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IIR 05-062 – HSR&D Study

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IIR 05-062
Culture and Communication in Hypertension Management
Barbara G. Bokhour PhD
Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA
Bedford, MA
Funding Period: October 2006 - September 2010

BACKGROUND/RATIONALE:
Hypertension affects more than 50 million Americans, and studies in VA have confirmed a disproportionate number of veterans with poorly controlled blood pressure are ethnic minorities. The underlying causes of the disparities in control and adherence are poorly understood. Patient beliefs and behaviors as well as patient-provider communication may all contribute to poor adherence to medications and other recommendations.

OBJECTIVE(S):
In this study we sought to examine the relationships between patient explanatory models, their social context, patient-provider communication and hypertension (HTN) self-management. The objective was to better understand how patient level factors and patient-provider communication affect patients' hypertension self-management behaviors. This innovative study used mixed methods to study the ways in which patients' cultural backgrounds, perspectives and preferences affect communication with providers about hypertension care and patients' health behaviors related to their blood pressure.

METHODS:
We audio recorded 54 provider-patient interactions and conducted 48 patient semi-structured interviews, and 12 provider semi-structured interviews. Interview data were analyzed using grounded theory methods. Interaction data were analyzed using discourse analysis and content analysis. Phase II: We conducted a structured telephone survey of 43 White, 40 African-American (AA)and 20 Hispanic patients to assess differences in explanatory models (EM), daily lived experience (DLE) and patient-provider communication. We extracted patients' blood pressure from VISTA over 180 days to assess HTN control where uncontrolled HTN, was defined as having more than two measurements of >140/90 (or 130/80 for diabetic patients) in the past 180 days. We conducted analyses of variance to examine differences in EMs and DLE among AA, White or Hispanic veterans. We used logistic regression to examine whether individual EM or DLE items predicted BP control, adjusting for race/ethnicity.

FINDINGS/RESULTS:
Both qualitative and quantitative findings suggest that patient's explanatory models such as beliefs about the cause of HTN, the value of treatment and the meaning of symptoms affect HTN management. Moreover, patients' daily lived experiences - their social context, daily routines and habits and other comorbidities - all affect how they manage their HTN. For example, explanatory models that include stress as a primary cause of HTN and perceived symptoms of HTN were related to suboptimal HTN management practices. Patients who lived alone often eat in restaurants regularly as a means of having social contact, which leads them to consume high levels of sodium. In clinical encounters, providers rarely asked patients about patients' EMs or DLEs. Instead, providers focus on standard medical scripts to assess adherence and educate patients about HTN. This represents a significant gap between provider clinical tasks and patient illness experiences.

IMPACT:
Educational materials about HTN may focus more on addressing some of the explanatory models and daily lived experiences. This may be particularly effective for African-American patients. Improving providers' patient-centered communication skills is another approach to addressing patients' EMs and DLEs in clinical care. Teaching providers to ask questions such as, "what do you think is causing your high blood pressure?" or "What do you think about taking medications to help with your blood pressure?" might lead providers to greater insights about their patients' HTN management behaviors.

PUBLICATIONS:

Journal Articles

  1. Fix GM, Cohn ES, Solomon JL, Cortés DE, Mueller N, Kressin NR, Borzecki A, Katz LA, Bokhour BG. The role of comorbidities in patients' hypertension self-management. Chronic Illness. 2014 Jun 1; 10(2):81-92.
  2. Bokhour BG, Cohn ES, Cortés DE, Solomon JL, Fix GM, Elwy AR, Mueller N, Katz LA, Haidet P, Green AR, Borzecki AM, Kressin NR. The role of patients' explanatory models and daily-lived experience in hypertension self-management. Journal of general internal medicine. 2012 Dec 1; 27(12):1626-34.
  3. Cohn ES, Cortés DE, Fix G, Mueller N, Solomon JL, Bokhour BG. Habits and routines in the daily management of hypertension. Journal of Health Psychology. 2012 Sep 1; 17(6):845-55.
  4. Hanlon JT, Wang X, Castle NG, Stone RA, Handler SM, Semla TP, Pugh MJ, Berlowitz DR, Dysken MW. Potential underuse, overuse, and inappropriate use of antidepressants in older veteran nursing home residents. Journal of the American Geriatrics Society. 2011 Aug 8; 59(8):1412-20.
  5. Solomon J. How strategies for managing patient visit time affect physician job satisfaction: a qualitative analysis. Journal of general internal medicine. 2008 Jun 1; 23(6):775-80.
Conference Presentations

  1. Vimalananda V, Solomon J, Bokhour BG. Relation of patient-provider communication to perceived adherence and treatment intensification in hypertension. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2013 Apr 25; Denver, CO.
  2. Bokhour BG, Fix GM, Solomon J, Cohn ES, Cortes DE, Elwy AR, Mueller N, Haidet P, Katz LA, Borzecki A, Kressin NR. Racial/ethnic differences in explanatory models, daily lived experience and hypertension management behaviors. Poster session presented at: International Conference on Communication in Healthcare; 2011 Oct 16; Chicago, IL.
  3. Bokhour BG, Solomon J, Cohn ES, Cortes DE, Elwy AR, Katz L, Haidet P, Borzecki AM, Fix GM, Mueller NM, Kressin NR. Racial/ethnic differences in explanatory models, daily lived experience and HTN management behaviors. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2011 May 7; Phoenix, AZ.
  4. Bokhour BG. Communicating About Hypertension: The Role of Explanatory Models & Daily Lived Experiences. Poster session presented at: VA HSR&D National Meeting; 2011 Feb 16; Washington, DC.
  5. Fix GM, Solomon J, Cohn EC, Mueller NM, Cortes DE, Elwy AR, Kressin NR, Haidet PM, Borzecki AM, Bokhour BG. Using an Illness Web to Understand the Role of Co-Occurring Illnesses in Veterans’ Self-Management of Hypertension. Poster session presented at: VA HSR&D National Meeting; 2011 Feb 16; National Harbor, MD.
  6. Bokhour BG, Solomon J, Cohn EC, Cortes DE, Elwy AR, Haidet L, Katz L, Borzecki AM, Green AR, Fix GM, Kressin NR. Explanatory models & daily lived experience in patient-provider communication about hypertension. Poster session presented at: VA HSR&D National Meeting; 2011 Feb 14; Baltimore, MD.
  7. Bokhour BG. Communicating About Hypertension: The Role of Explanatory Models & Daily Lived Experiences. Poster session presented at: American Academy on Communication in Healthcare International Annual Conference; 2010 Oct 15; Phoenix, AZ.
  8. Bokhour BG. Racial/ethnic differences in explanatory models, daily lived experience and HTN management behaviors. Paper presented at: VA HSR&D Field-Based Equity Conference; 2010 Sep 13; Boston, MA.
  9. Fix GM, Cohn ES, Cortes DE, Solomon J, Bokhour BG. "When I found out I had all the sickness”: Using an illness-web to understand patient barriers to high blood pressure management. Poster session presented at: Communication, Medicine and Ethics (COMET) Interdisciplinary Annual Conference; 2010 Jun 28; Boston, MA.
  10. Solomon J, Fix GM, Cohn EC, Cortes DC, Mueller NM, Bokhour BG. The Role of Speech Registers in Negotiating Problem-Solving: A Qualitative Analysis of Patient-Provider Communication. Paper presented at: Communication, Medicine and Ethics (COMET) Interdisciplinary Annual Conference; 2010 Jun 18; Boston, MA.
  11. Bokhour BG, Cohn EC, Fix GM, Cortes DE, Haidet P, Green AR, Elwy AR, Katz LA, Borzecki AM, Solomon J, Kressin NR. Patient Explanatory Models of Symptoms and Causes of Hypertension: Relationship to Patient Self-Management Strategies. Paper presented at: Communication in Healthcare International Annual Conference; 2009 Oct 5; Miami, FL.
  12. Solomon J, Cohn ES, Cortes DE, Haidet P, Fix GM, Bokhour BG. U.S. Primary Care Providers’ ‘Narrative Mind Reading’ of Patients: Examples from Hypertension and Asthma (Mis)management. Presented at: American Anthropological Association Society for Medical Anthropology International Conference; 2009 Sep 24; New Haven, CT.
  13. Fix GM, Solomon J, Cortes D, Cohn ES, Bokhour BG. When I found out I had all the sickness, hypertensive patient experiences integrating management of co-occurring health conditions. Paper presented at: American Anthropological Association Society for Medical Anthropology International Conference; 2009 Aug 24; New Haven, CT.
  14. Bokhour BG, Cohn ES, Cortes DE, Fix GM, Solomon J. Patients’ cultural models of hypertension: The discourse of stress. Paper presented at: Communication, Medicine and Ethics (COMET) Interdisciplinary Annual Conference; 2009 Jun 21; Cardiff, Wales.
  15. Bokhour BG, Solomon J, Cohn ES, Cortes DE, Elwy AR, Haidet P, Katz L, Borzecki AM, Green A, Kressin NR. Patient perspectives on managing hypertension: Developing a new conceptual model of patient behavior. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2009 May 20; Miami, FL.
  16. Bokhour BG, Solomon J, Cohn EC, Cortes DE, Haidet P, Elwy AR, Katz L, Borzecki AM, Green AR, Kressin NR. Patient Perspectives on Managing Hypertension: Developing a New Conceptual Model of Patient Behavior. Poster session presented at: VA HSR&D National Meeting; 2009 Feb 13; Baltimore, MD.


DRA: Health Systems
DRE: Treatment - Observational
Keywords: Communication -- doctor-patient, Ethnic/cultural, Hypertension
MeSH Terms: none

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