Complex Risk Factors Underlying Pre-hypertension ...

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 contexts—society, the community, interpersonal relationships, and the individual—with 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 meaningful way to improve these patients’ health.

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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 primary HTN in adolescence are risk factors for HTN in early adulthood,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 predisposition and excess weight.1,4 The genetic predisposition for HTN at all ages has been established; what is not clear is how genetics interacts 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 separate 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 adulthood.6 Of more urgent concern, elevated systolic BP (SBP) in children and adolescents has been

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found to compromise cognitive and neuropsychologic performance, impairing attention, concentration, and mathematical skills.8,9 An established body of literature has identified family history of HTN, low birth weight, and obesity as risk factors for pediatric HTN, but little is known about other factors, including race/ethnicity, that are contributing to the increased prevalence of primary HTN in the adolescent population.1,10-13 Understanding 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

as it develops in adolescence, even if at a mild stage, could help reduce the incidence of CVD, renal disease, and stroke in adults.3

Social-Ecological Model The social-ecological model is a good fit with the holistic perspective that NPs use in caring for their adolescent patients. Preventing HTN development requires an understanding of environmental factors that influence this condition. The social-ecological model considers the complex interplay among societal, community, interpersonal, 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

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 preHTN/HTN in adolescents, particularly 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-ecological perspective to analyze the effects that each of the four contexts can have on an adolescent’s health—specifically, on BP.

FIGURE. ECOLOGICAL MODEL OF THE ADOLESCENT HYPERTENSION LITERATURE MACRO LEVEL

MESO LEVEL

MICRO LEVEL

MICRO LEVEL

(SOCIETY)

(COMMUNITY)

(INTERPERSONAL)

(INDIVIDUAL)

IDEOLOGIES Racism ■ Discrimination ■

ACCESS TO HEALTH CARE

Chronic Stress

HEALTH OUTCOMES ■ Pre-hypertension/ hypertension ■ Normal blood pressure

Anger and Violence DEMOGRAPHICS Age ■ Gender ■ Race ■ Genetics ■ Education ■ Parental Income ■

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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 example, 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/discrimination and elevated BP. For example, Harris et al used data from Healthy People 2010 to identify longitudinal trends and racial/ethnic disparities in terms of 20 leading health indicators from adolescence through young adulthood.21 They found a “black-white male-female disparity” in 50% of the Healthy People 2010 indicators and a “Hispanic-white malefemale disparity” in 35% of the indicators. Native Americans, nonHispanic 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/ethnic groups. Jago et al verified the prevalence of elevated BP among eighthgrade adolescents from three US locations and ascertained whether the prevalence in their study sample 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 participants aged 12-19 years was

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) participants, 11.3% for MexicanAmerican (MA) participants, and 7.5% for white participants.22,23 Few studies have investigated BP in Native-American adolescents. One study conducted on NativeAmerican grade-school children showed that this group, compared with black children and white children, 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 management 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 origin, including perceived racism. Much of the research conducted regarding the effect of racism on BP was done >10 years ago and was primarily on adult AAs.30 Clark and Gochett found that the ways in which psychosocial and environmental 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 experience 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 18item scale, was both comprehensive and sensitive to differences among blacks, with clear psychometric integrity. The study reported that dark-skinned blacks were 11 times more likely than lightskinned blacks to experience frequent 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-quality 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 suggest 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 appropriate 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 adolescents, 7.8% of white nonHispanic adolescents, and 25.2% of Hispanic adolescents lacked health insurance.33 For persons


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aged 18-24 years, these rates rose to 35% for AAs, 26% for nonHispanic 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 NativeAmerican adolescents were lack of transportation, lack of health insurance or inadequate health insurance, and bureaucratic health plan problems. In a study of CVD risk factors, Winkleby et al found that lack of health insurance was a concern for all groups, but that 52.8% of MAs and 24.1% of AAs were more likely to be uninsured, compared with 20.7% of whites.26 A report by Hansen et al demonstrated that HTN and preHTN 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) showing 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 respondents 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 evaluating 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 measured, not all practitioners address newly identified pre-HTN/HTN.1 Lack of health insurance or ade52

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quate coverage reduces adolescents’ chance of being diagnosed with HTN or, if diagnosed, being managed appropriately.1,35 Access to health care for adolescents is complex. Adolescents must recognize the need for care, must have transportation to the healthcare facility, and must have time and money for the care rendered. Furthermore, adolescents must adhere to the recommended treatment. 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 conditions such as HTN. Adolescents’ access to developmentally appropriate health care not only affects the genesis of HTN, but also the diagnosis and prompt and appropriate treatment of HTN.

Interpersonal Context Interpersonal factors that may influence the development of HTN in adolescents of color include violence, 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 violence—a stressor that can affect BP at multiple points in daily life.29,38,39

Violence—Psychological 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, psychological, and constitutional factors.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 physically assaulted, threatened with a knife, shot, or stabbed, indicating that violence is part of life for most inner-city children and adolescents.43 Clark and Armstead investigated the relationship between family conflict and mean arterial pressure changes in 39 AA adolescents.29 Resting mean arterial pressure, SBP, and DBP were assessed on two occasions 6 months apart. Assessments of perceived family conflict (eg, assaults between family members) and adverse life events were made at baseline. Findings from multiple regression analyses indicated that family conflict predicted mean arterial BP changes, independent of the effects of age, gender, and BMI. Although preliminary, these findings highlight 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 adolescents in relation to their effect on BP. Yan et al found that impatience and hostility had a direct “dose-response” effect on longterm HTN risk.44 These findings solidly implicated negative emotions 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 significantly higher SBP and a higher level of cardiac reactivity than did their non–anger-suppressing counterparts.45 A study of 140 schoolaged children showed that increasing age and BMI were associated with increased cardiovascular responses.46 Aggressive children exhibited higher heart rates at baseline and lower heart rate reactivity. Aggressive children with a positive parental history of HTN exhibited the greatest cardiovascular response. This finding reinforces the idea that a heritable link to the development of HTN in adolescents may exist.46 Health Behaviors—The growing obesity epidemic in the United States has prompted many studies assessing the effects of health-related behaviors such as exercise patterns 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 levels independent of obesity/weight status.47 Bassett et al found that non-Hispanic blacks were less like-

ly to engage in leisure time physical 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 development 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 urinary excretion of epinephrine, which may be related to a sympathetic reaction to everyday stressors.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 relationship 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 nonHispanic 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 adolescents 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 essential HTN. As previously mentioned, Poole et al. linked greater cardiac reactivity to anger suppression in subjects whose parents had HTN.45 All these findings suggest the possible existence of a genetic link to the development of essential 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 discrimination), the community (eg, access to health care), interpersonal relationships (eg, violence, anger, stress, aggression), and individual factors (eg, gender, race/ethnicity, health-related behaviors, genetics) on BP and the development of preHTN/HTN in adolescents. To improve care of individual adolescents with pre-HTN/HTN, including adolescents of color, NPs need to understand how each of these contexts, alone and together, affects health. Some factors identified 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 possibilities is warranted. The impor-


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tance of understanding the interactions 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 adolescent pre-HTN/HTN, especially in adolescents of color, calls for NPs to consider the complex environment contributing to the development 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 findings and explore areas that capture the complexity of adolescent preHTN/HTN are needed. Extensions of previous research could assess the relationships between adolescent pre-HTN/HTN and racism and perceived discrimination (links between chronic stress and racism and between chronic stress and CVD have already been established). Research could also explore the effects of interpersonal stressors (eg, neighborhood violence, dangerous health-related behaviors, lack of access to health care, lack of social support) in relation to adolescents’ BP (Figure). Other areas open for study include (1) ways in which the built environment (eg, housing, transport systems, services) affect the development and treatment of adolescent HTN, (2) how social support systems and community involvement can influence adolescent HTN, and (3) how an adolescent’s psychological well-being (eg, sense of hope, body image, life satisfaction, quality of life) affects the development and progression of HTN. Further research in these 54

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Many adolescents of color are exposed to violence—a 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 implications 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 typically includes information such as family history, social history, and medication adherence. Missing are the social contexts and related factors identified in this article. These factors may contribute to a greater stress load and affect cardiovascular 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 adolescents with pre-HTN/HTN, particularly 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 measurements in children and adolescents should use the correct-sized cuff, proper location of the cuff, and correct technique. Appropriate training in the procedure is essential to avoid overdiagnosis and ensure appropriate treatment. Furthermore, research has demon-

strated that the odds of diagnosis increase when patients have frequent BP readings in conjunction with documentation of age, height, and diagnosis of obesity.1 In practice, 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 normal BP ranges for adolescents and show vigilance in assessing previous BP measurements. Because interpretation of BP values in children and adolescents depends on their age, sex, and height percentile, 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 Adolescents: 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 preHTN/HTN in adolescents, NPs can play a role in reducing the risk of developing these conditions in this age group.45 Strategies include educating adolescents and their parents 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 checkups. 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 cardiovascular effects both at rest and during periods of stress.52

Conclusion The rising prevalence of preHTN/HTN in adolescents is a major concern. NPs should follow the most recent guidelines in terms of identifying and managing preHTN/HTN in their adolescent patients. Measuring BP in adolescents on a regular basis will identify those most at risk for HTN and potential future complications. Furthermore, NPs should make sure that pre-HTN/HTN is identified and addressed from a socialecological perspective. Keeping the social-ecological context in mind, which complements nursing’s holistic paradigm of care, will allow NPs to intervene within the context of an adolescent’s lived experience. ■

adolescents. JAMA. 2007;298(8):874-879. 2. Mitsnefes M. Hypertension in children and adolescents. Pediatr Clin North Am. 2006; 53(3):493-512. 3. US Preventive Services Task Force. Screening for high blood pressure: recommendations and rationale. Am Fam Physician. 2003;68(10):20192022. 4. Robinson RF, Batisky DL, Hayes JR, et al. Significance of heritability in primary and secondary pediatric hypertension. Am J Hypertens. 2005;18(7):917-921. 5. Miller SM, McDaniel SH, Rolland JS, Feetham SL, eds. Individuals, Families, and the New Era of Genetics: Biopsychosocial Perspectives. New York, NY: WW Norton & Co.; 2006:423-444. 6. National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. 2004;114(2 suppl 4th Report):555-576.

17. Riner ME, Saywell RM. Development of the social ecology model of adolescent interpersonal violence prevention. J School Health. 2002;72(2): 65-70. 18. Bronfenbrenner U. Ecological systems theory. Ann Child Devel. 1989;6:187-249. 19. Dressler WW, Oths KS, Gravlee CG. Race and ethnicity in public health research: models to explain health disparities. Annual Rev Anthropol. 2005;34:231-252. 20. Keppel KG, Pearcy JN, Wagener DK. Trends in racial and ethnic-specific rates for the health status indicators: United States, 1990-98. Healthy People 2000 Stat Notes. 2002;23:1-16. 21. Harris MB, Harris RJ, Davis SM. Ethnic and gender differences in Southwestern students' sources of information about health. Health Educ Res. 1991;6(1):31-42. 22. Jago R, Harrell JS, McMurray RG, et al. Prevalence of abnormal lipid and blood pressure values among an ethnically diverse population of eighth-grade adolescents and screening implications. Pediatrics. 2006;117(6):2065-2073.

7. National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. A Pocket Guide to Blood Pressure Measurement in Children. 2007. Available at: http://www.nhlbi.nih.gov/

23. Nazroo JY. The structuring of ethnic inequalities in health: economic position, racial discrimination, and racism. Am J Public Health. 2003; 93(2):277-284.

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Jennifer Fleming is a registered nurse at St Joseph Mercy Hospital in Ann Arbor, Michigan, and a master’s student at Wayne State University College of Nursing in Detroit. Nancy George is an assistant professor (clinical) 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 commercial product named in this article.

10. Savoca MR, Evans CD, Wilson ME, et al. The association of caffeinated beverages with blood pressure in adolescents. Arch Pediatr Adolesc Med. 2004;158:473-477.

26. Winkleby MA, Robinson TN, Sundquist J, Kraemer HC. Ethnic variation in cardiovascular disease risk factors among children and young adults. JAMA. 1999;281(11):1006-1013.

11. Savoca MR, MacKey ML, Evans CD et al. Association of ambulatory blood pressure and dietary caffeine in adolescents. Am J Hypertens. 2005;18(1):116-120.

27. Krieger N. and Stephen S. Racial discrimination and blood pressure: The CARDIA study of young black and white adults. Am J Public Health. 1996;86(10):1370-1378.

12. Páll D, Katona É, Zrínyi M, et al. Screening of adolescent hypertension, and evaluation of target organ damages. results from the Debrecen hypertension study. Am J Hypertens. 2005;18(5 suppl 1):A113.

28. Manatunga AK, Jones JJ, Pratt H. Longitudinal assessment of blood pressures in black and white children. Hypertension. 1993;22(1):84-89.

Acknowledgment

14. Schulz A, Northridge ME. Social determinants of health: Implications for environmental health promotion. Health Educ Behav. 2004;31(4):455471.

The authors thank Beth Langelier, Manuscript Technician, College of Nursing, Wayne State University, for her assistance with this article. References 1. Hansen ML, Gunn PB, Kaelber DC. Underdiagnosis of hypertension in children and

13. Israeli E, Schochat T, Korzets Z, et al. Prehypertension and obesity in adolescents: a population study. Am J Hypertens. 2006;19(7):708-712.

15. Mandara J, Murray C, Bangi AK. Predictors of African American adolescent sexual activity: an ecological framework. J Black Psychology. 2003;29 (3):337-356. 16. Grzwacz JG, Fuqua J. The social ecology of health: leverage points and linkages. Behav Med. 2000;26(3):101-115.

29. Clark R, Armstead C. Family conflict predicts blood pressure changes in African-American adolescents: a preliminary examination. J Adolesc. 2000;23:355-358. 30. Peters RM. The relationship of racism, chronic stress emotions, and blood pressure. J Nurs Schol. 2006;38(3):234-240. 31. Clark R, Gochett P. Interactive effects of perceived racism and coping responses predict a school-based assessment of blood pressure in black youth. Ann Behav Med. 2006;32(1):1-9. 32. Krieger N, Smith K, Naishadham D, et al. Experiences of discrimination: validity and reliability of a self-report measure for population health research on racism and health. Soc Sci Med. 2005;61(7):1576-1596.


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