African Americans, faith-based, hypertension, nursing, Reed's Self-Transcendence Theory, self-transcendence



  1. Harvin, Lori A.
  2. Winter, Dorothea M.
  3. Hoover, Evelyn L.
  4. Lewis, Lisa M.


ABSTRACT: High mortality rates continue among African Americans related to complications of uncontrolled hypertension. The purpose of this study was to determine if a faith-based self-management education program would improve self-care activities related to the management of hypertension among African American adults. Ten African American adults who reported a diagnosis of hypertension for 6 months or longer completed an 8-week education program focused on strategies for hypertension management. The education program was enhanced with the utilization of spiritual components of prayer, Scripture reading, and journaling.


Article Content

A frican Americans have the highest prevalence of hypertension, with more than 40% of non-Hispanic African Americans being diagnosed with hypertension (American Heart Association, 2016). Associated chronic diseases such as kidney disease, heart disease, and stroke contribute to high mortality rates of African Americans with high blood pressure. Successful management of chronic diseases such as hypertension requires self-care behaviors that foster healthy outcomes and limit morbidities and mortalities.

Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.

The beneficial use of faith-based approaches to improve health behaviors among African Americans is well documented. This practice project sought to determine if a faith-infused intervention would improve health outcomes for African Americans with hypertension. The clinical question addressed was: Among African Americans diagnosed with hypertension, will a faith-based self-management education program improve self-care activities related to hypertension management?



Considerable health-related literature acknowledges the importance of spirituality, as it contributes to physical, social, and emotional well-being (Lewis, 2011). For this reason, The Joint Commission (2011) encourages healthcare organizations to assess and support spirituality. To empirically illustrate how faith and healthcare can connect, Dodani, Arora, and Kraemer (2014) conducted a study that documented how use of spiritual practices such as reading sacred Scriptures, attending a behavioral intervention at a church, and prayer encouraged healthful lifestyle and hypertension self-care behaviors among African Americans (N = 34).


Culturally appropriate models of care contribute to improved health outcomes (Lewis, 2011). Historically, the African American church community has played a significant role in engaging and influencing individuals to adopt health-promoting behaviors (Woods-Jaeger et al., 2014). Thus, church venues can be successful for disseminating health information and promoting healthy behaviors. Churches offer a safe and trusted environment for most individuals and foster an environment where positive influence and behavioral changes can be learned and acquired.


The church is a strong force for bridging the gap between healthcare systems and African American communities (Parrill & Kennedy, 2011). Furthermore, churches can be a platform for health promotion (Butler-Ajibade, Booth, & Burwell, 2012). Suggestions for effective health promotion include making access for participants easy and creating an environment in the church where values and attitudes that contribute to living a "good" life are learned.


Boltri, Davis-Smith, Okosun, Seale, and Foster's (2011) study to identify the effectiveness of a research-designed Diabetes Prevention Program in African American churches provides an illustration of how church settings can promote health. Information from this study provides insight about program cost and suggests the appropriate time frame for implementation of successful health programs in an African American church setting. For example, Boltri et al. (2011) compared outcomes of a 6- and 16-session program and found that attendance was lower at the church where the 16-session program was offered. Also, the researchers recognized the need to offer interventions at times that did not compete with other planned church activities. Their study documented the positive effects of spirituality on health behaviors and the possible role of churches in supporting persons to improve their health.


Similarly, Lewis' (2011) qualitative study of older African American women diagnosed with hypertension revealed how theistic beliefs and practices fostered positive attitudes and behaviors. That is, prayer, Scripture reading, and discussion with members of the same faith who are faced with the same challenges (e.g., medication adherence) proved to be effective in promoting health practices. Participants also gained support from congregation members and leaders. Aspects of religion appeared to increase their motivation to implement healthful practices. Lewis concluded that use of faith-based interventions consistent with African American cultural beliefs is beneficial in improving health behaviors and outcomes.



The Theory of Self-Transcendence, which attempts to explain how people promote well-being in the midst of adversity (Reed, 2018), was used to explore health behaviors and spirituality among African Americans. The theory proposes that a significant change in one's health will result in an increased awareness of one's vulnerability. The awareness of vulnerability (in this context, hypertension) will prompt self-exploration and a greater awareness of relationships with others, the environment, and personal spirituality. This heightened awareness fosters the desire to improve circumstances (in this context, improve health behaviors) and to seek a life that is more meaningful. In addition to vulnerability and well-being, key concepts of the theory include self-transcendence-a fundamental component of spirituality (Coward, 2010).



This practice project implemented a pre- and posttest quasi-experimental design to explore the effectiveness of a faith-based educational program in improving self-care behaviors among African Americans diagnosed with hypertension. Approval was obtained from the institutional review board at an investigator's university. Standard ethical practices were observed; informed consent was obtained from all participants.


African American adults diagnosed with hypertension for 6 months or longer comprised the sample (N = 10). This project was conducted at a church in Baltimore, Maryland, where members of the congregation are predominately of African descent. Leadership at the church voiced concern regarding the health and well-being of the congregational members and volunteered to host the program. The church building was spacious with adequate classrooms, one of which was used for all sessions.


Participants attended an enrollment session that provided an overview of the program. Preintervention questionnaires were completed and included a demographic form, the Spiritual Perspective Scale (SPS) (Reed, 1986, 1987), the Self-Transcendence Scale (STS) (Reed, 1991), and the Hypertension Self-Care Activity Level Effects Scale (H-SCALE) (Warren-Findlow, Basalik, Dulin, Tapp, & Kuhn, 2013). After the intervention, the SPS and H-SCALE were completed at the last session to identify if changes had occurred. In addition, a program evaluation form was completed to gain further insight regarding the effectiveness of the program. The STS scores achieved prior to exposure to the hypertension management sessions were used to identify participants' level of self-transcendence.


The faith-based self-management education program was comprised of eight educational sessions, each lasting 45 to 60 minutes and held at the church. The sessions were scheduled biweekly over 4 months. One of the investigators served as the course instructor; assistance also was provided as needed by a registered nurse who was a member of the church's health ministry team.


Program content was guided by the Understanding and Controlling Your High Blood Pressure booklet from the American Heart Association (2015). Topics include understanding high blood pressure, measuring blood pressure, risk factors, consequences of hypertension, and treatment (including nutrition, exercise, medication). Biblical passages were introduced and discussed at each session as well (Table 1).

Table 1 - Click to enlarge in new windowTable 1. Project Bible Readings

Teaching and learning strategies employed lectures utilizing a PowerPoint presentation, distribution of written materials, and open discussion prompted by reflection questions developed by the investigators (Table 1). Each session included a lecture, introduction of pertinent scriptural texts about health, open discussion, and closure with prayer. A final wrap-up session involved collection of postintervention data and a potluck dinner of healthy food options.


Participants reflected about the challenges and victories of implementing hypertension self-management during open discussions and through journaling. A journal was provided, and participants were encouraged to reflect on daily challenges and triumphs related to the management of their hypertension and the scriptural texts presented during the sessions. Reflection during the open discussion was prompted by investigator-designed questions that allowed participants to consider how their faith might interact with their health behaviors. For example, participants were asked questions such as, "How have you honored God this week in managing your blood pressure?" Participants were actively engaged during the open discussions and also shared their journaling.



To compare pre- and postintervention health status and behaviors, spiritual perspective and various aspects of hypertension self-care were measured. To obtain a baseline description of participants, a demographic survey was completed and self-transcendence was assessed.


The Spiritual Perspective Scale (SPS) is a 10-item questionnaire that measures the extent to which individuals hold spiritual views and how often they engage in spiritually related behaviors (Reed, 1986;1987). Items that inquire about frequency of spiritually related behaviors include, "How often do you engage in private prayer or meditation?" and "I seek spiritual guidance in making decisions in my everyday life." Responses range on a Likert-type scale from Not likely (1) to Always (6) (Runquist & Reed, 2007, p. 9). Averages were used to determine a spiritual perspective score. Positive correlations between the scale and spiritual backgrounds have been noted and researchers have observed strong internal reliability, interitem scale correlations, and criterion-related and discriminate validity (Conner & Eller, 2004; Gray, 2006).


The Self-Transcendence Scale (STS) is a 15-item instrument measuring an individual's view of life and to what extent a person utilizes psychosocial resources and introspective means to promote a sense of well-being. Examples of this process include finding meaning in one's present or past experiences, having an interest in learning new things or sharing one's wisdom with others, and being able to accept help from others. For each of the 15 items, there is a 4-point Likert-type response option. The overall average of individual item averages was used to create the STS score, which ranged from 1.0 to 4.0 (Runquist & Reed, 2007). For this project, a score of 1 or 2 was interpreted as low, whereas 3 or 4 was considered high self-transcendence. In previous studies, Cronbach's alpha has ranged from 0.77 to 0.85 (Coward, 2010; Reed, 1991; Runquist & Reed, 2007).


The Hypertension Self-Care Activity Level Effects Scale (H-SCALE) is a self-report assessment designed to measure the degree to which a person implements recommended self-care activities known to control hypertension (Warren-Findlow et al., 2013). The H-SCALE is composed of six subscales: medication adherence, diet, physical activity, smoking, weight management, and alcohol.


The medication adherence subscale is composed of three questions regarding medication usage with Likert response options of 0 to 7 that measure how often respondents take their prescribed blood pressure medications. The possible range for the responses to these three questions is 0 to 21, where 21 is fully adherent to the medication regimen.


The 11-item diet subscale of the H-SCALE prompts participants to rate themselves on how often they consume healthy food items as prescribed by the Dietary Approach to Stop Hypertension (DASH) diet. Responses are summed and can range from 0 to 77. For this study, we considered scores less than 32 as a low diet quality, scores between 33 and 51 as medium quality, and scores of 52 or greater as adherent.


Participants were rated on how often they engage in physical activity by answering two questions. Responses were summed and could range from 0 to 14. For this project, scores of 8 or higher were considered adherent to the physical activity recommendations; lower scores were considered nonadherent. This threshold was chosen to ensure that participants had to report some combination of both physical activity and exercise to be considered adherent.


To assess smoking and exposure to secondhand smoke, participants were asked to provide the number of days during which they smoked or were exposed to smoking. Responses can range between 0 and 14. The score of 0 indicates adherence and any score above 0 is considered nonadherent.


The weight-management subscale includes 10 questions that assess how often over the past month weight-management activities, such as portion control and food substitutions, were practiced. Responses to the items range from Strongly disagree (1) to Strongly agree (5), with possible summative scores ranging from 10 to 50. Scores higher than 40 are considered adherent to good weight maintenance practices.


The alcohol subscale poses three questions to explore the frequency of the consumption of alcoholic beverages, recommended by the National Institute on Alcohol Abuse and Alcoholism (n.d.). Respondents indicate how often per day, per week, and within the last month they consumed an alcoholic beverage, where moderate alcohol consumption among men is <2 drinks/day (scores of 14 or less) and <1 drink/day for women (scores of 7 or less).


The H-SCALE tool also was designed to be a counseling tool to aid hypertensive patients who seek blood pressure control (Warren-Findlow et al., 2013). When administered to 154 patients with hypertension to assess self-care, Warren-Findlow et al. found that greater adherence to self-care was associated with lower systolic and diastolic blood pressure (BP) for five of the six self-care behaviors. The statistical Package for Social Sciences (SPSS) version 23 was used to manage and analyze data.



Ten adults with a diagnosis of hypertension participated in this project. The sample included two males and eight females. Participants' ages ranged from 48 to 81 years of age, with 50% of the participants being between 48 and 50 years of age. Whereas 40% were college graduates, 50% reported being high school graduates, and 10% had not completed high school. Family history was striking: 100% reported having a family history of hypertension. All participants, except for one who was in the process of searching for a new provider, reported being under the care of a healthcare provider. Poor responses to querying regarding frequency of visits to a healthcare provider leave lack of clarity about healthcare visits. Of the five participants who did respond, one reported visiting every 3 months, three reported every month, and one reported every 6 months.


Prior to the initiation of the educational intervention, participants completed the STS to measure ability to utilize psychosocial resources and introspective means to promote a sense of well-being. The STS scores indicated that 70% of the participants possessed high self-transcendence and 30%, low levels. In addition, participants completed the SPS and H-SCALE. Scores indicated that 100% of participants had high spiritual perspectives prior to intervention (i.e., scored a mean of 5 or 6). H-SCALE scores revealed the most reported challenges included exercise, diet, weight management, and medication compliance, with 30%, 50%, 50%, and 60% (respectively) nonadherence being reported at baseline.


The project proposed to address whether a faith-based hypertension self-management education program would affect outcomes among African Americans with hypertension. To assess the impact of the education program, pre- and postintervention data collected with the SPS and all H-SCALE subscales were compared using the Wilcoxon Signed Rank test. All participants' SPS scores remained either a 5 or 6 (Table 2), indicating high spiritual perspective. Considering that all participants were members of the hosting church, this finding is not surprising. Although not statistically significant, a decrease in spiritual perspective by two participants was observed at postintervention.

Table 2 - Click to enlarge in new windowTable 2. Pre- and Postintervention SPS and H-SCALE Scores (

Results showed a statistically significant increase in medication adherence scores of the participants following the hypertension management sessions (z = -2.117, p = .034) (Table 3). There was an increase by 30% (n = 3) in the number of participants who were compliant with medication adherence after the intervention. In addition, there was a 20% decrease in the number of participants who reported not being prescribed medications (Table 2).

Table 3 - Click to enlarge in new windowTable 3. Comparing Pre- and Postintervention Outcomes: Wilcoxon Signed Rank Test Results (

The scores of the remaining H-SCALE components (i.e., diet, weight management, activity, smoking, and alcohol) showed no statistically significant difference (Table 3) pre- to postintervention. In fact, some increases in nonadherence were observed for these behaviors contributing to hypertension. That is, for weight management and activity, a 20% increase in nonadherence occurred (i.e., two participants became less active and two reported fewer weight-management practices) (Table 2). Adherence to the DASH diet remained the same pre- and post intervention. All participants reported not smoking or consuming alcohol at baseline and postintervention.


A program evaluation survey was used to collect qualitative data postintervention. Participants reported valuing the information provided and perceived that those facilitating the sessions were genuinely concerned about the participants' health. Many enjoyed the group discussion and found that the biblical passages improved their perspectives regarding health. Participants expressed a desire to meet more often and continue the program.



Mortalities and morbidities related to uncontrolled hypertension continue to be problematic. The current healthcare environment does not allot providers sufficient time to offer thorough health education that will assist individuals with BP management. This practice project was designed as a pilot study to explore a strategy that can be utilized to fill the health education gap. This faith-based hypertension management program was designed to enhance the knowledge and improve healthcare practices among African American adults pertaining to hypertension.


Although spiritual perspective and several aspects of hypertension management behavior were not statistically different after the intervention, medication adherence was improved. Participants reported an increase in taking medications as prescribed, and those who reported not being on medications pre-intervention reported being on medications and adherent post intervention. It is presumed that there were participants who found it necessary to obtain care and were prescribed medications during the implementation of the program, contributing to the increase in medication adherence and the decrease in the number of participants who reported not taking medications. Discussions with the participants regarding medication regimens indicated as much. Considering the significant role that medication adherence plays in controlling high BP, this increase in adherence post intervention is consequential.


The hypertension management components of diet, weight management, and activity did not change. Interestingly, participants identified diet (30%) and exercise (30%) as most challenging for them in their attempt to manage BP. Weight management and activity are directly related to these components which could contribute to the lack of significant change in these scores. These nonsignificant findings may be explained by the reality that the sessions were offered over a short period of time, not allowing enough time for the participants to implement and routinize exercise, weight management, and diet strategies. Participants' inquiries, journaling, and discussions, however, validated the need to provide information about these topics.


Given the faith-based nature of this intervention, it is of interest to know if the intervention affected spiritual perspective. Results suggest that it did not. There are various events that the participants could have experienced which may have contributed to the slight decrease in post SPS scores, such as lifestyle changes, stress, changes in their faith or relationship with their faith community. Although a slight decrease was observed, it should be noted that the lowest SPS scores still indicated high spiritual perspective.


In addition to providing relevant education in accordance with the American Heart Association, special attention was given to the incorporation of religious faith. Prayer and Scriptures that would inform how to address health challenges were shared at each session. This enhancement to the sessions prompted the exploration of spirituality and health. Indeed, participants described that during the intervention was the first time they connected their spiritual way of life with their health behaviors. Some participants reported that the thought of displeasing God through the lack of caring for their physical bodies was a new way of thinking. Thus, insight was gained regarding the impact of the spiritual components of the program.


All participants were engaged and contributed to the open discussions. The sharing of personal challenges and triumphs related to managing hypertension proved to be beneficial, as participants' journals mentioned how hearing that others are facing the same challenges was strong encouragement. Participants freely discussed their deficits and asked for help from peers. Although the quantitative results did not consistently demonstrate improvements, conscious effort to improve health behaviors was evident in the discussions and journaling.



Small sample size made parametric statistical analyses impossible. The sample was comprised of persons from one church; therefore, understanding how this intervention would be impactful in another denomination or religious culture is unknown. As yet, the spiritual components are not manualized or specifically evaluated. It is possible that although the faith components were intended to develop a holistic and religio-culturally sensitive perspective for hypertension self-management, these components could have inadvertently interjected guilt for past unhealthful practices or brought to awareness a spiritual struggle associated with trying to be healthful.


This pilot project stimulates considerations for future research. Although a multisited design and larger sample would have made findings more robust, it is important to consider the unique needs of a local congregation and plan site-specific interventions accordingly. Through this project, it was learned that some church members do not link their religion to their disease management and that an intervention that overtly makes this link may be beneficial. According to anecdotal comments, the pedagogical method of asking participants to journal and to share their personal experiences with hypertension management during group discussion was found to be helpful.



Results of this project contribute to the evolving knowledge regarding spirituality and its potential role in managing chronic diseases, particularly among African Americans. Nurses, especially home health and faith community nurses who provide care for African Americans with hypertension, should explore how congregants' religious beliefs (e.g., how the body is the temple of God) and practices (e.g., reading the Bible or prayer) can encourage healthful choices. Strategies for engaging the community in health education appear in the sidebar. Nurses can also work to help church members participate in health-related support groups sponsored by churches. An educational intervention, such as that presented here, provides promise; it may allow nurses to harness spiritual and religious resources to more effectively and sensitively address chronic lifestyle-related diseases like hypertension.


Sidebar: Strategies to Involve the Congregation in Health Education

1. Pastor

Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.

* Educate the pastor about the problem, the resources, the project/event, the effect on the congregation's well-being, community impact, and involvement


* Provide denomination-specific materials when possible


* Request general support, sermons related to the topic, announcements and endorsement from the pulpit, clergy and staff participation for personal health



2. Key Lay Leaders


* Enlist understanding and support to move the project forward and provide financial support


* Educate and gain the support from the unofficial leadership of the congregation at the beginning of a project


* Be sure that various women, Sunday School, men, youth, and specialty groups are included


* Recruit spokespersons from each group


* Highlight each group's participation



3. General congregation


* Involve congregants in selecting dates and times


* Involve all age groups in creating portions of the project and promoting


* Recognize groups for participation and support


* Make it personal, fun, and interesting so individuals and groups will want to be involved


* Have a part for everyone to participate from prayer to funding to preparing to hosting to follow-up



4. Follow-up


* Send thank you notes, write an article, post pictures



-Sharon T. Hinton, DMin, MSN, RN, Contributing Editor, JCN


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For 24 additional continuing education articles related to faith community nursing, go to


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American Heart Association. (2016). High blood pressure and African Americans. Retrieved from[Context Link]


Boltri J. M., Davis-Smith M., Okosun I. S., Seale J. P., Foster B. (2011). Translation of the national institutes of health diabetes prevention program in African American churches. Journal of the National Medical Association, 103(3), 194-202. doi:10.1016/S0027-9684(15)30301-1 [Context Link]


Butler-Ajibade P., Booth W., Burwell C. (2012). Partnering with the black church: Recipe for promoting heart health in the stroke belt. Association of Black Nursing Faculty Journal, 23(2), 34-37. [Context Link]


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Reed P. G. (2018). Theory of self-transcendence. In M. J. Smith & P. R. Liehr (Eds.), Middle range theory for nursing (4th ed., pp. 105-128). New York, NY: Springer. [Context Link]


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