietary Approaches to Stop Hypertension (DASH) diet improve patient outcomes by lowering blood pressures? The purpose of this chapter was to analyze a conceptual-theoretical-empirical (CTE) structure and theory that supports or guides the implementer’s EBP. Health promotion is defined as lifestyle modification and behaviors recommended by the healthcare provider to promote one’s health and prevent disease. Health promotion is imperative in EBP to decrease blood pressure and increase patient knowledge while improving patient health outcomes. Health promotion as a concept is supported by Nola Pender’s health promotion model (HPM) that is directed toward positive health outcomes, such as optimal well-being, healthy eating habits, and regular exercise (Tomey & Alligood, 2002). The project implementer (PI) explored this concept even further by focusing on healthy eating diet plans for hypertensive patients.

The project intervention was a pretest-posttest and DASH food frequency questionnaire design guided by the theoretical framework of Pender’s health promotion model. The tool chosen was validated in a pilot study of DASH “Fruits and Vegetables” classroom lesson included a five-question pre-and post-test as a tool for measuring the effectiveness of the lesson plan (Apovian et al., 2010). Hypertension is a chronic disease that is in the top three diagnoses of all outpatient clinic visits annually (Mahmood et al., 2018). The current body of evidence supports the integration of an educational overview on DASH to increase patient knowledge and management of HTN. This model was chosen to guide this EBP because healthcare providers are the most influential in motivating others to change their lifestyles (Petirin, 2015). Therefore, implementing an educational intervention to patients on the benefits of DASH in controlling HTN has the potential to reduce healthcare costs associated with co-morbid chronic health conditions to include morbidity, mortality, coronary artery disease, renal disease, cerebrovascular accidents (Jiang et al., 2015). The patients gained a better understanding of nutritional knowledge of DASH, influence lifestyle change, and created a more accepting and empathic learning environment with the implementation of this EBP (Petirin, 2015).

Pender invented the original HPM described in the first edition of the text, Health Promotion in Nursing Practice, published in 1982 (Tomey& Alligood, 2002). The significance of this model is to assist patients in understanding the significant determinants of health behaviors as a basis for promoting healthy lifestyles (Petirin, 2015). Tomey& Alligood (2002) suggest the importance of Pender’s health promotion model is directed toward positive health outcomes such as optimal well-being, healthy eating habits, and regular exercise. Pender believed that prevention of these health problems could improve the patient’s quality of life, and health care dollars could be saved by the promotion of healthy lifestyles (Petirin, 2015).

The HPM motivates people to make lifestyle modifications for a healthy lifestyle (Petirin, 2015). People are more likely to commit to and engage in health-promoting behaviors when significant others model the behavior, expect the behavior to occur, and aid and support to enable the behavior (Tomey & Alligood, 2002). The HPM is an excellent theoretical choice for the project because the evidence reports that hypertension affects more than 50 million people in the United States, with health care costs totaling 42.9 billion in 2010 (Sacks et al., 2001).

Hypertension (HTN), also known as the “silent killer,” affects one out of every three African Americans. The reason for the higher incidence of high blood pressure (B/P) in African Americans is unknown. On average, African Americans with high blood pressure have a much higher rate of stroke, heart failure, and other diseases than whites (CDC, 2018).

A clinical practice change project was designed and implemented to educate patients about a Dietary Approach to Stop Hypertension (DASH). This project focused on increasing patient knowledge and improving HTN management by lowering patient blood pressures. Patients were recruited from an outpatient clinic in Washington D.C. The participants consisted of 20 African American patients diagnosed with hypertension. A pre-posttest design and DASH food frequency tool was utilized and guided by the Nola Pender health promotion model and the ACE star model of knowledge.

The ACE star model of knowledge transformation was developed to offer a comprehensive yet straightforward approach to translate evidence into practice. The model emphasizes five crucial steps to convert one form of knowledge to the next and incorporate the best quantitative evidence with clinical experts and patient preference, thereby achieving evidence-based practice (Stevens, 2013). This model was chosen to guide the EBP in all phases.

Application to practice change

The model emphasizes crucial steps that will be used to allow evidence that can be translated into daily practice, such as DASH education. The ACE Star Model is one of the most used models when transforming evidence into daily practice (Star Model, 2015).

Discovery Evidence

This is the knowledge-generating stage (Star Model, 2015). In this phase, the PI will conduct a thorough integrative literature review that resulted in supporting this EBP. EBP quantitative data is a continuous process that continued throughout the life of the practice change project.

Evidence Summary

A systematic review and synthesis of research are performed, and knowledge is generated (Star Model, 2015). In this phase, the PI spent quality time analyzing and reviewing the latest evidence and research supporting the evidence-based clinical change project. A summary and synthesis of the findings indicate a DASH diet has been established as an effective modality to reduce blood pressure. Current evidence supports the lack of provider counseling on DASH and patient lack of knowledge concerning DASH benefits.

Translation to Guidelines

This point requires two stages that include a translation into practice recommendations and integration into practice. The aim was to provide a useful and relevant package of summarized evidence to patients in a form that suits the time, cost, and care standard (Star Model, 2015). This phase includes an educational overview to patients on DASH diet, selection of the best questionnaire to assess patient’s knowledge on DASH, and utilization of the most current guidelines for HTN management using JNC8 guidelines. The data supported the need to educate patients on effective HTN management and recommend incorporating DASH into their daily lifestyle (Schwingshackl& Hoffmann, 2015).

Guidelines were made effectively and enforced efficiently to make sure that patients would practice them and notice a change in their blood pressure routines. DASH is a useful guide for patients suffering from hypertension because it helps patients to rearrange their diet and turn it towards healthier. They will feel the difference because of the edition of calcium and other healthy minerals in their diet.

Practice Integration

This point involves changing both individual and organizational practices of HTN management, incorporating DASH diet into daily practice (Star Model, 2015). This phase included an educational overview on DASH diet to patients, educational posters, patient education booklets, and statistical data analysis where the PI made recommendations in support of the EBP that resulted in improved patient outcomes by bringing the best evidence into practice (Star Model, 2015). Although the purpose of DASH diet is to add healthier nutrients to one’s diet, the needs of patients having some other diseases will be different from patients who are only suffering from hypertension. The purpose was to integrate theory into practice effectively, and patients would be motivated to achieve expected results by aligning their consumption practices according to the suggested plan.

Evaluation

The impact of evidence-based practice on patient satisfaction, provider satisfaction, patient health outcomes, economic analysis, efficiency, efficacy, and health status was measured and analyzed. In this stage, there was an evaluation of the success and strengths of the project. This practice change project was focused on lowering patients’ blood pressures after receiving education by providers on how a DASH diet can help with the management of their hypertension. Patients’ knowledge was measured using five-question posttests and a DASH food frequency questionnaire. Questions were analyzed by comparing aggregate pre- and post-means. Also, individual question item analysis was completed to determine which questions the participants scored the highest and lowest on. The benchmark for this outcome was a 20% increase in post-test scores, an increase in better food selection and a decrease in patients’ blood pressure after the intervention. A four-week posttest was administered. DASH test aggregate means was computed. These means were compared with the first post-test results. The benchmark for the retention of knowledge was 80%. The findings related to this outcome is visually displayed by using bar graphs. The PI assessed the patient’s willingness to incorporate DASH diet. The PI also analyzed patients’ blood pressures before and after the intervention. This outcome was measured by a 5-point Likert-style question on each pre and post-test. The pre and post-test measured the patient’s knowledge about DASH before and after the education session; The benchmark associated with this outcome was 50%. The findings related to this outcome will be visually displayed by using graphs (Apovian et al., 2010).

In conclusion, a C-T-E structure supported the evidence-based practice change project. The concept, health promotion is any activity that tries to improve one’s health by providing increased awareness through education on the risk factors of hypertension and healthy eating habits. The chosen theory, Pender’s HPM, empowered individuals to make healthy lifestyle modifications (Petirin, 2015). A DASH food frequency tool questionnaire was utilized as the empirical indicator to evaluate the change in health promotion with African Americans diagnosed with hypertension. The ACE Star model of knowledge transformation guided the process. The CTE structure and evidence-based practice theory in this chapter provided a clear definition pathway of the concept, theory, and empirical indicator to support the practice change project (Petirin, 2015).

Review of the Literature

Review and synthesis of the literature revealed that education and the implementation of a healthy lifestyle are imperative in managing HTN and improving patient outcomes. DASH was created 20 years ago, and over 30 clinical trials support DASH’s effectiveness in lowering blood pressure across a diverse range of patients with HTN and pre-hypertension (Steinberg et al., 2017). In the United States (US), dietary patterns contribute to the incidence of HTN (Steinberg et al., 2017). The optimal goal in the management and treatment of HTN is to educate and treat patients to achieve and maintain blood pressure, however, a key obstacle is the lack of knowledge in patients diagnosed early with appropriate interventions, including therapeutic lifestyle changes (Apple, 1997). DASH diet is particularly beneficial in all populations and has proven to reduce systolic blood pressure (SBP) and diastolic blood pressure (DBP), respectively, by 13.2 mmHg and 6.1 mmHg among African Americans participants with HTN (Jiang et al., 2015).

In a systematic review and random-effects meta-analysis of 17 randomized controlled trials (RCT) Saneei et al. (2014) found that DASH diet had a beneficial effect on both systolic and diastolic BP. This study evaluated the effectiveness of DASH diet in 2561 participants. Meta-analysis showed that DASH diet significantly reduced systolic blood pressure by 6.74 mmHg and diastolic blood pressure by 3.54 mmHg. The blood pressure-reducing impact from DASH diet was more significant among men (Saneei et al., 2014). Harrison (2014) conducted an exploratory observational study with 114 participants to test a companion (web-based learning) to classroom nutrition education on DASH diet knowledge using this tool. At the completion of the study’s pre-and posttest, average scores ranged from approximately 34% to 78%, respectively.

Providers should strongly recommend DASH diet to all African American patients, with or without high blood pressure, and provide educational materials, which are readily available (Jiang et al., 2015). Barriers to patients incorporating DASH diet into their hypertensive management are lack of provider knowledge and training, and patients lack awareness of potential DASH benefits. Challenges that providers incur in nutritional counseling are an overbooked clinic, lack of DASH knowledge, increased willingness to prescribe medications rather than provide counsel of DASH (Steinberg et al., 2017).

Provider Counselling on DASH

Hicks and Murano (2016) conducted an exploratory study with a convenience sample (n=54) to ascertain if Texas physicians incorporated dietary counseling into their medical plan. Results revealed 89% of physicians do not incorporate nutritional counseling into their medical practice. The lack of dietary counseling by physicians can be explained by the fact that one-half of all medical schools offer 17 hours or less of nutritional education and 9% of medical schools have no nutritional-based training incorporated into the curriculum. Nutrition education is harder to obtain after medical school graduation (Aggarwal et al., 2018). Over half of the physicians surveyed (52%) reported that their practice did not counsel or promote patient nutritional counseling. There is evidence that supports a lack of physician-patient-directed nutritional counseling (Hicks and Murano, 2016). Continuing Medical Education (CME) nutritional offerings, as well as evidence-based nutritional classes, can bridge the gap in knowledge and increase nutritional interventions. Valderrama et al. (2010) conducted a survey (n=5,399) 25.8% had HTN, with 79.8% taking medications, with only 21% reported nutritional counseling by their provider. DASH diet has been utilized in the clinical setting to improve HTN; however, lack of provider-patient counseling results in inadequate patient knowledge. Therefore, dietary modalities are not being utilized as a modality to reduce HTN.

Several lifestyle interventions have been proven to reduce blood pressure (Weber et al., 2014). Favorable effects on SBP and DBP in adults due to DASH diet are of considerable public health importance because this dietary pattern can be easily adopted, has the greatest effect on men, and is cost-effectively aids in the prevention of HTN and its complications (Saneei et al., 2014). A DASH-like diet can knowingly reduce the risk for cardiovascular disease (CVD), coronary heart disease (CHD), stroke, and heart failure (HF) by 20%, 21%, 19%, and 29%, respectively (Salehi-Abargouei et al., 2013). Effective HTN management must include DASH counseling as a proven modality to prevent and aid in HTN treatment. Incorporating DASH counseling with HTN patients gives them the best possible chance to control and reduce their blood pressure, which will reduce end-organ disease. For all persons with hypertension, the potential benefits of a healthy diet can improve BP control and even reduce medication needs (James et al., 2014).

Dash diet

The first DASH diet clinical project by Apple et al. (1997) was a multicenter 11-week feeding study that assessed the effects of dietary patterns on blood pressure. The participants in the study included 459 adults over the age of 22 with systolic blood pressures of less than 160 mm Hg and diastolic blood pressures of 80-95 mm Hg (Apple et al., 1997).

At the beginning of the study, all participants consumed a control diet low in fruits, vegetables, and dairy products for three weeks (Apple et al., 1997). For the next eight weeks, the participants received either the control diet, a diet rich in fruits and vegetables, or a combination diet that included fruits, vegetables, and low-fat dairy with decreased total fat (Apple et al., 1997). The blood pressure reduction began within two weeks of initiation of the diet and was maintained for six weeks (Apple et al., 1997).

The blood pressure realized with the combination diet was similar in magnitude to that observed in trials of drug monotherapy for mild hypertension.

The results of DASH trial showed that a diet rich in fruits, vegetables, and low-fat dairy products, with reduced statured and total fat, lowered systolic blood pressure by 5.5 mm Hg and DBP by 3.0 mm Hg more than the control diet. DASH diet emphasizes foods rich in protein, fiber, potassium, magnesium, and calcium, such as fruits, vegetables, beans, nuts, whole grains, and low-fat dairy products. The study concluded that DASH diet reduces blood pressure.

Another randomized controlled trial by Blumenthal et al. (2010) compared DASH diet to a control diet randomized into two groups. The first group was DASH diet alone, and the other group was DASH diet with weight management. DASH alone group received only guidelines for their diet and were asked not to exercise. DASH weight management group received a controlled menu plan with cognitive behavior weight loss intervention and supervised exercise program sessions. The controlled group consisted of the participants’ usual diet. These participants were instructed to maintain normal diets for four months. The study spanned two weeks and included 144 participants over the age of 35 in a tertiary medical facility. Blood pressure measurement in the clinic was obtained using a manual cuff method. Measurement was obtained four times daily in each individual’s home environment with an automatic blood pressure machine and twice at night. The mean BP was used.

Food frequency questions were used for nutritional assessment. The questionnaire recalled typical consumption in a four-week period and four-day food diary. This study found that DASH diet both significantly lowered SBP (p < 0.001) and DBP (p < 0.001) compared to a control group. DASH with weight management also lowered SBP (p = 0.10) and DBP (p =0.06). At the end of the study, six participants were clarified as hypertensive in DASH with a weight management group and seven in DASH alone group. This study concluded that DASH was more effective in lowering blood pressure with exercise, but that DASH alone was effective in lowering blood pressure as well.

Another study that evaluated the effects of DASH diet was conducted by Azadbakht et al. (2005). It examined the effects of DASH diet on patients with metabolic syndrome. This study was different because the patients used a weight management intervention with DASH diet. This study enrolled 116 patients (34 men and 82 women) with metabolic syndrome. Three diets were prescribed for six months: a control diet, a weight-reducing diet, and DASH diet with a sodium restriction to 2,400 mg daily. The participants were overweight or obese and had not participated in weight reduction during the past six months. The study spanned six months of interventional feedings, and the patients were followed monthly. DASH diet resulted in higher HDL cholesterol (7 and 10 mm/dl), lower triglycerides (-18 and -14 mg/dl), lower systolic blood pressure (12- and -11-mm Hg), lower diastolic blood pressure (-6- and -7-mm Hg), and decreased weight (-16 and -15 kg) respectively (p <0.001). This study concluded DASH diet could likely reduce metabolic risk in men and women with metabolic syndrome.

Patient Behavior toward DASH

Seangpraw et al. (2018) performed another study that evaluated the effects of DASH diet. This study used behavior modification instead of weight management intervention. A quasi-experimental study was employed with two groups of elderly patients aged 60-80 in a rural community in Thailand. Ninety participants were in the intervention group, and 80 were in the controlled group.

The intervention group used behavior modification guidelines of DASH program with self-efficacy for three months, including a 45-minute group education meeting, a 25-minute group activity training session, and a 15-minute individual checklist. The controlled group received no intervention. DASH diet, along with behavior modification, showed increased self-efficacy while SBP and DBP had decreased (p = 0.002). The results showed that self-efficacy increased, as did awareness regarding the severity of complications of hypertension (Seangpraw et al., 20158)

In a 3-period randomized crossover trial in free-living healthy individuals who consumed in random order a control diet, a standard DASH diet, and a higher-fat, lower-carbohydrate modification of DASH diet (HF-DASH diet) for three weeks each, separated by 2-wk washout periods. Laboratory measurements, which included lipoprotein particle concentrations determined by ion mobility, were made at the end of each experimental diet. Thirty-six participants completed all three dietary periods. Blood pressure was reduced similarly with DASH and HF-DASH diets compared with the control diet. The HF-DASH diet significantly reduced triglycerides and large and medium very-low-density lipoprotein (VLDL) particle concentrations and increased LDL peak particle diameter compared with DASH diet (Chiu et al., 2016). DASH diet, but not the HF-DASH diet, significantly reduced LDL cholesterol, HDL cholesterol, apolipoprotein A-I, intermediate-density lipoprotein and large LDL particles, and LDL peak diameter compared with the control diet. In conclusion, the HF-DASH diet lowered blood pressure to the same extent as DASH diet but also reduced plasma triglyceride and VLDL concentrations without significantly increasing LDL cholesterol (Chiu et al., 2016).

DASH and Hypertension Management

Ozemek et al. (2018) noted that appropriate prevention and management of hypertension was supported by adopting a diet rich in plant-based foods with whole grains, low-fat dairy products, and low sodium in accordance with the recommendations of DASH diet. The Ozemek et al. (2018) review also found DASH diet was more effective when paired with dietary counseling. In comparison, three studies found benefits from DASH diet. In two studies, lifestyle modifications were added to DASH diet intervention and found a greater reduction in the systolic and diastolic blood pressures. The original DASH study showed favorable effects on the reduction of BP but did not test diet adherence. All studies found DASH diet to be effective in lowering blood pressure in participants. This was consistent with a meta-analysis conducted by Ndanuko et al. (2016), who compared several studies of dietary patterns in lowering blood pressure and concluded that DASH diet lowers blood pressure.

In a recent RCT investigating the effects of DASH diet on cardiovascular risk factors and providing information on the energy and macronutrient contents of both DASH and control interventions were included in the meta-analysis. The minimum duration of the RCT for inclusion in the meta-analysis was two weeks. An important inclusion criterion was that DASH and control diet interventions had to be comparable in terms of energy intake and other lifestyle interventions, e.g., physical activity. In other words, RCT was included only if both control and DASH diet interventions involved a similar degree of energy restriction and/or physical activity to avoid the confounding effects of changes in body weight on cardiovascular risk factors. In addition, RCT was included if they altered minor components of DASH interventions (e.g., modified DASH) but retained the core characteristics of the archetypical DASH dietary plan (Bricarello et al., 2018). Examples of DASH dietary plan modifications include reduction of salt intake, increased consumption of lean red meat, and combination with other interventions such as weight loss or physical activity. Similarly, RCT having either a typical dietary pattern or a healthier dietary pattern (healthy diet) as a control were included, provided that these patterns matched DASH intervention in terms of both energy intake and physical activity level. Finally, RCT was not excluded according to dietary Na intake, as information regarding this variable was not consistently reported across trials; this approach was intended to minimize the risk of publication bias (Bricarello et al., 2018).

In conclusion, DASH diet interventions resulted in significant improvements in systolic and diastolic BP along with significant reductions in total cholesterol and LDL concentrations. However, these interventions did not affect TAG, glucose, and HDL concentrations (Bricarello et al., 2018). The responses of both systolic and diastolic BP to DASH diet were greater in participants with higher BP or BMI at baseline. The responses appeared to be independent of differences in dietary Na intake. Importantly, measures of the effectiveness of DASH diet were not modified by the type of study design or feeding protocol and the characteristics of control diet (Bricarello et al., 2018).

According to Challa et al., (2020), DASH diet is an essential strategy for lowering blood pressure in patients with diabetes mellitus type 2. The American Diabetic Association recommends that patients with diabetes who are at risk should achieve the US Department of Agriculture’s Dietary Reference Intake (DRI) for fiber, whole grains, and macronutrients. Moreover, these patients should limit saturated fat to < 7% total daily calories, reduce trans-fat intake, reduce cholesterol to < 200 mg/day, and limit sugar-sweetened beverages. Because DASH diet meets these recommendations, adherence in patients with diabetes mellitus should be advocated for adequate blood pressure control (Challa et al., 2020).

Based on these studies, it is safe to say that when combined with pharmacological intervention, DASH can be a very useful tool for physicians to tackle these diseases more efficiently (Challa et al., 2020). When compared to some other diet patterns, it has the added advantage of having clear guidelines on the serving sizes and food groups, which makes it easier for the physicians to prescribe and monitor their patient’s improvement (Challa et al., 2020).

Patient education

There are several methods of offering patient education. One of the most cost-effective means is face-to-face counseling. This technique lets providers answer questions without delay in communication. According to Magadza et al. (2009), a pamphlet is a cost-effective way to provide education in summary. Magadza et al. (2009) evaluated the patient’s understanding of HTN using motivational intervention questions. In their study, 45 patients were interviewed and completed a questionnaire. This study showed that educational intervention could positively impact patient adherence. The participants received a questionnaire pre- and post-education. The questionnaire was composed of four parts: the concept of HTN, antihypertensive medication, adherence to medication, and diet and lifestyle recommendations. In their case-controlled study, they found motivational interviewing and questionnaires increased participant knowledge about HTN and the importance of medication. These findings suggest that patient education provides patients with the opportunity to have questions answered, thus improving adherence to education.

Delichatsios and Weity (2005) performed a study on providing participants with resources to improve dietary habits. The resource was a dietary patient education booklet that focused on fruits and vegetables, red meat, and dairy foods. Booklets were mailed to patients’ homes. The patient then had two motivational counseling sessions by telephone at two-week and four-month intervals. For the control group, their servings were increased by an average of 1.1 servings per day compared to 0.3 serving per day for the intervention group. The finding showed no changes in the amount of red and processed meats.

The intervention group increased fiber by 1 gram per day. The study concluded that 71% of the participants discussed the educational booklets with their primary care providers. This study addressed a lack of time in the primary care setting and alternative means of educating by mailing booklets and having telephonic follow up (Delichatsios & Weity, 2005).

Wong et al. (2015) performed a study on 556 Chinese patients who were newly diagnosed with hypertension. The participants received DASH-based dietary counseling tailored to a Chinese diet and were given 25-minute dietary counseling and DASH diet pamphlets. The outcome data were evaluated after six months and showed lower blood pressure. Wong et al. (2015) concluded that a self-monitoring tool that reinforces the implementation of dietary counseling would be more effective.

Summary

A literature review confirmed the existence of a hypertension problem in the African American community as well as the overall efficacy of DASH. A review and synthesis of the current literature support DASH as an evidence-based patient education tool used in the management of patients with HTN to improve patient outcomes. DASH is an effective way to reduce blood pressure. Lifestyle modifications recommendations of diet and exercise can be difficult if patients are not given specific guidelines. Diet and lifestyle changes are more effective when healthcare providers give patients clear and concise guidance. DASH intervention offers patients clear dietary guidance and assists with meal planning. DASH can significantly impact HTN, especially in the African American population, and should be used as a primary intervention to decrease HTN.

Hypertension continues to be a worldwide health problem. HTN is one of the most common conditions treated in primary care and can lead to myocardial infarction, stroke, renal failure, and death if not detected early and treated appropriately (Oza&Garcellano, 2015). Quantitative data suggests that HTN rates in African Americans are higher than any other ethnic group, and BP control remains inadequate in this population. DASH dietary pattern can be easily educated and adopted by all population groups offering the most cost-effective intervention to serve as the primary and secondary prevention of elevated blood pressure and its complications (Saneei et al., 2014).

Advantages and disadvantages of findings

DASH diet has been shown to reduce both systolic and diastolic blood pressure in hypertensive and pre-hypertensive patients across subgroups, genders, races, and ethnicities. Further studies have found that adherence to DASH diet improves changes in cholesterol and reduces the risk of coronary heart disease and stroke. DASH diet has shown eating whole foods, rather than processed foods, lowers blood pressure due to their lower sodium content. DASH diet is beneficial, is well tolerated in these studies, and has yielded results with positive health outcomes in reducing blood pressure, with or without other interventions. The literature review of DASH diet, however, has shown that DASH diet is not well followed and that there is low adherence to DASH diet. Increasing adherence to DASH diet and improving education and implementation of the diet poses a challenge.

Utilization of findings in practice

Promoting a DASH diet education is vital for the clinician to encourage and motivate patients to make lifestyle changes in dietary choices and to develop ways to improve adherence and education on DASH diet. One can tailor these implementation strategies to improve adherence by translating some of the clinical findings into practice. One way to do this is by providing more DASH diet educational material to patients. Another suggestion is to provide more DASH diet education on initial clinic visits. A further solution is to offer DASH diet educational counseling, along with DASH diet material, to improve knowledge and awareness of DASH diet. These DASH diet pamphlets can be reproduced and utilized in other outpatient clinics.

Providing patient education in a primary care setting through face-to-face counseling is a cost-effective means. This technique allows providers to answer questions without delay in communication and to follow the discussion with a pamphlet. Providing a pamphlet while imparting educational information lifestyle changes increases the retention of information (Magadza et al., 2009).

Many healthcare providers are not educating patients on the recommended dietary guidelines for HTN (Sessoms et al., 2015). Therefore, the clinician needs to encourage patients to make lifestyle changes in dietary choices and to develop a DASH diet education session, along with pamphlets that will increase DASH diet knowledge and awareness for both patients and providers. Lack of preparation and understanding of dietary details affect patient’s motivation to adopt DASH plan and practice it. There are numerous strategies that can be used by healthcare practitioners can use to help patients integrate DASH plan into their routines, such as an educational role where healthcare practitioners can work with teachers and role models for patients to practice the dietary plan of DASH. They can also work as organizers to improve the dietary information and understanding of people by organizing public seminars and by working with professional societies. The pool of nutritionists can also be arranged to make recommendations about DASH diet plans for patients. Not only for patients, but the nutritionist pool can also help healthcare practitioners to learn techniques for dietary recommendations. Healthcare practitioners should be trained enough to help patients with dietary balance because too much emphasis on the theoretical aspect of the knowledge will affect the practice ratio. Training for nutritionists is important for the translation of dietary recommendations in the form of practical advice that patients can adapt conveniently(PR, 2018). Implementing this project will be beneficial to patients in the outpatient clinic setting, and it will increase their knowledge and awareness about DASH and will subsequently improve hypertension outcomes.

Methodology

Hypertension (HTN) is the leading preventable cause of premature death worldwide (Mills et al., 2016). In hypertensive individuals, lifestyle modification can serve as an initial treatment before the start of drug therapy and act as an adjunct to pharmacological therapy in persons already on drug therapy (Appel, 1997). The purpose of this quantitative quasi-experimental project was to determine if or to what degree the implementation of a Dietary Approach to Stop Hypertension education intervention for patients would impact the blood pressure readings of patients diagnosed with hypertension at an outpatient health clinic in Washington, D.C. over a four-week period of time. To evaluate this effect, it was necessary to design a robust study that would formalize the variables analyzed and determine the relationships between them. To that end, this chapter will present the study’s methodology, including the paradigm, sampling, data analysis, and other critical components.

Statement of the Problem

High blood pressure (HBP) prevalence in African Americans in the US is among the world’s highest. Many of non-Hispanic African American men and women have high blood pressure. High blood pressure also occurs earlier in life and is typically more extreme for African Americans (Maraboto & Ferdianand, 2020).

Uncontrolled hypertension (HTN) in the USA is particularly prevalent and devastating among Black people who are more vulnerable than people from other racial/ethnic groups to the effects of this disease. Moreover, the findings of evidenced-based data in this population are frequently underrepresented in cardiovascular clinical trials, restricting their ability to apply them accurately. In this analysis, we summarized and examined the information that is currently available regarding risk factors, manifestations, complications, and HTN management in this often difficult-to-treat population. This practice change project seeked to better understand to what degree of increasing patient’s knowledge on DASH diet is the best approach for the treatment of patients with hypertension (Maraboto & Ferdianand, 2020).

Health organizations urge healthcare providers to participate in programs that help patients control high blood pressure (CDC, 2017). Lifestyle changes recommendations to treat HTN include weight management, exercise, and diet (Yang et al., 2015). Many patients do not adhere to the recommendations because of insufficient education. Educating patients about lifestyle modifications can have a significant impact on their beliefs about hypertension (Yang et al., 2015). Patel et al. (2016) indicated that lack of education was a common reason that patients did not adhere to diet education.

There are many barriers to the management of patients with hypertension, and one that is seen daily by health care providers is the lack of patient education. It was not known if or to what degree the implementation of a Dietary Approach to Stop Hypertension (DASH) intervention education program would impact the patients’ blood pressure when compared to no intervention among African American patients diagnosed with hypertension in an outpatient clinic in Washington, D.C.

Clinical Question

The primary objective of this practice change project is to determine if a diet approach that emphasizes rich fruits, vegetables, and low fat significantly reduces the development and increased the management of HTN among African Americans. The DPI also evaluated if lifestyle practices such as exercise and physical therapy significantly reduced the development and management of HTN among black Americans. The PICOT question was: Does the implementation of a Dietary Approach to Stop Hypertension education intervention for patient’s impact blood pressure readings for patients diagnosed with hypertension at an outpatient clinic in Washington, D.C. over a four-week period of time?

The following clinical question guided this quantitative project:

CQ: To what degree does the implementation of a Dietary Approaches to Stop Hypertension education intervention for patient’s impact blood pressure readings for patients diagnosed with hypertension at an outpatient clinic in Washington, D.C. over a four-week period?

The independent variable was defined as the implementation of a Dietary Approaches to Stop Hypertension education for 20 African American adult patients with hypertension. The dependent variable was defined as mean systolic and diastolic blood pressure before and after the intervention. The question leads to a search for the best evidence that can contribute to a decision about the patient’s care (Harmic, 2009).

This DPI project employed a pretest-posttest design guided by the theoretical framework of Pender’s health promotion model. All patients were given a 20-minute educational overview on HTN and the effectiveness of DASH diet. There was a 5-question pre-posttest designed by DASH and a DASH food frequency questionnaire tool given to patients about DASH diet. Providers counseled and educated patients with hypertension about DASH, and patients’ blood pressures were evaluated before and after the intervention of DASH diet. DASH was created 20 years ago, and quantitative data demonstrate it consistently lowers BP across a diverse range of patients with HTN and prehypertension (Steinberg, Bennett, &Sevetkey, 2017). Barriers to patients incorporating DASH diet into their hypertensive management were lack of provider knowledge, and training and patients lack awareness of the potential benefits of DASH diet as a means of hypertension management.

Project Methodology

A clinical practice change project was designed and implemented to educate patients diagnosed with hypertension about DASH. This project focused on increasing patient knowledge and improving HTN management. Patients were recruited from an outpatient clinic in Washington, D.C. The participants consisted of 20 African American adults diagnosed with hypertension. A pre-posttest design and DASH food frequency questionnaire was utilized and guided by the Nolan Pender, health promotion model.

Quantitative methods are most appropriate in the following circumstance: a) clearly defined study variables. b) large sample size available in a cost-effective manner, c) validated instrument available for data collection, and d) a desire to generalize study findings (Leedy, Ormrod, & Johnson, 2019). Quantitative data follow a linear sequence in obtaining answers to quantitative questions (Polit & Beck, 2017). Quantitative methodology was most appropriate for this DPI project, as the focus of quantitative data was to determine the relationship or trends between independent and dependent variables (Polit & Beck, 2017).

The quantitative research method was used for this project because it provided quantifiable and easy to interrupt results. Results of the project interpreted through the quantitative research method helped readers to differentiate what was expected and what was obtained. The quantitative research method was divided into good and bad aspects of the dietary approach and made it clear where to put major focus to solve the problem. This approach, compared to other research methods, helped us to find out the frequency of the phenomena. Such as at the end of the project, we were able to understand the severity of the problem and its outcomes.

Population and Sample Selection

The target population for the study consists of African Americans, both within Washington, DC, and across the United States. Maraboto and Ferdianand (2020) find that their cardiovascular health indicators are mostly homogeneous across the nation. They are all liable to develop hypertension and could benefit from a lifestyle intervention that would reduce this probability. As such, the results of the study may be applied for all of them, reducing their blood pressure and the danger that they are facing.

The target population for this EBP practice change was African American patients between the age of 18 to 65 diagnosed with hypertension. The beneficiaries seen in this clinic include all patients that have been diagnosed and are currently being treated for HTN. The clinic is made up of 95% African Americans. A convenience sample of 20 patients diagnosed with hypertension volunteered from the outpatient clinic in Washington, D.C. All of them qualified for the study, and none were rejected.

Participant’s personal information nor protected data was recorded. The target patients were identified through the clinic’s electronic health record reports. Only patients that were fluent in English was be asked to participate in the project. Medical contraindications for blood pressure measurements in either arm (i.e., double mastectomy, poor circulation, arteriovenous shunt) were excluded from the DPI. With that said, the check found none of the patients had such contraindications, qualifying the entire sample for the intervention and subsequent analysis.

Recruitment strategies included email, verbal and written announcements, and invitations. Patients were emailed through the patient portal in the electronic health record by clinical staff. Other strategies included posters that were posted outside the clinic door and building. All of the recruitment methods featured detailed explanations of the purpose and method of the study meant for the patients to familiarize themselves with the study before consenting to participate in it. They also mentioned that the intervention would be held in-person at the clinic to ensure that the patients were aware of the COVID-related risks.

Instrumentation

The evidenced-based evaluation tool that will be used in this quality improvement project is a DASH validated food frequency questionnaire in DASH Eating Plan manual from the National Institute of Health (NIH, 2006). The pre-intervention questionnaires were to assess their knowledge and belief of DASH diet pre-intervention. The post-intervention questionnaires were to evaluate the effectiveness of education by re-evaluating knowledge and belief after DASH education. The post-intervention questionnaires were administered at the end of the four-week session. The post-intervention evaluated the effectiveness of DASH diet session. Blood pressure measurement were taken pre-and post-educational intervention by the clinic’s staff. Blood pressure were measured pre-intervention and post-intervention to allow adequate time for adjustment. The blood pressure was taken using a mercury manual sphygmomanometer. A blood pressure reading by auscultation was considered the gold standard according to (National Heart, Lung, And Blood Institute [NHLBI], 2017). Blood pressure was measured in the left and right arms in the sitting position. Medical contraindications for blood pressure measurements in either arm (i.e., double mastectomy, poor circulation, arteriovenous shunt) was excluded from the DPI. Blood pressures were taking in the morning on arrival. The patient’s blood pressure was documented in the electronic health record in the vital signs section. The blood pressure was measured to evaluate if a significant reduction in blood pressure is obtained in the patients that followed DASH. Blood pressures were recorded on paper, then entered on an Excel flow sheet in the computer system.

Validity

The plan for evaluation of this practice change project was to administer a five-question pre-and post-test measuring the effectiveness of the lesson, educating patients on the use of DASH diet for HTN management, and measuring patients’ blood pressures before and after the intervention. The validated DASH pre-post-test and DASH food frequency tool was free to use and did not require the author’s permission to use it. DASH food frequency questionnaire, created by DASH for Health team, was initially used in an online format and validated against the well-known Block Food FFQ by Apovian et al. (2010). The Block FFQ and DASH online questionnaire (OLQ) were found to have significant positive correlations among all eleven DASH food groups (Apovian et al., 2010). Weighted kappa statistics found the level of alignment between DASH OLQ and the Block FFQ by energy level to have a value of 0.48 (95% CI 0.38, 0.57; P < 0.0001), meaning the moderate agreement was observed (Apovian et al., 2010). DASH food frequency questionnaire is based on a diet recall from the previous 24 hours only and encompasses 11 dietary categories with additional questions to determine sodium and fat intake (Apovian et al., 2010). The estimated time for the questionnaires took participants approximately 20 minutes to complete and was given on paper. DASH questionnaire tools are free for public use (NHLII, 2006). As Apovian et al. (2010) find, they also correlate to other well-established tools and provide an overall adequate method for evaluating one’s dieting habits.

Reliability

The reliability of the project depended on the information used by the PI to support the project. All the research and literature used for the project are reliable and effective that ensures that the project is reliable and trustworthy, offering accurate information to readers and giving realistic and practicable guidelines and translations for patients. The reliability of the project was also evaluated by the results of the project that have shown positive results. The internal consistency of DASH is strong enough that it is proved through the relevant domains and results of the questionnaire.

Data Collection Procedures

The DPI student stored and secured the intake data for all participants. The demographic data collected for this project included the following: 1) age, 2)ethnicity, and 3) gender. Other demographics that were collected from the electronic health record are the participant’s systolic and diastolic numbers of patients that are diagnosed with hypertension and participated in the DPI. Onsite de-identified data was collected by the clinical staff. The clinical staff provided the education intervention and give the pre-posttest to patients before and after the education intervention. The clinical staff also obtain de-identified blood pressures from patients at the beginning and end of the quality improvement project. Data collection also include the number of hypertension patients that received the counseling for DASH diet during their visit to the clinic. Clinical staff included Registered Nurses and Medical Assistants.

The questionnaires were placed in a labeled folder and placed, secured, and locked in a file cabinet. The intake surveys and questionnaires were coded with a number, and each participant will be given a separate number that will not contain any identifying patient information. All data collected remained secured until the data was entered into the Excel spreadsheet and the SPSs program. Once the DPI project was completed, the pre-post questionnaires will be shredded in the office locked shred box six months after intervention and sent out for bulk disposal. The SPSS Excel information was stored on the designated office computer that required a username and password for access. The Excel spreadsheet was also password protected to prevent manipulation by third parties. As such, only the researcher could access it, collecting and processing the pertinent information.

Data Analysis Procedures

To answer the clinical question, “Does the implementation of a Dietary Approaches to Stop Hypertension education intervention impact African American patients diagnosed with hypertension at a primary health clinic in Washington, D.C. over a four-week period?”, SPSS statistical software was used to examine the correlation between the independent and dependent variables.

The independent variable was defined as the implementation of a Dietary Approaches to Stop Hypertension education session for patients that are diagnosed with HTN. The dependent variable was the blood pressure measurements of patients identified in the QI project at the primary health clinic in Washington, D.C., over a four-week period.

The patient’s blood pressures before and after the intervention were entered into an Excel spreadsheet. Data analysis was performed using SPSS statistical software. The research department of clinical investigation at the clinical site provided statistician assistance. At the end of the four-week evaluation, the post-test scores were compared to prior post-test scores using descriptive statistics and a T-test to compare retained knowledge and rate of DASH counseling with a percentage value of.05 as the benchmark. This project did not reach statistical significance; therefore, a percentage change was collected from the pre-and post-test to determine the amount of knowledge gained and the number of patients’ blood pressures was measured. This data provided the information to ascertain if the intervention of DASH from patients had a positive patient outcome for those patients diagnosed with HTN over the four-week period.

Collected data is presented in tables and pie and chart graphs and analyzed by the computer software statistical package (SPSS version 27) using appropriate statistical methods. Frequency means and standard deviation was utilized to summarize the data. Categorical data was analyzed by using the chi-square test. Descriptive frequency and statistics were used to compute demographics. An overall increase in the proportion of participants who adhered to DASH guidelines in their diets was expected. This change was then evaluated to determine whether it was significant from a statistical perspective.

Potential Bias and Mitigation

As the quantitative method is used to conduct this project thus the possibility of the happening of bias is higher. The internal validity of the project is determined by the analysis of project results and methods used to record these results. And thus, the validity is higher and according to expectations that show there is no intentional bias in the project. There are some limitations that might affect the validity of the project and expected outcomes. Even the sampling population is not biased because the whole population are African Americans. The age group of participants is different but did not cause differences in them. Data analysis was also based on neutral interpretation to make sure that there is no bias and favoritism for any age group or participants of the project.

The data that collected was age, gender, and ethnicity of the participant. For the participants who had hypertension, we collected their systolic and diastolic numbers. The data was collected using a questionnaire to answer the clinical question “Does the implementation of a Dietary Approach to Stop Hypertension education intervention impact African American patients diagnosed with hypertension at a primary health clinic in Washington, D.C. over a four-week period?” Data on patients’ blood pressure was entered into Excel spreadsheets before being analyzed using SPSS software. At the end of the four-week evaluation, the posttest scores were compared to prior pretest scores and diastolic and systolic blood pressures before and after DASH counseling using descriptive statistics and T-test to compare retained knowledge and rate of DASH counseling with a percentage value of.05 as the benchmark.

Potential bias in data collection exists where participants fail to give accurate data on their age, gender, or ethnicity. During the collection of diastolic and systolic numbers, bias exists as the numbers can be taken as inaccurate. Bias did not exist during analysis and as there was no mismatch of data during entry to the spreadsheets. To ensure that bias was addressed, data was counterchecked before it was be entered as the final figure.

Ethical Considerations

The principles of the Belmont Report, respect, beneficence, autonomy, and justice will always be implemented (Polit & Beck, 2017). Anonymity will be achieved with de-identifiers to protect patient Health Information Portability Privacy Act (HIPPA) protected health data. All data collected was kept in a locked drawer in the PI’s office until project completion. De-identified data was transferred from the EHR to a password-protected Excel spreadsheet for storage. Any protected health information was shredded using the clinical practice site resources.

This DPI project involved minimal risk with the design (Polit & Beck, 2017). This DPI project did not increase the risk to participants any more than the standard of care. The purpose of this quantitative quasi-experimental project was to determine if or to what degree the implementation of a DASH education intervention for patients would impact blood pressure readings for patients diagnosed with hypertension at an outpatient clinic in Washington, D.C., over a four-week period of time. The quasi-experimental project was chosen to evaluate if patient education about DASH diet decreases blood pressures in patients with HTN. Patient information was collected from the electronic health record, which requires a password to gain access. IRB and site approval obtained.

Limitations

With the ongoing global pandemic, there are limited access to healthcare facilities; hence the desired number of participants was not obtained. There were issues regarding patients not completing the necessary pre-posttests needed for the DPI or DASH education to patients during their visit. The location was also limited to one clinic, which may mean that the sample’s performance is skewed relative to the total population because of the clinic’s practices. Biases also have to be considered, particularly social desirability bias. As DASH will be promoted to the participants as a positive intervention with few drawbacks, they should develop the understanding that they are expected to adopt it. As a result, even if they do not do so, they may omit items that they think would be in disagreement with the approach. Combined with other problems, such as forgetfulness, these limitations represent the possibility of significant data misrepresentation that needs to be considered.

Delimitations

Delimitations include the DPI only being conduct at one outpatient clinic. Also, only African American adults between the age of 18 and 65 years of age enrolled at the university with no prior education about DASH diet participated in the project. As such, there is no control group to confirm that the change has resulted from the adoption of DASH. Patients with contraindications (i.e., double mastectomy, poor circulation) were excluded from the project. The patient clinic population is 95% African Americans, which prevents a comparison between different racial and ethnic groups to determine the influence of diets on the prevalence of hypertension.

Summary

In conclusion, a conceptual-theoretical-empirical structure was created to support an evidence-based practice change project. The concept, health promotion is any activity that tries to improve one’s health by providing increased awareness through education on the risk factors of hypertension and healthy eating habits. As evidence highlighted, DASH has the potential to address this problem through clearly-defined, effective dietary guidelines. The chosen theory, Pender’s HPM, empowers individuals to make healthy lifestyle modifications. DASH food frequency questionnaire served as the empirical indicator to evaluate patient knowledge and examine how it relates to the change in health promotion with African Americans diagnosed with hypertension.

The ACE Star model of knowledge Transformation guided the process. The CTE structure and evidence-based practice theory in this chapter provided a clear definition pathway of the concept, theory, and empirical indicator to support the practice improvement project. The entire project advocated for proper dietary habits and a healthy lifestyle to reduce the risks of getting hypertension and improving the management of hypertension.

The purpose of this chapter was to provide an overview of the implementation process for this EBP. Hypertension is a common diagnosis within this outpatient clinic. DASH diet has been established as a useful modality to reduce blood pressure. Current evidence supports lack of provider counseling on DASH and patient lack of knowledge concerning DASH benefits. The clinical site was assessed for its HTN population and current treatment modalities. Through a retrospective chart review, it was identified that HTN patients were being managed primarily with pharmacological agents with little or no documentation on diet and lifestyle modifications. Addressing conjunctive HTN management such as DASH gives the patients a better chance at optimal blood pressure instead of pharmacological agents alone. This EBP has the support of key stakeholders and the opportunity to improve patient outcomes.

The data analysis was simple due to the nature of the information that was collected. The patients’ compliance with DASH (expressed through descriptive frequency) and blood pressure level were measured before and after the intervention and compared at these two points. The chi-square test was used to compare the means of the two datasets and determine whether the changes were meaningful. The results of this analysis are described in the next chapter.

Data Analysis and Results

The quality improvement project aimed to evaluate the effectiveness of DASH diet education in the nutritional plans of hypertensive patients at an outpatient primary care clinic. To that end, it gathered numeric information and conducted a quantitative analysis of it. The data collection process produced two sets of data, one describing the patients before the intervention and the other one, after it. The two sets were then compared and investigated for the presence of any meaningful differences. The project increased patient awareness and knowledge of DASH diet, and its relationship with blood pressure improvements, food selection and DASH awareness. This project determined that DASH education was effective in implementing a change in diet education in the outpatient clinic and increased self-efficacy in hypertensive patients by changing food habits that can promote better blood pressure management.

The practice change project’s primary objective was to determine if a diet approach that emphasizes rich fruits, vegetables, and low fat significantly reduces the development and increased the management of HTN among African Americans. The quality improvement project also evaluated if lifestyle practices such as healthy food options significantly reduced the development and management of HTN among black Americans. The PICOT question is: Does the implementation of a DASH program intervention for patient’s impact blood pressure readings for patients diagnosed with hypertension at an outpatient clinic in Washington, D.C. over a four-week period of time?

A clinical practice change project was designed and implemented to educate patients about DASH. This project focused on increasing patient knowledge and improving HTN management. Patients were recruited from an outpatient clinic in Washington, D.C. The participants consisted of 20 African American adults diagnosed with hypertension. A DASH pre-posttest design was utilized and guided by the Nolan Pender, health promotion model.

This chapter will discuss the methodology or design as to exactly how the project was carried out. It includes: 1) project purpose; 2) project management, that will cover organizational readiness for change, interprofessional collaboration, and organization approval process; 3) informational technology that was used to implement the project; 4) plans for Institutional Review Board approval and process obtained; 5) project evaluation that includes demographic information collected; 6) defining and discussing the outcome measurements; and 7) a discussion of the evaluation tool used to evaluate outcomes.

The target population for this EBP practice change was African American patients between the age of 18 to 65, patients diagnosed with hypertension. The beneficiaries seen in this clinic include all patients that have been diagnosed and are currently being treated for HTN. The clinic is made up of 95% African Americans. A convenience sample of 20 patients diagnosed with hypertension participated from an outpatient clinic in Washington, D.C. The best approach for this DPI project was a quantitative pre-posttest to answer the clinical question. Taking the pre-test at the beginning, patients were not expected to know the answers to all the questions; however, they were expected to utilize previous knowledge to predict rational answers.

Descriptive Data

The participants recruited were 20 African American adult patients of age between 16-85 that use the primary care clinic with a diagnosis of hypertension identified through the electronic medical records quality improvement reports. 12 of them were female, and the other 8 were male. The project was limited to English-speaking African American adult patients with a diagnosis of hypertension. The participant’s ages, races, and ethnic backgrounds were being collected. The participants were asked to provide gender identity. This information was collected using an intake survey tool. The results are illustrated with the use of graphs, bar charts, pie charts, and a table format.

The purpose of collecting data was 1) to determine if the nutritional educational intervention had a significant effect on knowledge, understanding, and retention of DASH diet. 2) To determine if the intervention will increase patient educational knowledge of DASH. 3) To determine the likelihood that patients will follow DASH recommendation. 4) To determine if the patient will be able to adopt recommendations. 5) To evaluate the effectiveness of an education program in changing patient behavior 6) To determine if a decrease in systolic and diastolic blood pressure could be achieved post DASH education. Evidence has shown that lifestyle change and teaching of DASH improved a patient’s hypertensive state, increased knowledge about DASH, and increases healthier food choices. These outcome measures are to promote healthy eating following DASH diet education to improve blood pressure from patients that follow the diet plan. Blood pressure will be taken pre-DASH diet initiation and post-DASH diet initiation. Studies have shown that following DASH diet has lowered blood pressure, systolic, and diastolic in people with hypertension. According to National Heart, Lung, And Blood Institute (2017), there could be an 8-14 mm Hg reduction in blood pressure. Lifestyle modification has been useful in the control of hypertension through a healthy diet (AHA, 2015).

Data Analysis Procedures

Collected data is presented in tables and pie and chart graphs and analyzed by the computer software statistical package (SPSS version 27) using appropriate statistical methods. Frequency means and standard deviation will be used to summarize the data. Frequency means can be used to represent patient adherence to DASH, which is derived from their answers to the survey. Standard deviation was used to characterize the samples and determine whether there was homogeneity among them. Categorical data was analyzed using the chi-square test. It enabled the determination of whether the changes that occurred after the educational intervention were meaningful. Descriptive frequency and statistics were used to compute Demographics.

All intake data was stored and secured. The Primary Investigator placed both the pre-questionnaire and post questionnaire in a vanilla folder and placed them in the locked filed cabinet with a secured, locked door. The intake surveys and questionnaire were coded with a letter and numbers, and each participant will be given a separate number. The questionnaire was stored in a secured place until the data were collected and entered in the Excel spreadsheet and the SPSS program. The pre/post questionnaires will be shredded in the private office shredder and sent out for bulk disposal 60 days after the project is completed. The SPSS and excel information were stored on the private department drive.

Results

The clinical question was whether the intervention would help the patients reduce their blood pressure level through conscious behavioral change. DASH project showed an increase in the participants’ knowledge and awareness of DASH and its relationship to blood pressure and a decrease in participants’ systolic and diastolic blood pressures. Post-DASH food frequency questionnaires indicated that participants had changed some dietary habits during their participation in DASH education.

Table 1: Gender
		Frequency	Percent	Valid Percent	Cumulative Percent
Valid	Male	8	40.0	40.0	40.0
	Female	12	60.0	60.0	100.00
	Total	20	100.00	100.00

There was a total of 20 participants in the DPI project that consisted of 60 % females (N=12) and 40% males (N=8).

Table 2:Ethnicity
		Frequency	Percent	Valid Percent	Cumulative Percent
Valid	African Americans	20	100.00	100.00	100.00

All participants in the DPI project where African Americans (N=20).

Table 3: Participants Pre-and Post-DASH Intervention Blood Pressure Measurements

Descriptive Statistics
		Pre-Education Systolic BP	Post-Education Systolic BP	Percentage Of Systolic Change	Pre-Education Diastolic BP	Post- Education Diastolic BP	Percentage Of Diastolic Change
N	Valid	20	20	20	20	20	20
N	Missing	0	0	0	0	0	0
Mean		133.70	131.30	-1.7755	93.30	90.20	-3.3175
Median		132.00	130.00	-2.1400	94.00	90.00	-4.1250
Mode		130	130	-4.41^a	86^a	84^a	.00
Std. Deviation		7.767	6.027	2.92208	6.997	6.187	3.66082
Skewness		-.036	.310	.345	-.035	.121	.354
Std. Error of Skewness		.512	.512	.512	.512	.512	.512
Kurtosis		-.628	-.450	-1.040	-1.535	.127	-.937
Std. Error of Kurtosis		.992	.992	.992	.992	.992	.992
Minimum		118	122	-5.71	82	78	-9.30
Maximum		146	144	3.39	104	104	2.44
a. Multiple modes exist. The smallest value is shown

The sample consists of 20 individuals whose systolic BP and diastolic BP is recorded, once before the education and once after the education. If we look at the Systolic BP levels, the sample had a mean of 133.70 mmHg before undergoing the education. The sample mean for systolic BP declined to 131.30 mmHg levels post the education program. The median systolic BP level also declined by 2 mmHg post the education for the sample. The mode systolic BP level remained unchanged at 130 mmHg that means most people having 130 mmHg of systolic BP level in the sample, in the pre-education and post education. If we look at the percentage change in Systolic BP levels of the sample from pre-education to post education periods, we observe that the mean change of Systolic BP declined by about 1.78%. Thus, the education reduces the levels of systolic BP by about 2% for the sample observations. The Standard deviation pre- education is high, which means the values are far from the mean but if we see post- education the SD becomes low than before from 7.767 mmHg to 6.027 mmHg that is a good sign. If we look at the skewness of the data then the data is negatively skewed in pre-education and post-education the skewness becomes positive, when skewness becomes 0, we can say that the data is normally distributed. Similarly, if we look at the maximum and minimum in systolic BP the minimum increased in post-education by 4 mmHg from 118 mmHg to 122 mmHg, the maximum also decreased by 2 mmHg.

Next, considering the Diastolic BP levels, we see that the diastolic BP level mean declines from 93.40 mmHg to 90.20 mmHg, after the education program. The median diastolic BP levels also fall post education by almost 4 mmHg. The mode diastolic BP levels decline from 86 mmHg to 84 mmHg, which is also a great sign for the education program. If we look at the percentage change, the mean change of diastolic BP levels declined by 3.3%. This shows how effective the education program was. The standard deviation for post education program, for both diastolic and systolic BP levels decline meaning, the data tends to get more towards the mean, which is a great sign, and the probability of eliminating outliers is high once the individuals go through the education program. If we look at the skewness of the data in pre-education the data is negatively skewed (-0.035) it is near to zero means normally distributed but if we see after the education, then the data is positively skewed (0.121). Similarly, if we look at the maximum and minimum in Diastolic BP the minimum decreased in post-education by 4 mmHg from 82 mmHg to 78 mmHg, the maximum remained same. The mean, median Declined percentage is high in Diastolic BP. Also, minimum percentage is high in Diastolic BP.

Table 4: Response to Food Frequency Questionnaire Pre and Post DASH Intervention Descriptive Statistics
		Before event Grain consumption	Before event Vegetables consumption	Before event Fruits consumption	After event Grains consumption	After event Vegetables consumption	After event Fruits consumption
N	Valid	20	20	20	20	20	20
N	Missing	0	0	0	0	0	0
Mean		1.45	1.30	1.40	2.05	2.20	1.85
Median		1.00	1.00	1.00	2.00	2.00	2.00
Mode		1	1	1	1	1^a	2
Minimum		1	1	1	1	1	1
Maximum		3	3	4	4	4	4
a. Multiple modes exist. The smallest value is shown

Observation showed that grain consumption mean increases from 1.45 times to 2.05 times, and the median increases from 1 to 2. This shows more people are inclined towards consuming grains more times during the day, the maximum increases 3 to 4 in grain consumption means the event generated awareness of grain consumption and the minimum remained same. The mean and median consumption times for Vegetables also increase from pre-event to post-event. Consequently, more people prefer high times consumption of fruits post-event than pre-event. Thus, the event generated awareness about the health benefits of consuming fruits, vegetables, and grains more times a day to better BP levels and the health of an individual. So, The Consumption of Grain, Vegetable and Fruits increased after the event. The mean values increased after the event.

Table 5: Pre-DASH and Post-DASH Education Questionnaire Responses

Descriptive Statistics
	N		Mean	Median	Mode	Minimum	Maximum
	Valid	Missing	Mean	Median	Mode	Minimum	Maximum
Before event I know what DASH stands for	20	0	1.80	1.00	1	1	5
Before event I know about The benefits of DASH diet	20	0	1.95	1.50	1	1	5
Before event I can identify Foods in DASH diet	20	0	2.25	2.00	1	1	5
Before event It is important to understand DASH diet	20	0	2.90	3.00	3	1	5
Before event Following DASH diet can improve my blood pressure	20	0	2.90	3.00	1	1	5
After event I know what DASH stands for	20	0	3.70	4.00	4	1	5
After event I know about The benefits of DASH diet	20	0	4.45	4.00	4	4	5
After event I can identify Foods in DASH diet	20	0	4.55	5.00	5	4	5
After event It is important to understand DASH diet	20	0	4.70	5.00	5	4	5
After event Following DASH diet can improve my blood pressure	20	0	4.75	5.00	5	4	5

Before DASH program intervention, the following were the statistics observed. Before the education program most participants did not have any idea about what DASH stood for. Post the education program, most participants knew somewhat what DASH meant, thus the program bought about awareness among sample observations on what DASH meant.

Before the program, most participants did not know the benefits of DASH. Post the awareness program on DASH, majority people understood the benefits of DASH. Most people could not identify foods with DASH before the program, but they started understanding that post the program. Participants did not feel there was a need to understand DASH diet before the program, but post the program, they agreed to the importance of understanding DASH diet.

Very importantly, before the education program, only a few strongly agreed to the fact that DASH diet could improve BP levels. But post the education program, almost half the sample shifted to strong agreement that DASH diet could in fact improve BP levels. With that said, potential bias should be considered, as the question is highly susceptible to social desirability bias. Moreover, while agreement that DASH can improve blood pressure is necessary, physical adherence to the diet is more relevant. As such, a study into the long-term effects of DASH education on diets and blood pressure is warranted.

The average concept of about DASH diet increases 1.95 to 4.45, which is very important figure for an event. Similarly, if we look at the Improvement in BP by DASH diet, the mean value increased from 2.9 to 4.7 a significant change occurred after the event. The mean value of the benefits of DASH diet also increased after the event from 1.95 to 4.45, the understanding of DASH diet mean value increased after the event from 2.9 to 4.7. Overall, the statistics improved after the event.

Summary

There were improvements in the participants’ responses to increasing daily servings of grains, vegetables, and fruits. The results of the pre- and-post-questionnaires showed that DASH education enhanced participants’ knowledge, awareness, and the likelihood of making dietary changes. DASH education also showed there was a significant decrease in participants’ systolic and diastolic blood pressures post DASH program intervention. The findings indicated that the structured DASH educational intervention presented increases the knowledge, awareness, and attitudes of change in nutritional habits after DASH intervention.

For this DPI, the percentage of was 40% male and 60% female participants. There was 100% of African Americans participated in the DPI. Descriptive statistics were utilized to answer the clinical question, “Does the implementation of a Dietary Approach to Stop Hypertension education intervention impact African American patients diagnosed with hypertension at a primary health clinic in Washington, D.C. over four weeks?

The pre-pre-and post-DASH Intervention Blood Pressure Measurements data analysis showed that the systolic and diastolic BP decreased after the event. The minimum diastolic BP percentage is high than systolic BP after the event. Also observed was the mean change of systolic BP declined by about 1.78%. The mean difference of diastolic BP levels declined by 3.3%.

Similarly, in the pre-DASH and post-DASH Education Questionnaire Responses, the analysis of the meaning of DASH, benefits of DASH, identify the food in DASH, understanding of DASH diet and how DASH diet can improve the BP, all the values increased on average after the event. The mean value of DASH diet also increased after the event from 1.95 to 4.45. Response to Food Frequency Questionnaire Pre and Post DASH intervention showed that the consumption of grains, vegetables, and fruits highly increased after the event of DASH Intervention.

Summary, Conclusions, and Recommendations

Hypertension remains a growing problem among the African American workforce, especially in production facilities, where there is limited access to healthy food choices due to long shifts and short break periods. According to Blumenthal et al. (2010), lifestyle modification, such as the adoption of the Dietary Approach to Stop Hypertension (DASH) diet, has the potential to reduce blood pressure. Dietary modification is often discussed with patients and can provide a significant benefit in blood pressure management. The objective of this quality improvement was to determine whether post-DASH education would show a reduction in the participants’ systolic and diastolic blood pressure. This project was centered around a DASH diet intervention aimed to improve awareness and knowledge of nutritional components in hypertensive African American patients in an outpatient clinic.

This project implementation introduced DASH diet and education on the nutritional components of DASH at an outpatient primary care clinic. It collected a sample of 20 African American individuals with hypertension to determine whether education about the approach would help them improve their situations. Overall, the project was successful, leading to tangible blood pressure reduction and improved DASH awareness. This chapter will discuss the significance of the findings, strengths, weaknesses, and challenges that took place during the planning and implementation of this DPI project in the clinic.

Summary of the Project

The strategies that were implemented through this quality improvement project focused on the contributions that nutritional education and subsequent adoption of DASH program can play in blood pressure reduction for individuals. The results of this project answered the clinical question; “To what degree does the implementation of a Dietary Approaches to Stop Hypertension program impact blood pressure of patients diagnosed with hypertension when compared to no intervention among African American patients in an outpatient clinic in Washington, D.C.?” and showed that some participants exhibited a reduction in blood pressure and low to moderate modifications in daily servings of grains, vegetables, fruits and increased knowledge about DASH.

The increase in the food frequency intake as recommended by DASH diet could demonstrate improved nutritional knowledge and awareness of the benefits of increasing servings in grain, fruits, and vegetables, which are essential components of DASH. The findings indicated that some individuals simply lacked knowledge about dietary benefits prior to DASH education program. Once the education was provided, these individuals used their newly acquired education to increase their daily intake of beneficial foods, resulting in 30-40% improvements in their consumption of grains, vegetables, and fruits. These findings have the potential to support a need for ongoing structured nutritional education programs for pre-hypertensive and hypertensive patients in the outpatient clinic setting. The aim of this quality improvement project was to show that participants will be better prepared to adopt some recommendations of DASH diet, including appropriate amounts of sodium, potassium, calcium, magnesium, and fiber. All these components affect blood pressure.

Studies have shown that DASH diet adherence reduces hypertension and can lower cardiovascular risk factors such as strokes, heart attacks, and congestive heart failure, which are high-dollar emergency room visits (CDC, 2017). As such, a patient’s understanding of DASH diet can reduce the long-term disease burden of hypertensive diagnoses. The goal for this quality improvement project was to examine if there was a need for expanding the services of the outpatient clinic to include nutritional education with patients. This quality improvement project has improved patient activation for self-management of hypertension.

With that said, the study also has considerable limitations that require its results to be verified with additional evidence before they can be fully applied. The sample was small and localized, leading to a high probability that the data was skewed compared to the overall population. Moreover, there was no control group, and only a single ethnicity was considered, which means it would be challenging to detect confounding factors. Lastly, the research was subject to biases, most importantly the social desirability bias, as DASH was considered to be a unilateral improvement and presented to the participants as such. With that said, the Project Facilitator was aware of these limitations and addressed them as best possible.

Summary of Findings and Conclusions

Hypertension continues to be a growing problem in America. There is an increasing need to reduce the burden of chronic disease associated with hypertension, including the increased risk of death and the costs related to treating and managing the hypertension-related disease. According to National Heart, Lung, And Blood Institute (2015), initiating lifestyle modification, such as dietary changes, can have a significant effect on the reduction of blood pressure.

This quality improvement project demonstrated an effective way to increase patient’s knowledge and adherence to DASH diet for participants in an outpatient primary care clinic. Another aim for this quality improvement project was for patients to have lower diastolic or systolic blood pressures at the end of the four-week DASH diet education series. This was an indication of positive benefits from DASH education program for patients diagnosed with hypertension. This project provided participants with face-to-face education on hypertension and DASH diet, as well as DASH diet pamphlets that could be used to guide food choices.

DASH program provided education sessions that were interactive and motivational. Following the education course, the participants became considerably more aware of its foundation and effects and overwhelmingly agreed that the diet could improve their blood pressure. Moreover, most patients experienced blood pressure reduction between 4 and 7%. They also started exhibiting healthier habits in their food consumption, making efforts to include the three healthy food categories listed in each of their meals. The sustainability of this project required an interprofessional team, minimal financial resources, and increased staff support to provide patients with ongoing DASH education in the primary care clinic.

Overall, the project has demonstrated that DASH education is an inexpensive and effective intervention that can achieve noticeable reductions in patient blood pressure, even in the short term. The long-term effects have not been examined due to time constraints, but they are likely to be more influential as the patients adjust to the new habits. As such, with the study’s limitations taken into consideration, it can be used to design similar programs at other medical facilities. Most organizations should be able to implement the program due to its low cost and the limited effort required.

Implication

Theoretical Implications

The HPM that is used universally for science, education, and practice was developed by Pender. The aim of this model used in this DPW was to help people achieve higher levels of well-being and to recognize background factors influencing health behavior. It promotes the provision of supportive services by health providers to help patients make specific behavioral improvements. Using the model in the outpatient clinic setting and working with the patient/client in partnership, the provider and other clinic staff can encourage the client to adjust habits and maintain a healthier lifestyle. The HPM’s goal, therefore, is not only to help patients avoid disease through their actions but to look at ways a person can pursue better health, specifically better hypertension management.

Practice Implications

Teaching DASH eating plan as a health promotion initiative can support healthy dietary habits that patients can use throughout life. Education on DASH has been shown to prevent other serious medical conditions such as heart attack, strokes, heart failure, kidney disease, and colon cancer (CDC, 2017). Creating a structured approach to educating patients on this diet is an easy, low-cost health promotion initiative for any size outpatient primary care clinic. While DASH is primarily known to lower blood pressure, it may also promote weight loss (CDC, 2017). This could help decrease healthcare costs associated with obesity and obesity-related diagnoses. An additional benefit of DASH diet education is the mental and physical health benefits experienced by patients due to increased energy from proper nutrition. Improved nutrition could help to combat stress-related work-life balances.

Future Implications

This DASH education quality improvement project can be a lifelong eating plan that focuses on consuming fruits, vegetables, lean proteins, whole grain, and the reduction of foods high in sugar or sodium. Providing nutritional education in the clinic increases accessibility to patients during their visits. Another benefit is participants have distributed DASH diet pamphlets that can be used as ongoing guides to assist in maintaining adherence to DASH diet recommendations. Outpatient clinic interventions, such as those used in this quality improvement project, can improve the provider-patient relationship, which can increase the likelihood that patients will maintain healthy eating habits.

Overall, DASH appears to have numerous benefits for the health of patients beyond its ability to reduce hypertension. Moreover, it is inexpensive as it only requires the dissemination of information throughout the community. Lastly, the education appears to be effective, as the project shows participants have improved their opinion of DASH and started adhering to it more closely as a result of the intervention. As such, while the shortcomings of the project need to be considered and researched further, it shows opportunities for potential practical implementation.

Recommendations

Recommendations for Future Projects

After implementation, data recommended that this quality improvement project be replicated at other clinics as an intervention to increase participants’ motivation and self-efficacy toward pre-hypertension and hypertension self-management. The result of this project could bridge the gap to offer a more structured nutritional program to empower patients to optimize wellbeing through dietary choices. This project could open a collaboration with health insurance companies to negotiate nutritional services to be covered in an outpatient clinic. Outpatient primary care clinic settings should include prevention of chronic disease and other health promotion activities, as well as treatment and management of chronic diseases.

At the end of this quality improvement project, it is recommended that an interprofessional group provides education and counseling sessions to assist patients in changing dietary habits that contribute negatively to pre-hypertension and hypertension. It is also recommended that patients be given time during their office visit to receive or attend education and counseling sessions. This will likely maximize patient participation. Empowering patients to optimize their wellbeing through diet education would be best achieved with the addition of health coaches or nutritional coaches. Health coaches promote wellness and lifestyle changes, including dietary counseling, lifestyle modification through behavior change, and chronic disease self-management sessions.

Another recommendation would be the onboarding of nutritional health promotion through telephonic or virtual nutritional counseling. Providing service at this level could support the health, nutrition, and stress management of the employees. This could allow patient spouses and family to be integrated into the nutritional education process; spouses may be shopping for food or preparing the meals. Providing spouses with nutritional counseling could have a direct impact on family health. Costs for the nutritional health promotion staff could be minimized by other clinic staff members such as nurse educators, nursing students, or interns.

Recommendations for Practice

Interprofessional collaboration for improving patient and population health outcomes is essential. The focus would be on inter-professional collaboration with inter-professional teams to improve patient, population, and health care delivery system outcomes (AACN, 2006). The growing complexity of health care often requires a collaborative approach to best address patient needs. The successful implementation of this project could possibly involve collaboration between providers and the health system, specifically the primary care outpatient clinics and a DNP-prepared clinical education director.

Communication with leaders of the organization was necessary to be granted permission to implement this project at the outpatient clinic locations: clinical prevention and population health for improving the nation’s health. After the quality improvement project, the investigator was able to analyze data on individual and population health and synthesize concepts related to health promotion and illness prevention (AACN, 2006). Healthcare providers will be able to use education on DASH diet to address health promotion and population health among a hypertensive and pre-hypertensive population in the outpatient wide health care settings. The risks associated with hypertension are significantly reduced when blood pressure is decreased. This quality improvement project has shown that it could contribute to decreasing the burden of hypertension through participants’ awareness of DASH diet as a lifestyle modification.

The project’s goal was to increase dietary knowledge, adherence and increase patient self-efficacy of hypertension and self-management through education on DASH eating plan. The application of this knowledge resulted in improvements in systolic and diastolic blood pressure, increased knowledge of DASH, and improved patient food choices. The work that was invested in this quality improvement project enhanced my current knowledge of nutrition and uncovered new knowledge because of DASH diet education. This DPI project has generated new knowledge for practice through the integration of systematic literature review and utilizing clinical expertise and patient preference to make changes in the outpatient care clinics. These changes lead to improved patient hypertensive outcomes and increase providers professional development.

References

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Background of the Project

Problem Statement

Purpose of the Project

Clinical Question

Advancing Scientific Knowledge

Significance of the Project

Rationale for Methodology

Nature of the Design

Definition of Terms

Assumptions, Limitations, Delimitations

Summary and Organization of the Remainder of the Project

Literature Review

Background

Theoretical Foundations

Application to practice change

Discovery Evidence

Evidence Summary

Translation to Guidelines

Practice Integration

Evaluation

Review of the Literature

Provider Counselling on DASH

Dash diet

Patient Behavior toward DASH

DASH and Hypertension Management

Patient education

Summary

Advantages and disadvantages of findings

Utilization of findings in practice

Methodology

Statement of the Problem

Clinical Question

Project Methodology

Population and Sample Selection

Instrumentation

Validity

Reliability

Data Collection Procedures

Data Analysis Procedures

Potential Bias and Mitigation

Ethical Considerations

Limitations

Delimitations

Summary

Data Analysis and Results

Descriptive Data

Data Analysis Procedures

Results

Summary

Summary, Conclusions, and Recommendations

Summary of the Project

Summary of Findings and Conclusions

Implication

Theoretical Implications

Practice Implications

Future Implications

Recommendations

Recommendations for Future Projects

Recommendations for Practice

References

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