Overcoming barriers to hypertension control in African Americans

Patient education

Patient education can improve blood pressure control.^58,79–82 Its aims are to increase patients’ understanding of the disease⁸³ and to encourage them to be more active in their own care.^80,84,85

Patient education has a moderate effect on blood pressure control. The average proportion of patients whose hypertension was under control in community-based trials of various interventions ranged from 60% to 70%, compared with 38% to 46% with usual care.^56,80,81

However, these strategies largely did not address misconceptions patients have about hypertension. This issue is especially critical in African Americans, who may have different perceptions of hypertension and different expectations for care⁴¹: beliefs that hypertension is “curable,” not chronic, and that medication is needed only for hypertension-related symptoms may translate to poorer rates of medication adherence.

Levine et al¹ evaluated the efficacy of home visits by trained community health advisory board workers in a neighborhood in Baltimore, MD, with a high prevalence of hypertension. Participants were randomized to receive either one visit or five visits during the 40-month study period. Both groups had a statistically significant reduction in blood pressure, and in both groups the proportion of patients with adequate blood pressure control increased significantly. The results support the use of a practice- and community-based partnership to improve blood pressure control in African American patients.

Ogedegbe et al² randomized 190 hypertensive African American patients to receive usual care or quarterly counseling sessions that used motivational interviewing focused on medication adherence. The counseled patients stayed adherent to their medications, whereas adherence declined significantly in those receiving usual care. This effect was associated with a modest, nonsignificant trend toward a net reduction in systolic blood pressure with motivational interviewing.

A novel method of health education is the use of narrative communication—ie, storytelling. It has a good amount of evidence to support it, as culturally appropriate storytelling may allow patients to identify with a story as it relates to their own lives.^86–89 Examples of educational storytelling include:

• A woman with hypertension discussing what it means to have high blood pressure, and the benefits of controlling it, such as living long enough to see her grandchildren grow up
• A man discussing the importance of involving family and friends to help control blood pressure, and how dietary modifications can be made to ensure that salt alternatives are used when the family does the cooking.

Storytelling should be done in a culturally appropriate context. For example, storytellers should have the same background as the patient (ie, similar socioeconomic status and ethnic background): patients are more likely to be influenced if they identify with the storyteller and imagine themselves in a similar situation.

Houston et al³ randomized 299 hypertensive African Americans to view either three DVDs that featured patients with hypertension or three “attention-control DVDs” on topics not related to hypertension. The intervention group’s DVDs focused on storytelling and “learning more.” In the storytelling section, patients told personal stories about what it meant to have hypertension and gave advice on how to best interact with health care providers and methods to improve medication adherence. A “learning more” section focused on what high blood pressure is, addressed therapeutic lifestyle changes, and encouraged patients to communicate with their health care providers. The patients who viewed the patient narratives had significantly lower blood pressure at 3 months than those assigned to usual care. Although blood pressure subsequently increased in both groups, the benefits of the intervention still existed at the end of follow-up.

Important to note about two of the above three studies^1,3 is that the interventions were done by people other than physicians, thus emphasizing the importance of a team approach to blood pressure control.

Behavioral counseling

The effectiveness of lifestyle modifications such as diet, weight loss, and physical activity in preventing and treating hypertension is well established.^74–78 For example:

• In the Dietary Approaches to Stop Hypertension (DASH) trial,⁷⁶ a healthy diet lowered blood pressure about as much as single drugs do, particularly in African Americans.
• The Trial of Nonpharmacologic Interventions in the Elderly (TONE)⁷⁴ showed that exercise can lower blood pressure in obese hypertensive patients.
• The PREMIER trial (Lifestyle Interventions for Blood Pressure Control)⁷⁵ showed that a single brief counseling session could produce substantial decreases in blood pressure in patients with stage 1 hypertension or high-normal blood pressure.

Unfortunately, these results have been hard to translate into primary care practice, especially for African American patients. Several studies have evaluated the impact of lifestyle interventions on blood pressure control in primary care practices with a large population of African American patients.

Bosworth et al,⁴ in a study of a practice in which almost half the patients were African American, randomized patients to receive usual care, nurse-administered tailored behavioral telephone counseling, home blood pressure monitoring, or home monitoring plus tailored behavioral telephone counseling. The combination of home monitoring and tailored behavioral telephone counseling led to a statistically significant improvement at 24 months compared with baseline.

Home blood pressure monitoring

The effectiveness of self-monitoring in improving blood pressure control is also well documented.^{62,63,65–67,90–95}

Pickering et al⁶² studied patients with poorly controlled hypertension in a managed-care setting and found a reduction of 7 mm Hg systolic and 5 mm Hg diastolic pressure after 3 to 6 months of home monitoring compared with usual care.

Mengden et al,⁹⁴ in a similar study, found average blood pressure reductions at 6 months of 19.3/11.9 mm Hg in the home-monitoring group vs 10.6/8.8 mm Hg in the usual-care group.

The effect of home blood pressure monitoring may be greater in African Americans.

Rogers et al⁹³ found it to be more effective at lowering blood pressure than usual care in a group of 121 patients with poorly controlled hypertension followed in primary care practices, and these reductions were twice as large in African American patients than in white patients.⁹³

Bondmass,⁹² in a study of 33 African American patients with poorly controlled hypertension, reported a 53% control rate within 4 weeks of home monitoring. All patients in the study had uncontrolled blood pressure at baseline (> 140/90 mm Hg).

Artinian et al⁵ evaluated the effect of nurse-managed telemonitoring on blood pressure control vs enhanced usual care. All participants were African American. The monitored group had a significantly greater reduction in systolic pressure at 12 months compared with those who received enhanced usual care.