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IIR 10-132 – HSR&D Study

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IIR 10-132
Using Stories to address disparities in Hypertension
Thomas K Houston MD MPH
Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA
Bedford, MA
Funding Period: August 2011 - January 2016

BACKGROUND/RATIONALE:
Despite improvements in hypertension (HTN) control in VA, disparities remain. Control rates for minority veterans, in particular African-American veterans, are significantly lower, and poor HTN control leads to higher rates of end organ damage, stroke and cardiovascular complications in these populations. Interventions to improve HTN control have had varying levels of success in the VA. But few have focused their efforts on culturally-sensitive interventions to improve control among African-American veterans. Our previous studies have indicated that explanatory models (ways of thinking) and daily lived experience (routines and habits in daily life) influence patients' decisions to act and their ability to manage their HTN. Moreover, providing information in a narrative form (i.e. stories) has been found to be an effective mode of delivering health information.

OBJECTIVE(S):
We build on our 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 patients. We will recruit 30 African-American veterans and videotape them telling their actual stories about managing their blood pressure. With these stories, we will develop the interactive multimedia intervention targeted to African-American patients, "Stories to Communicate about Managing Hypertension" and deliver it using an easy-to-use DVD resource. We will conduct a two-arm RCT to evaluate HTN stories DVD delivered to African-American outpatients with uncontrolled blood pressure. We will compare the stories intervention DVD to an informational control (blood pressure education DVD, non-narrative). Our main hypothesis is that at six months after enrollment, veterans randomized to the intervention will have greater reduction in blood pressure, as compared with control.

METHODS:
We will create a DVD with videotaped stories of African-American veterans who have successfully controlled their hypertension (Phase 1) and use this DVD - along with a control DVD - in a randomized control trial (Phase 2) of African-American veterans who have uncontrolled hypertension.
Phase 1: We will videotape 10 patients per site in each of 3 participating sites. We will conduct in-person video-recorded interviews in which patients will be asked to tell their stories about how they came to control their high blood pressure. Segments of each participant's video will be included in the final intervention DVDs.
Phase 2: We will conduct a two-arm, randomized control trial to improve HTN control, comparing the "Stories" DVD with a control didactic, non-narrative educational DVD. We will enroll a total of 780 African-American veterans with uncontrolled HTN (as defined by 2 blood pressure readings >140/90 - or >135/80 for patients with diabetes - in the past year. Participants will view the randomly-assigned control or intervention DVD first at the VA and then again at home. Participants will be sent a 'Booster' DVD at 3 months to view at home; which will contain either control or intervention content similar to the initial DVD.
We will collect survey and blood pressure data at baseline and 6 months later. The survey will include questions on demographics, beliefs about HTN and antihypertensive medications, their experiences managing HTN and their HTN management behaviors, participation in clinical encounters, medication adherence, and social support.

FINDINGS/RESULTS:
We have completed recruitment and enrolled 620 participants. Two (2) of these were not included in analysis due to (1) incomplete baseline visit and (1) duplicate enrollment. Follow-up for 534 participants was completed. African American Veterans (N=618) were randomized to Stories intervention or control, with 39% over 65, 8.3% female, 89% did not graduate college, and 53.6% with $20,000 yearly income (characteristics are balanced across the two groups). After watching the DVD, Intervention patients reported the content more emotionally engaging (mean=4.3 (SD 2.3) on 7-point Likert scale) compared to control (mean= 3.2 (SD 2.2), p=0.001). At follow-up, 86.9% intervention strongly agreed/agreed that they were confident they could maintain lifestyle change, compared with 77% controls (p= 0.045). Looking at physiologic outcomes, at baseline, mean systolic BP was 138.4 (SD 18) with no significant difference by group. At follow-up, there was a 3.3mmHg difference in blood pressure, favoring the intervention (p= 0.04).

IMPACT:
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 BP.

PUBLICATIONS:

Journal Articles

  1. Houston TK, Fix GM, Shimada SL, Long JA, Gordon HS, Pope C, Volkman J, Allison JJ, DeLaughter K, Orner M, Bokhour BG. African American Veterans Storytelling: A Multisite Randomized Trial to Improve Hypertension. Medical care. 2017 Sep 1; 55 Suppl 9 Suppl 2:S50-S58.
  2. Bokhour BG, Fix GM, Gordon HS, Long JA, DeLaughter K, Orner MB, Pope C, Houston TK. Can stories influence African-American patients' intentions to change hypertension management behaviors? A randomized control trial. Patient education and counseling. 2016 Sep 1; 99(9):1482-8.
  3. Fix GM, Bokhour BG. Understanding the context of patient experiences in order to explore adherence to secondary prevention guidelines after heart surgery. Chronic Illness. 2012 Dec 1; 8(4):265-77.
  4. Fix GM, Houston TK, Barker AM, Wexler L, Cook N, Volkman JE, Bokhour BG. A novel process for integrating patient stories into patient education interventions: incorporating lessons from theater arts. Patient education and counseling. 2012 Sep 1; 88(3):455-9.
  5. Houston TK, Cherrington A, Coley HL, Robinson KM, Trobaugh JA, Williams JH, Foster PH, Ford DE, Gerber BS, Shewchuk RM, Allison JJ. The art and science of patient storytelling-harnessing narrative communication for behavioral interventions: the ACCE project. Journal of Health Communication. 2011 Aug 1; 16(7):686-97.
Conference Presentations

  1. Bokhour BG, Fix GM, Orner M, DeLaughter KL, Rao S, Long JA, Gordon HS, Pope C, Houston TK. The impact of a stories based educational DVD on patients' intentions to change hypertension management behaviors: a randomized control trial. Paper presented at: Communication in Healthcare International Annual Conference; 2015 Oct 10; New Orleans, LA.
  2. Bokhour BG, Fix GM, Orner M, DeLaughter KL, Rao S, Long JA, Gordon HS, Pope C, Houston TK. The impact of a stories based educational DVD on patients' intentions to change hypertension management behaviors: A randomized control trial. Poster session presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 8; Philadelphia, PA.
  3. Bokhour BG, Fix GM, Volkman JE, Pope A, Barker A, DeLaughter KL, Houston TK. Hearing stories: Identifying key strategies for successful blood pressure control with the context of individuals daily lives. Presented at: International Conference on Communication in Healthcare; 2013 Oct 1; Montreal, Canada.
  4. Volkman JE, Houston TK, Fix GM, Barker A, Delaughter K, Cook N, Bokhour BG. Using community-based participatory research: The role of stories for self-management of hypertension among African-American Veterans. Poster session presented at: American Academy on Communication in Healthcare International Conference on Communication in Healthcare; 2012 Oct 12; Providence, RI.
  5. Fix GM, Barker A, Bokhour BG, Houston TK. Developing DVDs of patient STORIES to Improve the Control of Hypertension. Paper presented at: International Conference on Communication in Healthcare; 2011 Oct 31; Chicago, IL.


DRA: Cardiovascular Disease
DRE: Treatment - Comparative Effectiveness, Technology Development and Assessment
Keywords: Adherence, Attitudes/Beliefs, Ethnicity/Race, Outcomes - Patient
MeSH Terms: none