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February is Black History Month, which celebrates the achievements of African Americans in every area of endeavor, including their vital contributions to our military.
African Americans represent the second largest minority population in the United States following Hispanics (12% and 18%).1 According to the 2017 Minority Veterans Report, minority Veterans made up about 23% of the total Veteran population in 2014, and 52% of minority Veterans were Black non-Hispanics compared with 32% of non-Veteran minorities. Moreover, in 2014 about 46% of minority Veterans were enrolled in VA healthcare – increasing from 871,918 in 2005 to 1,261,559 in 2014.
Understanding how to reduce disparities in healthcare quality and outcomes is critical to achieving VA's mission of maximizing the health of the Veteran population. HSR&D funds two Centers of Innovation that specifically focus on issues related to health equity, including the Charleston Health Equity and Rural Outreach Innovation Center and the Center for Health Equity Research & Promotion. HSR&D also collaborates with the VHA Office of Health Equity on the Office of Health Equity-QUERI Partnered Evaluation Initiative. Following are descriptions of just a few select studies that HSR&D investigators are conducting on issues important to providing optimal healthcare for African American Veterans, including:
Control rates for hypertension (HTN) among minority Veterans, in particular African American Veterans, are significantly lower compared to white Veterans. Poor HTN control leads to higher rates of organ damage, stroke, and cardiovascular complications. Few strategies to improve HTN control have focused on culturally-sensitive interventions to improve control among African American Veterans. Moreover, providing information in a narrative form (i.e. stories) has been found to be an effective mode of delivering health information. This HSR&D study builds on the investigators’ prior work to evaluate the effectiveness of a "Stories" intervention among African American patients at three VA medical centers with a high prevalence of African American Veterans. Investigators recruited more than 600 African American Veterans and will videotape them telling their actual stories about managing their blood pressure. With these stories, they will develop an interactive multimedia intervention targeted to African American patients, "Stories to Communicate about Managing Hypertension," and deliver it using an easy-to-use DVD resource.
Participants included 618 African American Veterans who were randomized to the Stories intervention or the control group. After watching the DVD, Veterans in the intervention group reported the content more emotionally engaging compared to Veterans in the control group. At follow-up, 87% of those in the intervention group strongly agreed/agreed that they were confident they could maintain lifestyle change, compared with 77% of Veterans in the control group. Looking at physiologic outcomes, at baseline the mean systolic blood pressure was 138.4 with no significant difference by group. However, at follow-up there was a 3.3mmHg difference in blood pressure, favoring Veterans in the intervention group.
Implications: In this population of at-risk African American Veterans, adding personal stories of Veterans resulted in increased emotional engagement and downstream positive effects on self-reported behavior and objectively measured blood pressure.
Houston T, Fix G, Shimada S, et al. African American Veterans Storytelling: A multisite randomized trial to improve hypertension. Medical Care. September 2017;55:S50-S58.
Chronic musculoskeletal (MSK) pain is one of the most common conditions among Veterans, affecting approximately 60% of those seen in VA primary care. Although perceived effectiveness of chronic pain treatment is low among all VA patients, black patients are less likely than whites to perceive their treatment as effective, and are more likely to experience functional limitations due to pain. There is growing consensus that chronic pain is best addressed by a biopsychosocial approach that acknowledges the role of psychological and environmental contributors to pain, some of which differ by race and, hence, contribute to disparities. For example, blacks experience greater pain-related fear and lower self-efficacy in coping with pain (psychological contributors), and neighborhoods that make physical activity difficult (environmental contributors). However, there is a lack of effective interventions to improve pain treatment among minority patients, particularly those that target psychological and environmental contributors. The primary objective of this HSR&D-funded study is to test the effectiveness of a multi-component intervention that specifically targets known barriers to effective pain care among black Veterans with chronic MSK pain. Investigators have developed a telephone-delivered intervention that emphasizes walking and incorporates action planning, motivational interviewing, and cognitive behavioral therapy techniques, as well as the use of pedometers. They are currently testing the effectiveness of this intervention in a randomized trial that compares it to usual care among 250 black and 250 non-black Veterans with chronic MSK pain.
Implications: The research is expected to result in a non-pharmacological intervention, delivered by telephone and designed to reduce pain and improve functioning among black patients with MSK pain by promoting walking.
Patient-provider communication has been identified as one of the key mediators for racial health disparities in physical and mental health. Yet the views and experiences of ethnic minority Veterans regarding health communication, especially in mental health, remain under-studied. This HSR&D study investigated the processes, facilitators, and barriers to mental health treatment decisions for African American Veterans. Investigators conducted interviews with 36 African American Veterans receiving VA outpatient psychiatric care and 9 VA mental healthcare providers to identify barriers and facilitators to patient engagement and treatment decisions in mental healthcare. Veterans completed self-report measures that assessed patient-provider working alliances, attitudes towards medication, and patient activation.
Findings show that most participants (83%) preferred to have a collaborative treatment decision-making process with their mental health providers; however, only 40% reported that they actually experienced their preferred method of treatment decision-making. Comparisons between African-American and White Veterans (N=141) on two key aspects of patient engagement – patient activation and working alliance, showed significant differences. After adjusting for demographics, race was significantly associated with patient activation, working alliance, and medication adherence scores. African-American Veterans had significantly lower levels of patient activation and working alliance than White Veterans. Patient activation also was associated with working alliance, even after adjusting for sociodemographic factors and participants' length of time with their providers. Further, results indicated that African-American Veterans scored lower on items related to self-efficacy and patient-provider communication (e.g., "I am confident that I can tell my mental health clinician concerns I have even when he or she does not ask."). In addition, study participants provided several suggestions for improving patient-provider communication among African-American and other minority Veterans, including:
Implications: This study contributes to VA's efforts to implement its comprehensive Mental Health Strategic Plan and the design of an intervention for reducing health disparities and supporting mental health recovery among African American Veterans.
Eliacin J, Coffing J, Matthias M, et al. The relationship between race, patient activation, and working alliance: implications for patient engagement in mental health care. Administration and Policy in Mental Health and Mental Health Services Research. January 2018;45(1):186-192.
Eliacin J, Rollins A, Salyers M, et al. Engaging African-American Veterans in mental health care: Patients’ perspectives. Journal of Nervous and Mental Disease. 2016;204(4):254-60.
Primary care is often the first step in treatment for Veterans with a mental health or substance use disorder (MHSUD). How persons with MHSUDs experience care in Patient-Centered Medical Homes (PCMHs) is unknown. This study examined racial and ethnic differences in positive and negative experiences in VA PCMH settings among 65,930 Veterans with MHSUDs who completed VA’s 2013 PCMH Survey of Healthcare Experiences of Patients. This included ratings across 7 domains: access, communication, office staff helpfulness/courtesy, provider ratings, comprehensiveness, medication shared decision-making, and self-management support. Study participants were 67% White, 20% Black, 11% Hispanic, 1% American Indian/Alaska Native (AI/AN), and 1% Asian/Pacific Islander (A/PI).
Findings show that in this large sample of Veterans with MHSUDs, positive experiences were reported least often for access (22%). Negative experiences were reported most often for self-management support (30%) and comprehensiveness (16%), defined as provider attention to MHSUD concerns. One or more racial/ethnic minority groups reported more negative and/or fewer positive experiences than Whites, including:
Implications: Solutions are needed to improve access to care for all Veterans with MHSUDs, with additional attention on improving access for Black, Hispanic, and AI/AN Veterans. Interventions to reduce racial/ethnic disparities in patient experiences should also target providers’ communication skills and attention to MHSUD concerns, and office staff helpfulness and courtesy.
Jones A, Mor M, Cashy J, Gordon A, et al. Racial/ethnic differences in primary care experiences in patient-centered medical homes among Veterans with mental health and substance use disorders. Journal of General Internal Medicine. December 2016;31(12):1435-1443.
Arthritis is a prevalent and disabling source of chronic pain for which African Americans bear a disproportionate burden. This ongoing HSR&D study is testing a patient-centered, non-invasive intervention to improve pain outcomes and reduce disparities among African American and white Veterans with knee arthritis. The intervention was created to help Veterans develop positive psychological skills such as gratitude and kindness, the health benefits of which are well-documented. A randomized design is being used to assess the effects of a six-week positive activities program on pain and functioning at one, three, and six months post-intervention. The program consists of at-home activities that have been shown to increase positivity and showed promise for reducing pain in prior studies. A total of 517 Veterans were enrolled in the study and participated in weekly telephone calls from trained interventionists to assess program completion and clarify activity instructions. Outcomes, including self-reported pain and physical functioning, were evaluated, in addition to potential mediating variables such as depressive symptoms, positive/negative affect, satisfaction with life, arthritis self-efficacy, pain coping, pain catastrophizing, perceived discrimination, global stress, and social support. Analyses are ongoing.
Implications: In the future, this program could be used by Veterans with other chronic pain conditions and adapted for widespread implementation using electronic modalities.
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