Continuing the Conversation: A Multi-site RCT Using Narrative Communication to Support Hypertension Self-Management among African-American Veterans

背景：为了响应 VA HSR&D 医疗保健公平和健康差异主要优先领域，我们 提议继续对话，这是一项随机对照试验，测试使用叙述性沟通来支持和维持 非裔美国退伍军人的高血压（HTN）自我管理。与其他种族和民族相比， 非西班牙裔非洲裔美国人的 HTN 发病较早，患病率较高，且发病率不成比例。 并发症的风险更高，导致心血管发病率和死亡率更高。在之前的工作中，我们使用了 在退伍军人管理局以外的非洲裔美国人中讲故事，使血压得到显着改善。我们翻译了 将这些发现提交给退伍军人管理局，开发和测试我们向非洲人展示的视频记录的退伍军人叙述 - 美国退伍军人。我们在改变 HTN 管理行为的意图上表现出显着差异 观看视频后立即；然而，对血压的影响并未持续，六个月的结果 与控制相比仅显示出适度的益处（p = 0.06）。我们的研究结果强调了纵向支持的必要性 讲故事的效果。我们提出的研究通过短信提供纵向支持，纳入来自 参与者选择的同伴叙事作为维持 HTN 自我管理动机和参与的一种手段。 创新性：尽管医学文献中短信研究不断涌现，但严格的研究却很少 随机试验。非裔美国人在技术辅助干预措施和使用技术辅助的试验中代表性不足 尚未对退伍军人进行 HTN 自我管理短信。我们的建议“继续对话”是 同伴叙事交流与技术的新颖整合。虽然使用信息学工具（短信）作为 支持自我管理的渠道本身并不新颖，通过纵向短信扩展叙述是一种 支持和维持 HTN 自我管理行为的创新机制。我们的具体目标包括： 目标 1. 完善和试点继续对话 (CTC) 干预措施。之前我们制作了视频 非裔美国退伍军人用 HTN 讲述的故事，描述了他们的自我管理策略。我们将通过以下方式完善 CTC： 改编这些视频中的内容来创建与叙述一致的文本，我们将试点 CTC。 目标 2. 通过进行随机对照试验来测试 CTC。 CTC 通过展示退伍军人故事“开始对话” 向参与者提供视频，然后邀请参与者选择喜欢的叙述。然后我们‘继续对话’ 通过 6 个月的叙述性短信提供纵向支持。消息涵盖HTN关键内容， 提供教育、提醒和每周评估，并包括来自所选叙述的引文。 对照组参与者每周都会收到针对相同关键 HTN 自我管理行为的评估文本。 目标 3. 评估 CTC 有效性和中介因素，并进行成本分析。我们假设，对于 CTC 干预组与对照组相比：（H1）基线至 6 个月（初级血压）的血压差异 与控制变化相比，CTC 干预更有利于 CTC 干预。 (H2)：自我效能感与HTN管理 CTC 干预组在 6 个月的随访期间的行为将比对照组更好。 方法：在一项随机对照试验中，将招募 600 名高血压控制不佳的非裔美国退伍军人 来自 2 个 VA 医疗机构，这些机构在高血压控制方面存在已知差异。我们将使用现场随机化（CTC 与 控制）。结果将包括血压、自我效能和高血压管理行为。纵向文本是 旨在将讲故事的人带回到退伍军人的日常生活中，在我们的退伍军人参与时提醒和强化 影响他们血压和生活的众多日常决定。将同行内容合并到文本中 这种方式传递的信息具有高度的创新性，并为支持我们的退伍军人提供了一种有前景的方法。 后续步骤：在此试验期间和之后，我们将向我们的运营合作伙伴 Connected 办公室提供材料 Care (OCC)，向国家领导委员会（包括 VISN 董事）进行演示，并探索其他途径 用于传播。我们将与 OCC 合作创建基于电子健康记录的转诊工具，以鼓励临床 团队将招募患者，并将探索退伍军人可以发起注册请求的机制。

Background: In response to the VA HSR&D Healthcare Equity and Health Disparities major priority domain, we propose Continuing the Conversation, an RCT testing use of narrative communication to support and sustain hypertension (HTN) self-management among African-American Veterans. Compared to other racial and ethnic groups, non-Hispanic African Americans have an earlier onset and higher prevalence of HTN as well as a disproportionately higher risk of complications, leading to higher rates of cardiovascular morbidity and mortality. In previous work, we used storytelling in African Americans outside the VA, yielding significant improvements in blood pressure. We translated these findings to the VA, developing and testing video-recorded Veteran narratives which we showed to African- American Veterans. We demonstrated significant differences in intention to change HTN management behavior immediately after video viewing; however, effects on blood pressure were not sustained, and six-month outcomes revealed only modest benefit over control (p = 0.06). Our findings highlight the need for longitudinal support to sustain the storytelling effect. Our proposed study provides longitudinal support via text messages, incorporating content from the participant’s chosen peer narrative as a means of sustaining motivation and engagement in HTN self-management. Innovativeness: Despite the proliferation of texting studies in the medical literature, very few have been rigorous randomized trials. African-Americans have been under-represented in technology-assisted interventions, and trials using texting for HTN self-management in Veterans have not been conducted. Our proposal, “Continuing the Conversation,” is a novel integration of peer narrative communication into technology. While use of an informatics tools (texting) as a channel to support self-management is not novel per se, the extension of a narrative via longitudinal texting is an innovative mechanism for supporting and sustaining HTN self-management behaviors. Our Specific aims include: Aim 1. Refine and Pilot the Continuing the Conversation (CTC) intervention. Previously, we created video-recorded stories told by African-American Veterans with HTN, describing their self-management strategies. We will refine CTC by adapting content from these videos to create narrative-aligned texts and we will pilot CTC. Aim 2. Test CTC by conducting a randomized controlled trial. CTC ‘begins the conversation’ by showing Veteran Story videos to participants, then inviting participants to select a preferred narrative. We then ‘continue the conversation,’ offering longitudinal support via 6 months of narrative-aligned text messages. Messages cover key HTN content, providing education, reminders and weekly assessments, and include quotations derived from the chosen narrative. Control participants receive weekly assessment texts addressing the same key HTN self-management behaviors. Aim 3. Evaluate CTC effectiveness, and mediating factors, and conduct a cost analysis. We hypothesize that, for the CTC Intervention group as compared to the control: (H1)the difference in blood pressure from baseline to 6 months (primary outcome) will favor CTC intervention compared with the change in control. (H2): Self-efficacy and HTN management behaviors during 6-month follow-up will be greater for those in the CTC intervention group than control. Methods: In a randomized controlled trial, 600 African-American Veterans with poorly controlled HTN will be recruited from 2 VA healthcare sites with known disparities in HTN control. We will use within-site randomization (CTC vs. Control). Outcomes will include blood pressure, self-efficacy and HTN management behaviors. Longitudinal texts are designed to bring the storyteller back into the Veteran’s everyday life, reminding and reinforcing as our Veterans engage in the numerous daily decisions that will impact their blood pressure and their lives. Incorporating peer content into text messages in this way is highly innovative and offers a promising approach to supporting our Veterans. Next Steps: During and following this trial, we will provide materials to our operational partner, the Office of Connected Care (OCC), for presentations to National Leadership Council including to VISN Directors and also explore other avenues for dissemination. We will work with OCC to create an Electronic Health Record-based referral tool to encourage clinical teams to enroll patients and will explore mechanisms by which Veterans can initiate the request for enrollment.