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 - July 2015

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.
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:
There are currently no findings for this study. We are in the process of completing the information DVD.

IMPACT:
The "Stories" intervention continues to have great potential to influence blood pressure management behavior for African-American veterans. This study will help to assess the impact of the intervention on both patient behavior and outcomes. When the study is complete, we will have several discrete products that can be used for future intervention: a reusable manual and protocol for efficiently developing stories-based intervention in multiple conditions; a training curriculum for research assistants; and a refined "Stories" DVD for use in the VA outpatient setting.

PUBLICATIONS:

Journal Articles

1. 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.
2. 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.

Conference Presentations

1. 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 Annual Conference; 2012 Oct 12; Providence, RI.
2. Fix GM, Houston TK, Barker A, Bokhour BG. 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
Keywords: Adherence, Attitudes/Beliefs, Ethnicity/Race, Outcomes - Patient
MeSH Terms: none