L Ebony Boulware1,2,3,4, Patti L Ephraim5,6,7, Felicia Hill-Briggs6,8,9,10, Debra L Roter10, Lee R Bone7,10, Jennifer L Wolff11, LaPricia Lewis-Boyer6,8, David M Levine8, Raquel C Greer6,8,7, Deidra C Crews6,8,7,12, Kimberly A Gudzune6,8, Michael C Albert8,13, Hema C Ramamurthi6, Jessica M Ameling6,14, Clemontina A Davenport15, Hui-Jie Lee15, Jane F Pendergast15, Nae-Yuh Wang5,6,8,16, Kathryn A Carson5,6,8,7, Valerie Sneed6,8, Debra J Gayles6,8, Sarah J Flynn6, Dwyan Monroe17,18, Debra Hickman17,19, Leon Purnell17,20, Michelle Simmons17, Annette Fisher17,21, Nicole DePasquale22,6, Jeanne Charleston5,6, Hanan J Aboutamar6,8,23, Ashley N Cabacungan22, Lisa A Cooper5,6,8,7,10. 1. Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, 200 Morris Street, 3rd Floor, Durham, NC, 27701, USA. ebony.boulware@duke.edu. 2. Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA. ebony.boulware@duke.edu. 3. Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD, USA. ebony.boulware@duke.edu. 4. Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA. ebony.boulware@duke.edu. 5. Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA. 6. Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD, USA. 7. Johns Hopkins Center for Health Equity, Johns Hopkins University, MD, USA. 8. Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA. 9. Department of Acute and Chronic Care, Johns Hopkins University School of Nursing, Baltimore, MD, USA. 10. Department of Health, Behavior and Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA. 11. Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA. 12. Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA. 13. Johns Hopkins Community Physicians, Johns Hopkins Medicine, Baltimore, MD, USA. 14. Division of General Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor, MI, USA. 15. Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA. 16. Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA. 17. Community Advisory Board, Johns Hopkins Center to Eliminate Cardiovascular Health Disparities, Baltimore, MD, USA. 18. Institute for Public Health Innovation, Washington, DC, USA. 19. Sisters together and Reaching, Inc., Baltimore, MD, USA. 20. Men and Families Center, Inc., Baltimore, MD, USA. 21. American Heart Association, Baltimore, MD, USA. 22. Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, 200 Morris Street, 3rd Floor, Durham, NC, 27701, USA. 23. Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD, USA.
Abstract
BACKGROUND: Effective hypertension self-management interventions are needed for socially disadvantaged African Americans, who have poorer blood pressure (BP) control compared to others. OBJECTIVE: We studied the incremental effectiveness of contextually adapted hypertension self-management interventions among socially disadvantaged African Americans. DESIGN: Randomized comparative effectiveness trial. PARTICIPANTS: One hundred fifty-nine African Americans at an urban primary care clinic. INTERVENTIONS: Participants were randomly assigned to receive (1) a community health worker ("CHW") intervention, including the provision of a home BP monitor; (2) the CHW plus additional training in shared decision-making skills ("DoMyPART"); or (3) the CHW plus additional training in self-management problem-solving ("Problem Solving"). MAIN MEASURES: We assessed group differences in BP control (systolic BP (SBP) < 140 mm Hg and diastolic BP (DBP) < 90 mmHg), over 12 months using generalized linear mixed models. We also assessed changes in SBP and DBP and participants' BP self-monitoring frequency, clinic visit patient-centeredness (i.e., extent of patient-physician discussions focused on patient emotional and psychosocial concerns), hypertension self-management behaviors, and self-efficacy. KEY RESULTS:BP control improved in all groups from baseline (36%) to 12 months (52%) with significant declines in SBP (estimated mean [95% CI] - 9.1 [- 15.1, - 3.1], - 7.4 [- 13.4, - 1.4], and - 11.3 [- 17.2, - 5.3] mmHg) and DBP (- 4.8 [- 8.3, - 1.3], - 4.0 [- 7.5, - 0.5], and - 5.4 [- 8.8, - 1.9] mmHg) for CHW, DoMyPART, and Problem Solving, respectively). There were no group differences in BP outcomes, BP self-monitor use, or clinic visit patient-centeredness. The Problem Solving group had higher odds of high hypertension self-care behaviors (OR [95% CI] 18.7 [4.0, 87.3]) and self-efficacy scores (OR [95% CI] 4.7 [1.5, 14.9]) at 12 months compared to baseline, while other groups did not. Compared to DoMyPART, the Problem Solving group had higher odds of high hypertension self-care behaviors (OR [95% CI] 5.7 [1.3, 25.5]) at 12 months. CONCLUSION: A context-adapted CHW intervention was correlated with improvements in BP control among socially disadvantaged African Americans. However, it is not clear whether improvements were the result of this intervention. Neither the addition of shared decision-making nor problem-solving self-management training to the CHW intervention further improved BP control. TRIAL REGISTRY: ClinicalTrials.gov Identifier: NCT01902719.
RCT Entities:
BACKGROUND: Effective hypertension self-management interventions are needed for socially disadvantaged African Americans, who have poorer blood pressure (BP) control compared to others. OBJECTIVE: We studied the incremental effectiveness of contextually adapted hypertension self-management interventions among socially disadvantaged African Americans. DESIGN: Randomized comparative effectiveness trial. PARTICIPANTS: One hundred fifty-nine African Americans at an urban primary care clinic. INTERVENTIONS:Participants were randomly assigned to receive (1) a community health worker ("CHW") intervention, including the provision of a home BP monitor; (2) the CHW plus additional training in shared decision-making skills ("DoMyPART"); or (3) the CHW plus additional training in self-management problem-solving ("Problem Solving"). MAIN MEASURES: We assessed group differences in BP control (systolic BP (SBP) < 140 mm Hg and diastolic BP (DBP) < 90 mmHg), over 12 months using generalized linear mixed models. We also assessed changes in SBP and DBP and participants' BP self-monitoring frequency, clinic visit patient-centeredness (i.e., extent of patient-physician discussions focused on patient emotional and psychosocial concerns), hypertension self-management behaviors, and self-efficacy. KEY RESULTS: BP control improved in all groups from baseline (36%) to 12 months (52%) with significant declines in SBP (estimated mean [95% CI] - 9.1 [- 15.1, - 3.1], - 7.4 [- 13.4, - 1.4], and - 11.3 [- 17.2, - 5.3] mmHg) and DBP (- 4.8 [- 8.3, - 1.3], - 4.0 [- 7.5, - 0.5], and - 5.4 [- 8.8, - 1.9] mmHg) for CHW, DoMyPART, and Problem Solving, respectively). There were no group differences in BP outcomes, BP self-monitor use, or clinic visit patient-centeredness. The Problem Solving group had higher odds of high hypertension self-care behaviors (OR [95% CI] 18.7 [4.0, 87.3]) and self-efficacy scores (OR [95% CI] 4.7 [1.5, 14.9]) at 12 months compared to baseline, while other groups did not. Compared to DoMyPART, the Problem Solving group had higher odds of high hypertension self-care behaviors (OR [95% CI] 5.7 [1.3, 25.5]) at 12 months. CONCLUSION: A context-adapted CHW intervention was correlated with improvements in BP control among socially disadvantaged African Americans. However, it is not clear whether improvements were the result of this intervention. Neither the addition of shared decision-making nor problem-solving self-management training to the CHW intervention further improved BP control. TRIAL REGISTRY: ClinicalTrials.gov Identifier: NCT01902719.
Entities:
Keywords:
community health worker; hypertension; self-management; social disadvantage
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