THE OFFICIAL JOURNAL FOR NURSE PRACTITIONERS

A Peer-Reviewed Journal

VOL. 12 NO. 11/12 WWW.WEBNP.NET NOVEMBER/DECEMBER 2008

The American Journal

for Nurse Practitioners
Clinical Challenges In
PEDIATRICS
Risk Factors Underlying
Hypertension in Adolescents
of Color

NP PRACTICE
Interdisciplinary Nursing
Home Practice

CLINICAL SUPPLEMENTS
Long-term Inhaled Corticosteroids
in Pediatric Patients
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Vaginal Atrophy: Etiology,

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Consequences, and Management

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AJNP 2008 EDITORIAL INDEX

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 PEDIATRICS

Complex Risk Factors

Underlying Pre-hypertension
and Hypertension in
Adolescents of Color:
A Review
Jennifer A. Fleming RN, MSN and Nancy George PhD, FNP-BC

Using a social-ecological model, the authors review studies assessing factors in addition to obesity that
may be contributing to the rising prevalence of pre-hypertension (pre-HTN) and hypertension (HTN) in
adolescents (persons aged 11-21 years old), including adolescents of particular racial/ethnic groups. The
social-ecological model considers the effects of four contextssociety, the community, interpersonal rela-
tionships, and the individualwith respect to the development of pre-HTN/HTN in this population.
Understanding the environmental context that affects the lives of adolescents of color and their risk for
cardiovascular disease (CVD) can enhance nurse practitioners (NPs) ability to intervene in a meaning-
ful way to improve these patients health.

H
ypertension affects 2%-5% of
US children and adolescents;
recent data indicate that HTN
prevalence among all age groups
has been rising over the past
decade.1,2 Secondary HTN is more
common in children than in
adults, although most adolescents
with mild to moderate HTN have
primary HTN.1 Pre-HTN and pri-
mary HTN in adolescence are risk
factors for HTN in early adult-
hood,2 and HTN or elevated blood
pressure (BP) is the leading cause
of death related to CVD across gen-
ders and all racial and ethnic
groups.3 Two correlates of HTN in
adolescents are genetic predisposi-
tion and excess weight.1,4 The
genetic predisposition for HTN at
all ages has been established; what
is not clear is how genetics inter-
acts with environmental factors to
put adolescents at risk for HTN.5
HTN in children is defined as
having a BP >95th percentile for
age, sex, and height on three sepa-
rate office visits.6 In 2007, the
National Heart, Lung and Blood
Institute (NHLBI) defined pre-HTN
as a BP in the 90th-95th percentile.7
To assist NPs interpretation of
pediatric patients BP values, the
NHLBI has created a table based on
age, sex, and height that clearly
identifies normal BP, pre-HTN,
stage 1 HTN, and stage 2 HTN.7
Accurate interpretation of pediatric
BP values is important because, as
mentioned earlier, pre-HTN and
primary HTN in adolescence are
risk factors for HTN in early adult-
hood.6 Of more urgent concern,
elevated systolic BP (SBP) in chil-
dren and adolescents has been

VOL. 12 NO. 11/12 NOVEMBER/DECEMBER 2008 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS 49
 PEDIATRICS
found to compromise cognitive
and neuropsychologic perfor-
mance, impairing attention, con-
centration, and mathematical
skills.8,9
An established body of litera-
ture has identified family history of
HTN, low birth weight, and obesity
as risk factors for pediatric HTN,
but little is known about other fac-
tors, including race/ethnicity, that
are contributing to the increased
prevalence of primary HTN in the
adolescent population.1,10-13 Under-
standing all the environmental and
psychosocial factors associated
with pre-HTN/HTN in adolescents
is needed to target actions aimed at
decreasing the burden of suffering
in adulthood. Of note, >65 million
US adults have HTN.2 Preventing
HTN in the first place or treating it
FIGURE. ECOLOGICAL MODEL OF THE ADOLESCENT HYPERTENSION LITERATURE
MACRO LEVEL
(SOCIETY) (COMMUNITY)
IDEOLOGIES
Racism
Discrimination
50 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS NOVEMBER/DECEMBER 2008 VOL. 12 NO. 11/12
as it develops in adolescence, even
if at a mild stage, could help reduce
the incidence of CVD, renal dis-
ease, and stroke in adults.3
Social-Ecological Model
The social-ecological model is a
good fit with the holistic perspec-
tive that NPs use in caring for their
adolescent patients. Preventing
HTN development requires an
understanding of environmental
factors that influence this condi-
tion. The social-ecological model
considers the complex interplay
among societal, community, inter-
personal, and individual factors
(Figure). This model is a logical
framework to articulate the role of
societal determinants of health (eg,
the relationship between racism/
discrimination and pre-HTN/HTN
MESO LEVEL MICRO LEVEL
(INTERPERSONAL)
ACCESS TO
HEALTH CARE Chronic Stress
Anger and Violence
in adolescents),14-17 as well as the
contribution of the community in
which an adolescent resides and
goes to school; the interpersonal
relationships an adolescent develops
with family members, friends,
teachers, and others; and the traits,
including genetic predisposition,
of an individual himself or herself.18
To reduce the prevalence of pre-
HTN/HTN in adolescents, particu-
larly in adolescents of color
because they are at such high risk
of developing HTN as adults, NPs
need to understand this patient
population in terms of the varied
contexts of their lives. The authors
of this article use a social-ecologi-
cal perspective to analyze the
effects that each of the four con-
texts can have on an adolescents
healthspecifically, on BP.
MICRO LEVEL
(INDIVIDUAL)
HEALTH
OUTCOMES
Pre-hypertension/
hypertension
Normal blood
pressure
DEMOGRAPHICS
Age
Gender
Race
Genetics
Education
Parental Income
Societal Context:
Racism/Discrimination
Persistent health disparities exist in
the United States;19,20 some of these
disparities may be linked to
racism/discrimination. For exam-
ple, economic and racial/ethnic
inequalities in health care place
certain adolescents at risk for poor
diet and/or inactivity, both of
which can affect the incidence of
HTN.20 Studies have also explored
possible links between racism/dis-
crimination and elevated BP. For
example, Harris et al used data
from Healthy People 2010 to identi-
fy longitudinal trends and
racial/ethnic disparities in terms of
20 leading health indicators from
adolescence through young adult-
hood.21 They found a black-white
male-female disparity in 50% of
the Healthy People 2010 indicators
and a Hispanic-white male-
female disparity in 35% of the
indicators. Native Americans, non-
Hispanic blacks, and Hispanics
fared worst in terms of all the
health indicators. The study
showed a significant decline in
health from adolescence to young
adulthood for most US racial/eth-
nic groups.
Jago et al verified the preva-
lence of elevated BP among eighth-
grade adolescents from three US
locations and ascertained whether
the prevalence in their study sam-
ple differed by gender, ethnicity,
and body mass index (BMI).22
Almost 24% of the participants
had elevated BP, 19.8% were at risk
of becoming overweight (BMI
85th percentile), and 29% were
overweight (BMI 95th percentile).
The researchers also found that,
based on 1999-2000 National
Health and Nutrition Examination
Survey (NHANES) data, BP in par-
ticipants aged 12-19 years was
VOL. 12 NO. 11/12 NOVEMBER/DECEMBER 2008 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS
higher than that found in similarly
aged participants in previous
national surveys. HTN prevalence
in adolescents was 8% for all
NHANES participants, 12.7% for
African-American (AA) partici-
pants, 11.3% for Mexican-
American (MA) participants, and
7.5% for white participants.22,23 Few
studies have investigated BP in
Native-American adolescents. One
study conducted on Native-
American grade-school children
showed that this group, compared
with black children and white chil-
dren, had slightly higher SBP,
lower diastolic BP (DBP), and
higher rates of obesity.24
Most research assessing the
effects of discrimination and
racism on the detection and man-
agement of HTN has focused on
the AA experience.25-28 Clark and
Armstead reported associations
between psychological stress and
HTN in 39 AA adolescents.29 This
stress can have a psychosocial ori-
gin, including perceived racism.
Much of the research conducted
regarding the effect of racism on BP
was done >10 years ago and was pri-
marily on adult AAs.30 Clark and
Gochett found that the ways in
which psychosocial and environ-
mental factors contribute to HTN
development should be taken into
consideration when assessing BP
correlates in black youth.31 Peters
studied the relationship among
racism, chronic stress, and BP in
adults and found that racism was
commonly experienced and was
associated with chronic stress.30
However, no correlation between
racism and elevated BP was found.
Nevertheless, the perception of racism
could be stressful and could play a
role in the development of HTN in
adolescents.25,30,32 Further studies in
this area are warranted because of
the established link between chronic
stress and racism and between
chronic stress and CVD.
According to Klonoff and
Landrine, many people assume
that dark-skinned blacks experi-
ence higher rates of HTN than do
their lighter-skinned counterparts
because the former are victims of
racial discrimination.25 In their
study of 300 black adults, the
researchers established that the
Schedule of Racist Events, an 18-
item scale, was both comprehen-
sive and sensitive to differences
among blacks, with clear psycho-
metric integrity. The study reported
that dark-skinned blacks were 11
times more likely than light-
skinned blacks to experience fre-
quent racial discrimination (67%
vs. 8.5%). These findings suggest
that skin color may be a marker for
racial discrimination and highlight
the need to assess discrimination
(eg, in terms of access to high-qual-
ity healthcare) in studies of the
relationship between skin color
and HTN. Klonoff and Landrine
did not explicitly address the roles
of genetics and societal context (ie,
discrimination or racism) as risk
factors for HTN, but they did sug-
gest that both forces play a role.25
Community Context:
Access to Health Care
Access to health care for minority
adolescents encompasses being
insured, having an age-appropriate
clinic nearby, and receiving appro-
priate treatment. Without easy
access to health care, adolescents
with chronic conditions such as
HTN may never receive a diagnosis
or may be inadequately managed.
As of 2005, 15.8% of AA ado-
lescents, 7.8% of white non-
Hispanic adolescents, and 25.2%
of Hispanic adolescents lacked
health insurance.33 For persons
51
 PEDIATRICS
aged 18-24 years, these rates rose
to 35% for AAs, 26% for non-
Hispanic whites, and 51% for
Hispanics. Another study showed
that adolescents of color, including
AAs, Latinos, and Native
Americans, were less likely to have
their healthcare needs met than
were white or Asian/Pacific Islander
adolescents. 34 Possible barriers
for the AA, Latino, and Native-
American adolescents were lack of
transportation, lack of health insur-
ance or inadequate health insur-
ance, and bureaucratic health plan
problems. In a study of CVD risk
factors, Winkleby et al found that
lack of health insurance was a con-
cern for all groups, but that 52.8%
of MAs and 24.1% of AAs were
more likely to be uninsured, com-
pared with 20.7% of whites.26
A report by Hansen et al
demonstrated that HTN and pre-
HTN are often underdiagnosed in
adolescents.1 In this study, among
14,184 children and adolescents,
507 (3.6%) were found to have
HTN even though only 131 (26%)
of this group had a diagnosis of
HTN in their health record.
Rocchini cited a study by the British
Pediatric Association (BPA) show-
ing that only 68.6% of responding
pediatricians in outpatient settings
routinely measured BP in children
and adolescent patients.35 In the
same study, only 60.5% of respon-
dents had four or more BP cuff
sizes available in their office. The
American Academy of Pediatrics
emphasizes the importance of
using proper-sized cuffs in evaluat-
ing BP in adolescents.35 In the BPA
survey cited by Rocchini, 41% of
respondents stated that a nurse
always or sometimes measured
patients BP.35 Even if BP is mea-
sured, not all practitioners address
newly identified pre-HTN/HTN.1
Lack of health insurance or ade-
52 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS NOVEMBER/DECEMBER 2008 VOL. 12 NO. 11/12
quate coverage reduces adoles-
cents chance of being diagnosed
with HTN or, if diagnosed, being
managed appropriately.1,35
Access to health care for adoles-
cents is complex. Adolescents must
recognize the need for care, must
have transportation to the health-
care facility, and must have time
and money for the care rendered.
Furthermore, adolescents must
adhere to the recommended treat-
ment. Many minority adolescents,
including AAs, have difficulty with
at least one of these factors.
Overriding all of these concerns is
the need for insurance. Fox et al
found that among the factors of
health insurance coverage, income,
and maternal education level, lack
of insurance coverage was the
strongest predictor of adolescents
access (or lack thereof) to health
care.36 In addition, seeing many
different healthcare practitioners
(because of bureaucratic plans or
free/low cost access) can further
decrease the likelihood of timely
diagnosis and treatment of condi-
tions such as HTN. Adolescents
access to developmentally appro-
priate health care not only affects
the genesis of HTN, but also the
diagnosis and prompt and appro-
priate treatment of HTN.
Interpersonal Context
Interpersonal factors that may
influence the development of HTN
in adolescents of color include vio-
lence, anger, and health-related
behaviors such as an unhealthful
diet, lack of exercise, and cigarette
smoking. In addition, chronic
stress is known to affect the proper
functioning of the body and likely
has an adverse effect on BP.30,37
Furthermore, many adolescents of
color are exposed to violencea
stressor that can affect BP at multi-
ple points in daily life.29,38,39
ViolencePsychological stress
has been shown to increase BP and
the risk of future development of
HTN in adolescence.40-42 Exposure
to chronic stressful environmental
stimuli may increase the risk for
the development of essential HTN,
especially when experienced in the
context of other sociologic, psy-
chological, and constitutional fac-
tors.29 Witnessing violence and
harboring of anger are two such
stressors. Schuler and Nair found
that 60% of inner-city children had
witnessed someone being physical-
ly assaulted, threatened with a
knife, shot, or stabbed, indicating
that violence is part of life for most
inner-city children and adoles-
cents.43 Clark and Armstead investi-
gated the relationship between
family conflict and mean arterial
pressure changes in 39 AA adoles-
cents.29 Resting mean arterial pres-
sure, SBP, and DBP were assessed
on two occasions 6 months apart.
Assessments of perceived family
conflict (eg, assaults between fami-
ly members) and adverse life
events were made at baseline.
Findings from multiple regression
analyses indicated that family con-
flict predicted mean arterial BP
changes, independent of the effects
of age, gender, and BMI. Although
preliminary, these findings high-
light the importance of exploring
environmental processes that may
influence physiologic outcomes in
adolescents.
Anger and aggression are other
interpersonal stressors that have
been explored in children and ado-
lescents in relation to their effect
on BP. Yan et al found that impa-
tience and hostility had a direct
dose-response effect on long-
term HTN risk.44 These findings
solidly implicated negative emo-
tions in HTN development.44 Poole
et al reported that blacks of a cer-

The perception of racism could be
stressful and could play a role in the
development of HTN in adolescents.
tain genotype who reported high
levels of anger suppression had sig-
nificantly higher SBP and a higher
level of cardiac reactivity than did
their nonanger-suppressing coun-
terparts.45 A study of 140 school-
aged children showed that
increasing age and BMI were asso-
ciated with increased cardiovascu-
lar responses.46 Aggressive children
exhibited higher heart rates at
baseline and lower heart rate reac-
tivity. Aggressive children with a
positive parental history of HTN
exhibited the greatest cardiovascu-
lar response. This finding rein-
forces the idea that a heritable link
to the development of HTN in ado-
lescents may exist.46
Health BehaviorsThe grow-
ing obesity epidemic in the United
States has prompted many studies
assessing the effects of health-relat-
ed behaviors such as exercise pat-
terns and dietary habits on HTN
development in adolescents. Like
obese adults, obese children and
adolescents are at a greater risk of
developing essential HTN than are
their slimmer counterparts. Black
adolescents are more likely to be
obese and have lower fitness levels
than white adolescents.36 Links
have been made between low
activity levels and high BP. One
study concluded that sedentary
activities such as TV watching were
positively associated with SBP lev-
els independent of obesity/weight
status.47 Bassett et al found that
non-Hispanic blacks were less like-
VOL. 12 NO. 11/12 NOVEMBER/DECEMBER 2008 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS
ly to engage in leisure time physi-
cal activity than were non-Hispanic
whites or MAs.48
Few studies have investigated
the effects of dietary choices on
HTN in adolescents independent
of their implication in the develop-
ment of obesity. Savoca et al found
a caffeine dose-dependent increase
in BP among adolescents.10,11 These
authors and others have noted that
increased caffeine consumption
was accompanied by an increase in
ambulatory BP and increased uri-
nary excretion of epinephrine,
which may be related to a sympa-
thetic reaction to everyday stres-
sors.10,49 Also, black participants
were found to be more sensitive to
the effects of caffeine than were
white participants.10,11 These and
other findings support the rela-
tionship between interpersonal
factors and HTN in adolescents of
color.
Individual Context
Several non-modifiable factors
such as gender, race, and genetics
may affect HTN development.
Data from the 1988-1994
NHANES were examined for ethnic
variation in CVD risk factors in
children and young adults.26,50
Winkleby et al, after controlling for
socioeconomic factors and age,
found a strong ethnic variation in
CVD risk factors, including HTN.26
Bassett et al reported that non-
Hispanic blacks (older adolescents
and young adults), as a group, had
higher rates of HTN than did other
groups.48 Robinson et al found that
essential HTN was 80% heritable
and that primary HTN in adoles-
cents and children was most likely
due to additive effects of several
genetic factors.4 Among children
and adolescents in the study with
essential HTN, 49% had at least
one parent with essential HTN.4
The authors pointed out that an
interaction among genetic and
environmental components was
likely in the development of essen-
tial HTN. As previously men-
tioned, Poole et al. linked greater
cardiac reactivity to anger suppres-
sion in subjects whose parents had
HTN.45 All these findings suggest
the possible existence of a genetic
link to the development of essen-
tial HTN in adolescents.
Contextual Findings in a
Social-Ecological Model
The studies discussed in this article
reflect the complex influences of
society (eg, racism and discrimina-
tion), the community (eg, access to
health care), interpersonal rela-
tionships (eg, violence, anger,
stress, aggression), and individual
factors (eg, gender, race/ethnicity,
health-related behaviors, genetics)
on BP and the development of pre-
HTN/HTN in adolescents. To
improve care of individual adoles-
cents with pre-HTN/HTN, includ-
ing adolescents of color, NPs need
to understand how each of these
contexts, alone and together,
affects health. Some factors identi-
fied in the studies (eg, perceived
racism/discrimination, healthcare
access, health behaviors) may act
as mediators or modifiers with
respect to the association between
the independent variable and BP,
and a consideration of these possi-
bilities is warranted. The impor-
53
 PEDIATRICS
tance of understanding the interac-
tions and the adaptations that
occur in the setting of adolescent
pre-HTN/HTN has profound
implications for nursing research
and nursing practice.
Nursing Research Implications
The growing prevalence of adoles-
cent pre-HTN/HTN, especially in
adolescents of color, calls for NPs
to consider the complex environ-
ment contributing to the develop-
ment of this condition. However,
few nursing research studies in the
area of adolescent HTN have been
conducted, and current research
regarding adolescent HTN has not
captured its complexity. More
research to confirm previous find-
ings and explore areas that capture
the complexity of adolescent pre-
HTN/HTN are needed. Extensions
of previous research could assess
the relationships between adoles-
cent pre-HTN/HTN and racism
and perceived discrimination
(links between chronic stress and
racism and between chronic stress
and CVD have already been estab-
lished). Research could also
explore the effects of interpersonal
stressors (eg, neighborhood vio-
lence, dangerous health-related
behaviors, lack of access to health
care, lack of social support) in rela-
tion to adolescents BP (Figure).
Other areas open for study include
(1) ways in which the built envi-
ronment (eg, housing, transport
systems, services) affect the devel-
opment and treatment of adoles-
cent HTN, (2) how social support
systems and community involve-
ment can influence adolescent
HTN, and (3) how an adolescents
psychological well-being (eg, sense
of hope, body image, life satisfac-
tion, quality of life) affects the
development and progression of
HTN. Further research in these
54 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS NOVEMBER/DECEMBER 2008 VOL. 12 NO. 11/12
Many adolescents of color are exposed
to violencea stressor that can affect
BP at multiple points in daily life.
areas is well within the scope of NP
practice.
NP Practice Implications
The social-ecological perspective
outlined in this article has implica-
tions for NP practice in terms of
enhancing awareness regarding the
detection and treatment of HTN in
adolescents. The patient history for
pre-HTN/HTN in adolescents typi-
cally includes information such as
family history, social history, and
medication adherence. Missing are
the social contexts and related fac-
tors identified in this article. These
factors may contribute to a greater
stress load and affect cardiovascu-
lar reactivity. By ensuring that all
contextual components are
addressed in the history and the
plan of care, NPs can provide a
more holistic approach for adoles-
cents with pre-HTN/HTN, particu-
larly for those of color. Once
adolescents have been assessed for
pre-HTN/HTN, they need to
receive appropriate treatment
based on NHLBI guidelines.
Practice guidelines recommend
that BP be checked in all patients
aged 3 years.51 NPs taking BP mea-
surements in children and adoles-
cents should use the correct-sized
cuff, proper location of the cuff,
and correct technique. Appropriate
training in the procedure is essen-
tial to avoid overdiagnosis and
ensure appropriate treatment.
Furthermore, research has demon-
strated that the odds of diagnosis
increase when patients have fre-
quent BP readings in conjunction
with documentation of age, height,
and diagnosis of obesity.1 In prac-
tice, despite the preponderance of
evidence of pre-HTN/HTN in
patient records, these diagnoses are
not being made.1 NPs should
understand the parameters of nor-
mal BP ranges for adolescents and
show vigilance in assessing previ-
ous BP measurements. Because
interpretation of BP values in chil-
dren and adolescents depends on
their age, sex, and height per-
centile, NPs may need BP tables for
reference. Such tables are available
in the 2004 Update on the 1987
Task Force Report on High Blood
Pressure in Children and Adoles-
cents: A Working Group Report
from the National High Blood
Pressure Education Program (http://
www.nhlbi.nih.gov/guidelines/hype
rtension/child_tbl.pdf).7
In addition to diagnosing pre-
HTN/HTN in adolescents, NPs can
play a role in reducing the risk of
developing these conditions in this
age group.45 Strategies include edu-
cating adolescents and their par-
ents about modifiable and
non-modifiable risk factors.
Information should be provided
about following a heart-healthy
diet, avoiding excessive caffeine
intake, getting regular exercise, and
obtaining regular wellness check-
ups. Stress management should be
a component of patient and parent
education. Stress reduction and
relief techniques such as
Transcendental Meditation have
been shown to have beneficial car-
diovascular effects both at rest and
during periods of stress.52
Conclusion
The rising prevalence of pre-
HTN/HTN in adolescents is a
major concern. NPs should follow
the most recent guidelines in terms
of identifying and managing pre-
HTN/HTN in their adolescent
patients. Measuring BP in adoles-
cents on a regular basis will identi-
fy those most at risk for HTN and
potential future complications.
Furthermore, NPs should make
sure that pre-HTN/HTN is identi-
fied and addressed from a social-
ecological perspective. Keeping the
social-ecological context in mind,
which complements nursings
holistic paradigm of care, will
allow NPs to intervene within the
context of an adolescents lived
experience.
Jennifer Fleming is a registered nurse
at St Joseph Mercy Hospital in Ann
Arbor, Michigan, and a masters stu-
dent at Wayne State University
College of Nursing in Detroit. Nancy
George is an assistant professor (clin-
ical) at Wayne State University
College of Nursing in Detroit,
Michigan. The authors state that they
do not have a financial interest in or
other relationship with any commer-
cial product named in this article.
Acknowledgment
The authors thank Beth Langelier,
Manuscript Technician, College of
Nursing, Wayne State University,
for her assistance with this article.
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56 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS NOVEMBER/DECEMBER 2008 VOL. 12 NO. 11/12