Hospital Readmissions in African American Patients with Heart Failure:Application of the Pender Health Promotion ModelSheneeza Iqbal

University of Central Florida

NGR5800

Background and Significance of Heart Failure Heart failure is a clinical syndrome of decreased exercise tolerance and fluid

retention due to structural heart disease such as cardiomyopathy or valvular malfunction.

Heart failure(HF) affects over six million Americans with an estimate of over one million patients requiring annual hospitalization.

Annual cost for healthcare expenses is estimated to be over $20.9 billion; approximately 75% of the health care cost spent on HF is related to patient hospitalization.

Over 80% of patients hospitalized for HF are elderly over age 65.

African Americans are at a higher risk for developing HF compared to other ethnic groups.

African Americans risk of developing HF and requiring hospitalization is 4.6%, compared to a risk of 3.5% in Hispanics, and 2.4% in Caucasians.

(Albert, 2012, p.20; Cuyjet & Akinbobobye, 2014, p. 533; Dickson, McCarthy, Howe, Schipper & Katz, 2013; Zaya, Phan & Schwarz, 2011, p. 345).

Significance of Heart Failure African Americans are at higher risk for HF along with hospitalization due to

noncompliance to their prescribed health regimen.

Low health literacy, culture, and low socioeconomic factors contribute to African American patients’ noncompliance to their prescribed health regimen.

A study on health literacy in HF patients found those with poor literacy and knowledge on the role of sodium in their diet were three times more likely to be readmitted to the hospital within 90 days, compared to participants who were more educated (Kollipara, Jaffer, Amin, Toto, Nelson, Schneider, Markham & Drazner, 2008).

A study on culture found African Americans with HF made decisions about their health based on their sociocultural influences such as their belief in God, role in family, and support from relatives and peers (Dickson, et al., 2013).

A study done on medication compliance found HF African Americans were 1.38 times more likely to be noncompliant with medication due to cost in comparison to Caucasians. They were also 2.57 times more likely to be hospitalized for HF (Wu, Lennie, De Jong, Frazier, Heo, Chung & Moser, 2010, p. 142-147).

Problem Statement & Aim

Problem Statement:

African American patients are at higher risk for developing heart failure due to noncompliance with their prescribed health regimen. Noncompliance is due to low health literacy, culture, and low socioeconomic status.

Aim:

To identify nursing measures that will encourage African American heart failure patients to be compliant to their prescribed health regimen and to engage in health promoting behavior. The Pender Health Promotion Model will be applied to this problem to achieve the stated objective.

(Dennison, McEntee, Samuel, Johnson, Rotman, Kielty & Russell, 2011; Dickson, McCarthy, Howe, Schipper & Katz, 2013).

Middle Range Theory: Pender Health Promotion Model Created by Nola Pender, who began studying health-promoting behavior in the mid-

1970s. It was first published in 1982, and slightly modified in the 1980s and again in 1996. Pender constructed the model using a nursing perspective from the expectancy-value theory and social cognitive theory.

(McEwen & Wills, 2014, p.234)

Pender Health Promotion Model Purpose:

Proposed as a framework for integrating nursing and behavioral science perspectives on factors that influence health behaviors. The model is to be used as a guide to explore the biopsychosocial processes that motivate individuals to engage in behaviors directed towards health enhancement.

Concepts:

Individual characteristics and experiences: prior related behavior & personal factors: biologic, psychological, sociocultural.

Behavior specific cognitions and affect: perceived benefits of action, perceived barriers to action, perceived self-efficacy, activity-related affect, interpersonal influences, and situational influences.

Behavioral outcomes: commitment to a plan of action, immediate competing demands and preferences, and health- promoting behavior.

Nursing Implications:

Health promotion interventions are essential for improving the health of populations everywhere. Nurses can develop and execute health promoting interventions to individuals, groups, and families in any setting, and the community at large. Nurses should work toward empowerment for self-care and enhancement of client’s capacity for self-care through education and personal development.

(McEwen & Wills, 2014,p. 235-236)

Application of the Pender Health Promotion Model Kelley, Sherrod & Smyth (2009)

Interpersonal influences can determine patients participation in positive health promoting behaviors.

Purpose of study: to investigate the interpersonal influences from doctors and nurse practitioners participation in encouraging coronary artery disease (CAD) patients to stop smoking.

Only 68.7% of CAD patients in study were offered smoking cessation therapy by their healthcare providers after assessing their desire to quit smoking, offered counseling and nicotine replacement therapy (NRT). In the other 31% of CAD patients, providers did not document or offered any smoking cessation therapy.

Conclusion: A need for increased interpersonal influence was recommended for health care providers to reinforce smoking cessation with each patient visit, and be vigilant in their efforts to encourage CAD patients to quit smoking.

Application of the Pender Health Promotion Model

Nkosi & Wright (2010)

Perceived benefit of action, self-efficacy, interpersonal influences, and personal factors influence patients’ participation in health promoting behaviors.

Purpose of study: to investigate hypertension knowledge on nutrition and hypertension management.

Participants display a knowledge deficit of healthy food, continue to consume high sodium food while hypertensive

Overweight participants who viewed self as normal did not see a need for exercise, as a result commitment level to exercise was low.

Knowledge of untreated hypertension leading to stroke was not perceived as life threatening.

Conclusion: community wide interventions may be the only way to encourage positive health promoting behavior in hypertensive patients.

Application continues… Correlation between CAD, Hypertensive patients and African American patients

with heart failure:

They lack motivation

Knowledge deficit/low health literacy was a perceived barrier to action, and affected their perceived benefits of action and self-efficacy level to commit to positive health promoting behaviors.

Interpersonal influences from healthcare providers and support system influenced the patients’ decisions regarding their health.

Personal factors: psychological and sociocultural factors influence their decisions in health promoting behaviors.

Conclusion:

Utilization of the Pender Health Promotion Model by nurses and other healthcare providers can encourage and promote African American patients’ compliance to their prescribed health regimen. Nurses can help patients to be compliant by identifying nursing measures that will empower them to be more involve in their self-care through education and personal development. Education and personal development will help patients to overcome factors of low health literacy, and culture that are influencing their compliance to their prescribed health regimen.

References

Albert, N. M. (2012). Fluid management strategies in heart failure. Critical Care Nurse, 32(2), 20-33. doi: 10.4037/ccn2012877

Cuyjet, A. B., & Akinboboye, O. (2014). Acute Heart Failure in the African American Patient. Journal of Cardiac Failure, (7), 533. doi:10.1016/j.cardfail.2014.04.018

Dennison, C., McEntee, M., Samuel, L., Johnson, B., Rotman, S., Kielty, A., & Russell, S. (2011). Adequate health literacy is associated with higher heart failure

knowledge and self-care confidence in hospitalized patients. Journal of Cardiovascular Nursing, 26(5), 359-367.

Dickson, V., McCarthy, M. M., Howe, A., Schipper, J., & Katz, S. M. (2013). Sociocultural influences on heart failure self-care among an ethnic minority black

population. Journal of Cardiovascular Nursing, (2). 111

Kelley, J., Sherrod, R., & Smyth, P. (2009). Coronary artery disease and smoking cessation intervention by primary care providers in a rural clinic. Online Journal of

Rural Nursing & Health Care, 9(2), 82-94.

Kollipara, U., Jaffer, O., Amin, A., Toto, K., Nelson, L., Schneider, R., & ... Drazner, M. (2008). Relation of lack of knowledge about dietary sodium to hospital

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McEwen, M., & Wills, E. M. (2014). Theoretical basis for nursing (4th Ed.). Philadelphia: Lippincott Williams & Wilkins.

Nkosi, N., & Wright, S. (2010). Knowledge related to nutrition and hypertension management practices of adults in Ga-Rankuwa day clinics. Curationis, 33(2), 33-40.

Wu, J., Lennie, T., De Jong, M., Frazier, S., Heo, S., Chung, M., & Moser, D. (2010). Medication adherence is a mediator of the relationship between ethnicity and

event-free survival in patients with heart failure. Journal of Cardiac Failure, 16(2), 142-149. doi:10.1016/j.cardfail.2009.10.017

Zaya, M., Phan, A., & Schwarz, E. (2012). The dilemma, causes and approaches to avoid recurrent hospital readmissions for patients with chronic heart failure. Heart

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