HSR&D Home » Research » IIR 10-132 – HSR&D Study
Using Stories to address disparities in Hypertension
Thomas K Houston, MD MPH
VA Bedford HealthCare System, Bedford, MA
Funding Period: August 2011 - January 2016
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.
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.
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.
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).
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.
External Links for this Project
NIH ReporterGrant Number: I01HX000492-01A1
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DRA: Cardiovascular Disease
DRE: Technology Development and Assessment, Treatment - Comparative Effectiveness
MeSH Terms: none